Running on Pure Spite

Donald Trump will fix things. He’s the only one who can. He’s said so many times, and say something many times and people eventually just give up. Just enough voters in just the right places just gave up – sure, fine, whatever, Donald – fix things. Bring jobs back. How? That doesn’t matter. Just do it – and get rid of Obamacare. Everyone hates Obamacare, although they’re not sure why – it does good things and many Trump voters are on Obamacare, one way or the other – and not everyone hates it. But whatever – it’s awful, somehow. That’s been said for six years, and there were those fifty or sixty bills to repeal Obamacare – essentially symbolic of course – so it must be awful. Why else would the Republicans go to all that effort? Now they hold the House and Senate and the White House. Just do it. What will happen is just going to have to happen, but at least there will be no more talk about this. America can move on to other issues. The Republicans wore America down. Repeal the damned thing. Be done with it.

That was the idea, but the Republicans have discovered it’s damned hard to just be done with it. The good parts that people like, and want the Republicans to keep – like making sure those with preexisting medical conditions can actually buy health insurance – are dependent upon the “bad” parts – forcing everyone to buy health insurance so there’s a big enough pool of funds to cover those with those preexisting medical conditions. And there’s the matter of those twenty-two million folks now insured through Obamacare. Repeal the thing and there’ll be twenty-two million folks hopping mad, or in despair, and they’ll know who to blame, and they vote – or those that don’t die will vote. That won’t do – so it’s Repeal and Replace – but there’s no replacement yet – but this should be simultaneous. More and more Republicans say wait – we need to think this through. Others can’t afford to do that. The voters they made very angry about Obamacare want action. Waiting would be political suicide. Not waiting is also political suicide of course. Things have ground to a halt.

Donald Trump will fix things. He’s the only one who can, so a few days before his inauguration he said he has a plan:

President-elect Donald Trump said in a weekend interview that he is nearing completion of a plan to replace President Obama’s signature health-care law with the goal of “insurance for everybody,” while also vowing to force drug companies to negotiate directly with the government on prices in Medicare and Medicaid.

Trump declined to reveal specifics in the telephone interview late Saturday with the Washington Post, but any proposals from the incoming president would almost certainly dominate the Republican effort to overhaul federal health policy as he prepares to work with his party’s congressional majorities.

In fact, he’ll tell his Republican congress exactly what to do – set up “insurance for everybody” – that’s it, case closed. Why did they think this was so hard?

It’s this simple:

Trump said his plan for replacing most aspects of Obama’s health-care law is all but finished. Although he was coy about its details – “lower numbers, much lower deductibles” – he said he is ready to unveil it alongside Ryan and Senate Majority Leader Mitch McConnell (R-Ky.). …

As he has developed a replacement package, Trump said he has paid attention to critics who say that repealing Obamacare would put coverage at risk for more than 20 million Americans covered under the law’s insurance exchanges and Medicaid expansion.

“We’re going to have insurance for everybody,” Trump said. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” People covered under the law “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.” …

“It’s not going to be their plan,” he said of people covered under the current law. “It’ll be another plan. But they’ll be beautifully covered. I don’t want single-payer. What I do want is to be able to take care of people,” he said Saturday.

There may be more than a few Republicans who sense that Trump has no idea what he’s talking about, that he doesn’t understand the issues at all, although they’d never say that publicly. Paul Waldman says they’ve made a bad bet:

When even the most committed Republicans came around to support Donald Trump in 2016, they made a kind of bet. It wouldn’t matter much that Trump had no apparent fealty to conservative ideology or that he was a complete ignoramus about policy, because he’d be leaving all that boring stuff to them. The Republican Congress would pass its agenda, he’d sign whatever they put in front of him, and they’d all live happily ever after.

But now it’s not looking so simple. In fact, Trump just dealt a huge blow to their top priority: repealing the Affordable Care Act. Accomplishing repeal without causing the GOP a political calamity is an extremely delicate enterprise, and the last thing they want is to have him popping off at the mouth and promising things they can’t deliver.

But that’s what he just did, and that’s the problem:

We should begin with the assumption that nothing Trump says can be taken at face value; the “plan” that he claims is being devised could be no more real than the secret plan to defeat the Islamic State he used to claim that he had formulated. But that’s not the point. What matters is this: Donald Trump just emphatically promised universal health coverage. That’s an absolutely gigantic promise, and it’s one that Republicans have no intention of keeping.

