Over his first six months in office, President Trump has at times appeared to struggle to understand the complexities of healthcare as a public policy issue as well as the intricacies of the legislative process. On Sunday, in an interview with the friendly Fox & Friends, he showed what appeared to be a firmer grasp of the difficulty of producing a viable replacement for the Affordable Care Act, even if he still seems to be misreading what’s happening on Capitol Hill.
“Health care is a very complicated subject from the standpoint that you move it a little bit this way and this group doesn’t like it,” he said. “You move it a little bit over here, a very narrow path, and honestly nobody can be totally happy.
However, despite obvious rancor within the Republican Party over the status of the effort to repeal and replace the Affordable Care Act, Trump said, “I don’t think they’re that far off. Famous last words, right? But I think they’re going to get there.”
To be clear, that is a very optimistic assessment.
The Senate version, meant to improve on the American Health Care Act passed by the House last month, contains many of the same elements as the lower chamber’s bill, a number of which are giving pause to both conservative and more moderate members of the GOP. That’s a problem because, with no votes expected from Democrats, Senate Majority Leader Mitch McConnell needs at least 50 of the 52 Republicans in that chamber to support the bill.
On Sunday, the administration sent out Secretary of Health and Human Services Tom Price to try to address some of the criticisms being directed at the proposal, which most members of Congress hadn’t even seen until Thursday.
After Nevada Republican Dean Heller said on Friday that he could not support the bill as written because it would not reduce insurance premiums, Price said that he was incorrect.
“The plan in its entirety will absolutely bring premiums down because you increase competition, you increase choices for individuals, you allow folks to be able to purchase the kind of coverage that they want not that the government forces them to buy,” he said. “Those are all the secret keys to a market that actually works for healthcare and works for patients. That’s the key.”
It’s important to note that the two men are talking about distinctly different things. Under the ACA, the government set requirements for what kind of insurance plans federal subsidy dollars could be spent on. Plans had to provide specific benefits in order to be eligible.
Heller appears to be saying that premium levels would not fall under the GOP plan for plans offering good coverage, like those mandated by the ACA. In claiming that premiums will go down, Price is assuming that insurers will gain the ability to market much skimpier plans that will bring down average costs because they can offer less protection from medical disaster.
The Congressional Budget Office and Congress’s Joint Committee on Taxation have both said that they do not consider many bare-bones policies to be real insurance at all because they do nothing to protect individuals from a catastrophic financial impact in the event of serious illness or injury.
Heller and others also complained about the changes to Medicaid, which would reduce the amount the federal government is expected to spend on Medicaid by more than $830 billion over 10 years. It would do this by changing the rate at which the program’s funding grows from the expected inflation rate for medical costs to a broader measure of inflation based on general consumer goods.
Price and other supporters of the bill, including White House Counselor Kellyanne Conway and Pennsylvania Sen. Pat Toomey all made the similar sophistic argument: Because Medicaid spending still goes up every year, it is false to call the reduction in expected outlays spending cuts.
That’s a claim that carries no weight with the large number of associations representing hospitals, doctors, and patients who believe the cuts will translate into sharply reduced availability of medical care.
Appearing on Fox News, Price was also asked to address a glaring flaw in the Senate version of the bill. The proposal retains the requirement that insurers offer coverage to anyone who applies but has no mechanism to compel people who are not sick to purchase coverage before they need it, virtually guaranteeing a fiscal death spiral, as very sick people join immediately and healthy people stay away until they become sick.
That free-rider problem was addressed in the Affordable Care Act with the individual coverage mandate. In the House version, the penalty is a 30 percent surcharge on premiums for a year if a person sought to buy insurance after more than 63 days of lapsed coverage.
How would the Senate bill avoid the free-rider problem? Price insisted that deregulation is the answer.
“You provide the opportunity for insurance companies to sell something to young healthy people that they want to buy,” he said. “Not that they say...we’ll write a check so that we don’t have to buy what Washington tells us to buy.”
Referring to the pre-ACA era, in which insurers were free to offer bare-bones coverage, and the ranks of the uninsured were even larger than they are today, Price insisted that things were somehow better then and that the Senate bill would take the country back in that direction.
“Before individuals were able to purchase the kind of coverage that was actually responsive to them. Fit their system, fit their lifestyle, fit their situation in life. That’s the way that you get folks to buy coverage,” he said.
Republicans, in appearances scattered across the Sunday talks shows, still seemed dubious about the legislation, which McConnell has said he would like to see a vote on before the end of the week. Kentucky Sen. Rand Paul said that the GOP had “over-promised” with regard to what it could accomplish and that it ought to scale back the bill to focus on things that all Republicans agree on.
Sen. Ron Johnson, of Wisconsin, said that he and his colleagues simply haven’t had time to analyze the legislation and that the vote ought to be postponed.
Maine Sen. Susan Collins expressed grave concerns about the Medicaid cuts and the possible elimination of funding for Planned Parenthood and seemed reluctant to support the bill.
Some Republicans have called out Democrats for failing to engage with them on the repeal and replace effort, but West Virginia Sen Joe Manchin, probably the most centrist member of his party in the Senate, said flatly on Sunday that, while he’s open to working with Republicans to improve the existing law, they have to “take repeal off the table.”
In any case, he added, despite the rhetoric, there hasn’t really been a GOP effort to reach out to Democrats.
“If they don’t have me sitting down with them, someone who’s in the middle, who wants to work with them to get good policy, they’re in serious problems,” he said.