17 February 2017

Why ‘Trumpcare’ could define Trump’s presidency


It’s difficult to enter a room nowadays without being dragged into a discussion about the latest Trump controversy: the Muslim ban, the Wall, the links to Russia, yet another attack on the media.

While these are, of course, matters of great concern, there is one issue on Trump’s agenda which towers above everything else in terms of its importance to millions of ordinary Americans – and its potential toxicity. That issue is, of course, Obamacare.

During his campaign, Trump’s denunciations of Obama’s landmark healthcare reform won him a great deal of praise. He revelled in calling it a “disaster”, due to the costs it imposed on businesses and consumers, and promised its repeal as soon as he got to office.

Tom Price, Trump’s newly confirmed Health and Human Services Secretary, has been champing at the bit to assign Obamacare to history – as have many other conservatives, including Speaker Paul Ryan and Senator Ted Cruz. They see the health bill as an affront to personal freedom, and want to take American healthcare in a radically new direction.

Yet many moderate Republicans are having second thoughts about their President’s zeal in pushing for repeal as soon as possible. Various reports have surfaced of GOP members of Congress raising concerns about their constituents being left without insurance.

Rep. Charlie Dent of Pennsylvania, once a fervent supporter of repealing the Affordable Care Act, recently voted against a measure kicking off the repeal process, explaining: “We’re playing with live rounds this time.”

The fast-track “repeal and replace” faction have, admittedly, been bolstered by the pounding which Obamacare’s reputation has received in recent weeks and months.

On Wednesday, Mark Bertolini, the CEO of Aetna, one of America’s largest health insurers, claimed that the exchanges on which Obamacare is bought and sold were in a “death spiral”. The problem is that younger and healthier consumers are opting out of coverage, leaving insurers are struggling with low demand and high prices. Fellow health insurer Humana has announced its withdrawal from the ACA’s state-based insurance marketplaces for 2018, and Aetna may follow.

Clearly, there are huge problems with the system. As well as the difficulties with the exchanges, the ACA has struggled to halt soaring drug prices.

Yet according to the Congressional Budget Office, a nonpartisan federal agency, about 18 million people would lose or drop their health insurance in the first year if it were repealed, and health care premiums would shoot up. This is based on a repeal law passed in the House last year, which includes keeping some of Obamacare’s most popular provisions.

The truth is that Obamacare was never going to be perfect instantaneously. The Act is the most significant change to American healthcare since Medicare under Lyndon B Johnson. It had to struggle through a hyper-partisan Congress and numerous court challenges – not to mention the huge, unwieldy and expensive nature of the American healthcare system that it has been attempting to change.

And while some criticisms of the ACA are justified, many are completely unfounded. For example, the exchanges, which are discussed disproportionately, only actually affect 3 per cent of the US population. A third of Americans aren’t even aware that “Obamacare” and the “Affordable Care Act” are the same thing. And a survey last year by the Commonwealth Fund found that three out of four consumers were actually satisfied with its provisions.

Meanwhile, crazy rumours have spread which say Obamacare contains a provision that everyone over the age of 74 has to go in front of a “death panel”. It is a blatant lie, but one that a 2015 poll found was believed by 26 per cent of Republicans and 12 per cent of Democrats.

Partly, this is about politics. As the name suggests, “Obamacare” represents Obama’s biggest legacy as President, and there is nothing the GOP would like more than to tear that down as soon as possible. Yet the ACA was actually modelled on “Romneycare”, healthcare reforms initiated by Mitt Romney in Massachusetts, which saw the number of uninsured residents drop from 6 per cent in 2006 to 2 per cent in 2010.

The Republicans understandably have concerns about the way Obamacare expanded the government’s role in healthcare. But it has also expanded health coverage to about 20 million uninsured people, and saved the lives of many thousands who were previously uninsured. The ACA provides insurance protections for those with pre-existing conditions; brings people under 26 onto their parents’ insurance plans; prevents gender-based discrimination; and gives substantial benefits to the 170 million Americans on employer-based coverage.

In short, if they simply tear it down, the Republicans will find themselves with a lot of angry people, many of them in red states as well as blue.

So where do they go from here? There are lots of ideas flying around, including the sale of insurance across state lines, and increased personal control over doctors and insurance plans. But many of these alternatives would still see people stripped of ther coverage – Paul Ryan’s “A Better Way” plan, for example, would see four million Americans lose out. That’s hard to square with Trump’s promise of “insurance for everybody”.

During the campaign, and up until mid-January, Trump had backed plans to tackle America’s astronomical drug prices by getting drug companies to bid for contracts, with Medicaid negotiating bulk discounts. America’s fragmented purchasing system encourages price hikes, and a move towards collective buying is needed badly. Yet a few weeks later, those plans were dropped after he met with pharmaceutical industry representatives.

Obamacare has problems which need to be fixed. Yet even if repeal is the best solution, politicians need to be honest about the pros and cons of the current system, and of the potential replacements.

Healthcare dominated Obama’s presidency. Given the pivotal decision Trump now faces, it could well define his premiership too.

Jack Graham is a political commentator who specialises in American politics