But now they’re stuck with it. Democrats will be saying, “President Trump promised that everyone would be covered!” every day for as long as this debate goes on. Every time a congressional Republican is interviewed on this topic, they’ll be asked, “President Trump said that everyone would be covered. Does your plan do that?” and they’ll have to bob and weave as they try to avoid admitting the truth.

That’s because the Republican plan, in whatever final form it takes, will absolutely, positively not cover everyone. Universal coverage isn’t even one of their goals. Republicans believe it’s much more important to get government as far away from health care as possible. In place of the ACA’s expansion of Medicaid and subsidies for the purchase of insurance that have extended coverage to 20 million more people than used to have it, they’ll be offering some tax credits and health savings accounts, which would be very good for the healthy and wealthy, but not so great for other people.

That’s what they always offer – tax credits and health savings accounts – but that’s not going to cut it:

The truth is that there are really only two ways you can achieve universal coverage: by having the government cover everyone in some form of single-payer, or with a set of extremely coercive mandates to carry coverage, much more coercive than the ones in the ACA. Republicans would rather pluck out their own eyes than agree to either one of those. So the trick is to make the public think they won’t take away coverage from tens of millions of people, while doing just that.

That requires some rhetorical subtlety, which is something Trump is just not capable of.

They may understand that now, but there’s more:

Trump’s insistence that the Republican plan will give people “much lower deductibles” is absolutely false – in fact, every extant Republican plan promotes higher deductibles, as a way of forcing people to become aggressive health-care shoppers because they have “skin in the game” and, thereby, through the magic of the market, driving down costs.

If Trump understood the political and policy challenges Republicans face, he’d know that high deductibles are supposed to be complained about and wielded as evidence that the ACA is a failure, but you’re not supposed to actually promise that any Republican plan will lower them. You want people to assume that, of course, but you don’t want to promise it directly, because then you might be held accountable for that promise.

But Trump says whatever comes into his head, and whatever seems like it might be popular. People hate out-of-pocket costs, so he promises low deductibles. People don’t like the idea of tens of millions losing their coverage, so he promises that everyone will be covered.

And now, congressional Republicans are going to have to answer for breaking a promise they didn’t even make.

Well, he’s their guy. They’ll have to live with it, but Waldman adds more:

There are a lot of reasons why repealing the ACA is going to be a disaster. But for now I want to focus on just one: what’s going to happen to the estimated 52 million Americans who have pre-existing conditions…

To begin, let’s remember what it was like before the ACA was passed. When you applied for insurance, you had to give a detailed accounting of every major medical procedure you’d ever had, every serious condition you’d ever had, every time you had sought treatment for anything for years prior. The insurer would comb over your application to see if there was any grounds on which they could reject you. That didn’t just apply to people with chronic conditions like diabetes or a major illness like cancer. In the bad old days, insurers could deny you coverage for anything. Tore some cartilage in your knee on the basketball court a few years ago? Denied. Had sinus problems? Denied. Carpal tunnel? Denied. If you were lucky, they’d cover you but just refuse to pay for anything remotely related to your old condition or that particular body part.

And when you did get sick, they’d sometimes undertake a “recission,” in which they went back through your records to see if there was any excuse they could use to cancel your policy now that you were going to cost them money.

Those of us who know people in the industry can verify that. Many of us have worked with complex software systems that track eligibility per person per contract per procedure, to make sure no one gets away with anything – systems that pay for themselves in increased profits. There were whole departments dedicated to cancelling policies, but no more:

Now here’s how getting insurance works today, with the Affordable Care Act in effect, if you have a pre-existing condition. See if you can follow along, because it’s pretty complicated:

You buy coverage. The insurer doesn’t ask you about your medical history. It’s covered. That’s all.

And with the repeal of Obamacare you get this again:

The application process for insurance will become much more cumbersome and onerous.

Insurers will be able to charge people with pre-existing conditions higher premiums.

Insurers will be able to impose yearly and lifetime limits on benefits, which affects people who have serious illnesses or accidents. This could apply to those with good employer-provided coverage as well as those who buy on the individual market.

“Job lock,” in which people are afraid to leave their job and do something like start a new business for fear of losing the insurance they have, will return.

Insurers will be able to charge women higher premiums than men, because they consider being a woman to be a pre-existing condition.

Insurers will be able to rescind coverage when you get sick.

All of that was eliminated by Obamacare. Republicans might take steps to fix some of that, but they haven’t decided any of that yet. It’s complicated. Donald Trump says it isn’t. That complicates things even more.

