The Republicans have regained the White House, but they’re still trying to figure out if Donald Trump is a Republican. Sure, he hates regulations and has a plan to cut taxes on the few wealthiest Americans to next to nothing, and to do the same for corporations, but he like tariffs to shut down all trade he thinks is unfair, even if that strangles the economy, and he really likes Russia. And then there’s the matter of temperament. He’s vindictive. He doesn’t just win. He humiliates those who have opposed him. That’s how he defines winning. In September, Conor Friedersdorf documented that in detail and ended with this:
For decades, Trump has been deliberately cruel to others, often in the most public ways. He behaves this way flagrantly, showing no sign of shame or reflection.
What kind of person still acts that way at seventy? A bad person – it is that simple.
Giving a cruel man power and expecting that he won’t use it to inflict cruelty is madness. To vote for Trump – knowing all of this – is to knowingly empower cruelty.
Two months later, America decided it was time for a little cruelty, or a lot of it. Those left behind as the economy changed and the nation became less white and less Christian voted Trump into office and now paint swastikas and white-power stuff on walls, and blame those who have thrived in the new economy and those who just aren’t white and have other religions, or none at all, for their lot in life, because Donald Trump spent a year and a half telling them to do just that. Cruelty would put them in their place.
It wasn’t supposed to be like this. By all accounts Ronald Reagan was a pleasant fellow, and he was thoroughly sincere about what he believed without being a jerk about it, at least too often. Those who thought that what he believed was dangerous nonsense still liked that man. Tip O’Neill, a Democrat’s Democrat, stalwart friend of the unions and the poor working stiffs who were never going to get rich, got along famously with Reagan. They were two Irishmen of the American sort – full of bluster and blarney and good humor. They could get things done on the side and then swap old stories over a few drinks, or more than a few drinks.
Reagan was a good guy, a man’s man, and that goes a long way in national politics. Voters may not have paid close attention to what Reagan was actually proposing, but they never do pay attention to such things. They took the measure of the man and he would do just fine. In 1980, Reagan defeated the enigmatic Jimmy Carter easily, and in 1984 he wiped out Walter Mondale, carrying all but one state. Mondale carried only his home state of Minnesota (by 3,800 votes) and the District of Columbia – that was it. But this wasn’t surprising. As usual, and is always the case, the two Democrats insisted on talking about policy, and what needed to be done and could be done, and what we shouldn’t be doing at all. Reagan smiled. His message was simple. You know me. I’m a good guy.
There was no arguing with that, and now, to everyone on the right, he is that one iconic heroic figure from the past, the man who got everything right and convinced America that it was right.
That’s odd, because Reagan, who hated the whole idea of taxes, which led to big government doing things the private sector should be doing, raised taxes several times, out of necessity, and his spending on the military made the deficit grow alarmingly large. His virulent anticommunism, which had to do with being strong and never giving an inch, was impressive, but at his summit with Gorbachev in Reykjavik, the two of them almost reached an agreement to get rid of all nuclear weapons of any sort, finally settling for an agreement for both sides to get rid of a lot of them.
Reagan wasn’t a tax-and-spend Democrat or a peace-and-love hippie, but these things happened. They are left out of the grand narrative about the guy, and the angry old white Tea Party crowd, who wanted the government to keep its hands off “their” Medicare, tended to forget that 1961 LP Reagan made, financed by the American Medical Association, of a speech he often gave, all about how Medicare, if passed, would be the end of America as we know it – “We are going to spend our sunset years telling our children and our children’s children, what it once was like in America when men were free.”
That was a great line. In 1980, Jimmy Carter called him out on that. Reagan bumbled about and finally said he never opposed Medicare, really – old folks should be cared for by this sort of program – but he had opposed it. The evidence was there, on vinyl. He hated the idea of social insurance, a government safety net for everyone who is foolish enough to get old without being smart enough to get rich. If that happened, well, that was their problem. What about personal responsibility? We all should be free to succeed, or fail, and the consequences of either are ours alone. That’s what freedom is all about, and Medicare was socialized medicine. If it passed, as it did four years later, our precious freedom would be gone forever.
Medicare actually was socialized medicine in a way, and our precious freedom wasn’t gone forever. Those over sixty-five ended up with a lot more freedom – they were free from worry about how the hell they’d be able pay for their inevitable increasing medical needs and still manage to live out their sunset years without ending up dead in the gutter next week. They were free to tell their children and their children’s children what it was like when few of those who somehow got old had any way to keep themselves relatively healthy or even alive, way back when.
They were also free, now that they had few worries about medical costs and had the free time to get involved in big issues, to tell everyone in sight that the Affordable Care Act, Obamacare, would be the end of America as we know it. It was socialized medicine, even if it was no more than a way to hook up those who need health insurance with private parties willing to sell it to them, providing a government subsidy for those who couldn’t pay what those private parties decided to charge, and setting minimum standards for what a health plan should cover.
No matter – it was still wrong. What about personal responsibility? What about freedom? And what about the free market too? If enough people want something, the private sector will see those dollar signs and sell it to them. If there’s no money to be made insuring certain people, well, maybe it’s not worth doing. That’s how capitalism works. Health insurance should be market-based. The free market, through competition for what enough people want and are willing to pay for, will provide just that thing, and at the lowest cost and most efficiency, as private parties scramble to outdo each other to grab the few available dollars people are shoving at them to get what they want and need. Everyone wins. That’s our system, and the last thing we want is socialized medicine. What does the government know about medicine anyway?
That argument failed too. Congress passed the Affordable Care Act. It survived the court challenges. It survived a government shutdown to force its end. All forty or fifty attempts to repeal it failed. Life went on.
But now it seems to be 1961 again, as Jonathan Chait explains:
During the campaign, coverage of the issues was blotted out by coverage of Hillary Clinton’s emails and Donald Trump’s broad suite of sociopathic tendencies. And of the issues that did receive any attention, a conspicuously missing one was Paul Ryan’s plan to push Medicare beneficiaries into private health insurance. Reporters just assumed that, since Trump never talked about it, it won’t happen. But Paul Ryan still wants it to happen. And in a Fox News interview with Bret Baier, Ryan said Medicare privatization is on.
“Your solution has always been to put things together, including entitlement reform,” says Baier, using Republican code for privatizing Medicare. Ryan replies, “If you’re going to repeal and replace Obamacare, you have to address those issues as well. … Medicare has got some serious issues because of Obamacare. So those things are part of our plan to replace Obamacare.”
Ryan tells Baier, “Because of Obamacare, Medicare is going broke.”
If Donald Trump won’t be Ronald Reagan, circa 1961, Paul Ryan will be, except this just isn’t so:
In fact, it’s the complete opposite of the truth. The Medicare trust fund has been extended 11 years as a result of the passage of Obamacare, whose cost reforms have helped bring health care inflation to historic lows. It is also untrue that repealing Obamacare requires changing traditional Medicare. But Ryan clearly believes he needs to make this claim in order to sell his plan, or probably even to convince fellow Republicans to support it.
They might support it, as it is pure early Reagan, as Steve Benen explains:
Throughout the Obama era, Ryan has pushed a radical budget plan that would effectively eliminate the Medicare system, phasing it out of existence and replacing it with a voucher system. Seniors, under the Speaker’s vision, would stop receiving guaranteed care under a popular and effective government-run program, and would instead receive vouchers that would help pay for coverage through private insurers.
Ryan has been an enthusiastic proponent of such a scheme throughout his career – long before “Obamacare” became the law of the land. Now, however, the Wisconsin congressman seems to think he can use the ACA as an excuse to do what he’s wanted to do anyway for nearly a decade. In other words, Ryan’s message for years has been, “I want to privatize Medicare.” Now, his message has become, “It is Obamacare’s fault that we have to privatize Medicare.”
But we don’t. The Speaker is plainly and demonstrably wrong. Repealing the Affordable Care Act wouldn’t help Medicare’s finances; it would do the exact opposite, pushing the Medicare system closer to insolvency.
Perhaps no one will notice that, and Trump did win the presidency, and the Republicans held onto the House and Senate. They have a mandate. They can make Reagan’s original dream come true – we can spend our sunset years telling our children and our children’s children how we made it so men were finally free – we made Medicare wither and die. Of course, in 2004, after being reelected by the narrowest of margin, George Bush claimed that he had a clear mandate to privatize Social Security – what you paid in would have to be invested in the market, in stocks and bonds, which would jump-start the economy and produce amazing returns for you – and everyone would feel that they were part of the system, proud owners in it. He had never mentioned that before, and then the markets crashed. People remembered 1929. That didn’t go well.
Chait also notes another problem:
Will the incoming president reverse course and endorse his party’s Medicare privatization scheme? It’s hard to say for sure – because no one asked Trump during the campaign for his thoughts on Ryan’s budget blueprint.
Trump did say he wouldn’t touch Social Security or Medicare. He wasn’t going to hurt people. He’d save that for those few who questioned his awesomeness. He’d hurt them. Old folks and sick folks hadn’t done that. They should live and be happy, and that’s why he’s conflicted about Obamacare:
For some Republicans, obliteration of Obamacare can’t come soon enough.
Others want a gradual phase out, fearing both the political and practical consequences of throwing 20 million Americans off their health plans virtually overnight.
And President-elect Donald Trump, who vowed to repeal and replace “the disastrous” Obamacare, sent mixed signals Friday about how he will proceed. For the first time, he told The Wall Street Journal he might preserve the popular prohibition against insurers denying coverage because of preexisting conditions and another provision allowing young people to stay on their parents’ insurance plans to age 26. Trump said President Barack Obama personally asked him to consider it.
“Either Obamacare will be amended, or repealed and replaced,” Trump said.
He doesn’t seem to care, one way or the other. Fix it or dump it. Either is fine as long as no one gets hurt. These people have done nothing to him.
Others didn’t see it that way:
Trump’s statement heaped new confusion on how the GOP will move forward with its campaign pledge to repeal and replace Obamacare. A party rift was already emerging between lawmakers and advocacy groups who want a slow and orderly transition to give notice to the millions now covered – and those who want to repeal the entire law within minutes of Trump’s inauguration. And that’s only one of the disagreements as lawmakers, Trump’s transition team and conservative groups wade through the complicated policy and political ramifications of how to repeal Obamacare and how to replace it.
Those complicated policy and political ramifications or one thing, but the issue is, in the end, how much cruelty the party wishes to inflict:
For six years, Republicans have sought every possible way to kill the landmark health law – bringing failed lawsuits and waging unwinnable legislative fights that a Democratic president could always veto. Now that the stars have aligned to allow them to do it, they can’t agree on how to proceed.
For instance, Heritage Action, which is influential with House conservatives and is also advising the incoming administration, is demanding that Congress prepare a repeal bill that Trump could sign on Inauguration Day. Some conservative lawmakers agree.
“It should crumble immediately because Americans can’t afford it,” said Rep. Andy Harris (R-Md.), a member of the Freedom Caucus who wants to see the individual mandate scrapped right away.
Yeah, yeah – that’s what they’ve been saying, but they should know better:
That demand for immediacy is running up against others who insist on providing those enrolled in Obamacare plans with a transition period before an Obamacare-repeal takes effect. They also want to replace it with a new system – one that the GOP hasn’t even agreed upon.
“It’s not going to be easy to fix,” said Rep. Phil Roe (R-Tenn.), an ardent opponent of Obamacare. He pointed out that insurers are already selling 2017 health plans.
“There’s nothing you can do about that,” Roe said. “It’s going to take one to two years to reconstitute a marketplace.”
They have no replacement plan. They never had one. What’s already in place is contractually fixed in place for the next two years, in a complex national system of major insurers and tens of thousands of hospitals. What were they thinking?
They just started thinking:
Republicans leaders are just starting to wade into the mechanics of repealing the law, according to aides on Capitol Hill. Those plans are expected to pick up steam when lawmakers return to Washington next week. An abrupt change would affect not just the people covered, but virtually the entire health care system.
Complicating their discussions is the practical reality that they will have only one shot at passing a health bill using a difficult budget maneuver that prevents a Democratic filibuster.
Republicans favoring a transition period say they want to give Obamacare enrollees plenty of time and notice that their subsidies would go away. Others favor repealing the individual mandate almost immediately and want to push the Trump administration to move as aggressively as possible at undermining the law through regulation.
But there are problems with that:
The quickest thing a GOP administration could do is refuse to pay insurance companies the subsidies they make on behalf of low-income people. Insurers would face insurmountable costs and would be allowed to leave the markets almost immediately.
If Republicans aggressively attack the law through regulation, the law will quickly crumble because insurers will become unstable and customers would lose coverage with little notice. For some in the GOP, that’s the goal. But others fear that would generate backlash.
Trump, meanwhile, did not spell out the details of how he’d guarantee coverage to those with chronic health problems, without making insurance premiums soar. Many Republicans have proposed keeping a modified form of the preexisting condition measure that would protect people as long as they’ve maintained continuous coverage. It was not clear whether Trump wanted to keep the current ACA provision, or adopt the GOP suggestion.
Another point of friction: Some Republicans want to have a replacement ready when the law is repealed, while others are eager to get repeal done regardless of whether a replacement is prepped.
This is a mess, and it’s even more complicated than that:
Republicans will work off of a 2015 repeal bill passed under reconciliation, a special budget procedure that would bypass a Democratic filibuster. It is a complicated procedure that allows only some of the major parts of the law to be repealed. In theory, a replacement could be part of that.
But that’s also more difficult than it might appear: The complex budget process means they can’t start the replacement from scratch – they have to work off a part of Obamacare.
“It’s easy to build a ranch on an open lot,” said Sage Eastman, principle at Mehlman Castagnetti Rosen & Thomas and former Republican Ways and Means Committee staffer. “But to convert that into a different style house is different. … It’s often a more complicated effort once you have one structure in place.”
Now add this:
There are also questions about whether a replacement to the law can be done at the same time as the repeal through the reconciliation process. Some Republicans are worried about appearing reckless by getting rid of Obamacare without a new system in place, opening themselves up to accusations that they’re canceling consumers’ health plans – a huge vulnerability Democrats faced on late 2013 when some insurance plans were canceled.
“Certainly in the House, they are running for office constantly, only two years to go again,” said Joe Antos, a health care policy expert at the American Enterprise Institute. “Most of them are not going to want campaign ads in two years that say Mr. X or Mrs. X is responsible for throwing 20 million people off health insurance.”
Democrats, for their part, are preparing to do all they can to stop the GOP repeal effort, but they may be able to do little besides remind voters that Republicans are throwing millions off their healthcare plans.
That may be enough, and Kevin Drum adds this:
The pre-existing conditions ban will stay? Huh? How do you do that without also keeping the subsidies and the individual mandate? It would bankrupt every insurance company in America. Most likely, I suppose, this is just standard Trumpian deception. He’ll keep the pre-existing conditions ban, but surround it with so many qualifiers that it’s meaningless.
An item in the New York Times adds a little more background to that:
Policy experts say that the part of the law that Mr. Trump is rethinking, that prevents insurers from refusing to cover people with costly medical conditions, only works financially for insurers if there are plenty of healthy people also buying insurance. If only sick people enroll, premiums would soar. To get healthy people covered, the existing law includes generous subsidies to help more people to afford a policy and taxes people who don’t buy insurance.
Industry executives say their first priority is to persuade Mr. Trump and the new Congress to replace the law with some way for people to continue getting coverage.
The problem is that, until now, top executives from the biggest insurers have not heard from Mr. Trump or his close advisers about his plans. In fact, the industry as a whole made no contingency plans for a Trump victory and does not yet appear to have developed a strategy. In the last few days, executives have huddled hurriedly with their boards and advisers to discuss how to react.
Panic is in the air:
About 22 million Americans would be without insurance if the law were repealed. The state marketplaces, where about 10 million of those people buy insurance, would no longer exist. The millions of others who were newly eligible for Medicaid would also lose coverage.
“I’m concerned about the fear factor of what is going on,” said Bernard J. Tyson, the chief executive of Kaiser Permanente, the system based in California that includes hospitals, doctors and an insurance plan. He said the company was already getting calls from people worried about whether they would still be able to get coverage. Both federal officials and insurance executives say people should not hesitate to sign up during the current open enrollment period.
Better safe than sorry, when no one knows what’s going on, but no one is safe if the Republicans pull the trigger:
Insurers will feel the loss of customers both in the individual market and under state Medicaid programs. While most are well diversified into other areas of insurance, the Affordable Care Act was seen as a way to forestall the steady erosion in employer-based insurance. The companies spent years and millions investing in being able to sell new policies through the state marketplaces, operating under an entirely new model.
Hospitals, however, are likely to be the biggest losers. Under the law, they agreed to get less money from the government, essentially in exchange for having to cover fewer uninsured people.
Okay, if the Republicans pull the trigger the system falls apart. Twenty million newly-insured Americans get hurt, badly. Major insurers get hurt, badly. Hospitals get hurt, badly. Donald Trump, however, now seems reluctant to pull the trigger. He could tell Ryan and the other Republicans to forget it – just let it go. He does have a history of being deliberately cruel to others, often in the most public ways, but that depends on his mood. Who has questioned his awesomeness today? No questions? He can be a lovable pussycat. He can also burn down the house. It depends.
Ronald Reagan was a pleasant fellow. He hid his mean streak rather well. Trump is his mirror opposite. America has chosen to empower his cruelty, but they can’t depend on it. It’s going to be an interesting four or eight years.