Kevin Drum further explains the complications, starting with the good stuff about Obamacare:

Obamacare has provided more than 20 million people – most of them low-income or working class – with health coverage. It has done this with no negative effects on either Medicare or the employer health insurance market. It didn’t raise taxes more than a few pennies on anyone making less than six figures. It’s had no effect on the willingness of companies to hire full-time workers. Health care costs under Obamacare have continued to grow at very modest rates. And it’s accomplished all this under its original budget.

And then there’s the bad stuff:

Obamacare unquestionably has some problems. About 20 percent of its customers choose Bronze plans with very high deductibles. Some of the least expensive plans have narrow networks that restrict your choice of doctor. Some insurers have left the exchanges because they were losing money. And premium increases have been volatile as insurers have learned the market. But every one of these things is a result of Obamacare’s reliance on private markets – something that Republicans support. Insurers are competing. They’re offering plans with different features at different price points. Some of them are successful and some aren’t. That’s how markets work. It’s messy, but eventually things settle down and provide the best set of services at the best possible price.

And then there’s the popular stuff:

Obamacare is popular unless you call it “Obamacare.” If you call it Kynect its negatives drop. If you call it the Affordable Care Act its negatives drop. If you ask about the actual things it does, virtually every provision is popular among Democrats and Republicans alike. Even Obamacare’s taxes on the rich, which are fairly modest, are popular. Aside from the individual mandate, the only truly unpopular part of Obamacare is the name “Obamacare.” (And even that’s only unpopular among Republicans.)

That makes Drum puzzled about the “continued rabid opposition” to Obamacare:

It’s not because the government has taken over the health care market. On the contrary, Obamacare affects only a tiny part of the health insurance market and mostly relies on taking advantage of existing market forces. It’s not because the benefits are too stingy. That’s because Democrats kept funding at modest levels, something Republicans approve of. It’s not because premiums are out of control. Republicans know perfectly well that premiums have simply caught up to CBO projections this year – and federal subsidies protect most people from increases anyway. It’s not because everyone hates what Obamacare does. Even Republicans mostly like it. The GOP leadership in Congress could pass a virtually identical bill under a different name and it would be wildly popular.

What could explain the opposition to Obamacare then? Drum settles on pure spite:

Republicans hate the idea that we’re spending money on the working class and the poor. They hate the idea that Barack Obama is responsible for a pretty successful program. They hate the idea that taxes on the wealthy went up a bit. They hate the idea that a social welfare program can do a lot of good for a lot of people at a fairly modest price.

What kind of person hates all these things?

That’s a good question, and a week earlier, Philip Klein answered that in this item on the politics of Obamacare repeal, which is long and detailed but comes down to this:

Republicans are in serious danger of repeating Obama’s mistake, because they are having a tough time stating a simple truth, which goes something like this: “We don’t believe that it is the job of the federal government to guarantee that everybody has health insurance.”

They’re not bad people, no matter what Drum says. They just believe that, and Josh Marshall adds this:

Indeed, this is the specter haunting the whole repeal process. This is the reason why Republicans were never able to come up with an alternative in six years of opposition under Obama and aren’t able to do so now. That’s what “replace and delay” is about. There’s no technical issue with pushing through a new plan. In fact, there isn’t really a shortage of plans. There are LOTS of plans. There’s just no plan that enough Republicans agree on.

The real issue is that Republicans appear to have accepted the premise that all the people who gained coverage under Obamacare should not lose it. That is a political concession for which there appears to be no policy solution.

That gets to the heart of the matter. This problem cannot be solved. All the people who gained coverage under Obamacare should not lose it, but Obamacare is evil, and Obama was evil. That’s been the line for his two terms – and Obama pulled off the impossible. He made them look mean and foolish. They will have their revenge. Trump is part of that, and Adam Gopnik takes that further:

American conservatism has as many clear, resolute devotees of constitutional democracy as any other stream of ideology – or it once seemed to. For, in truth, those of us Cassandras who predicted a slow collapse of “respectable” Republicans in the face of Trump’s ascension turned out to be, well, too conservative. The collapse has been almost total, and shockingly uncritical. A few resisters aside – in the press, the names Jennifer Rubin, Max Boot, and David Frum come to mind – even those who know better, or did, have allowed the ancient habits of hatred to overwhelm their normal sense of right and wrong. Republican legislators who, a year ago, would have been aghast at any politician who praised the brutal dictator Vladimir Putin now have little trouble swallowing their tongues when Trump insists that Putin’s good opinion, however earned, is “an asset.” Those who made a fuss about pursuing any possible conflict of interest among Obama’s appointees now meekly allow the most conflict-ridden and least “vetted” of candidates for high office to walk through largely unmolested. And the insistence of the leader that he has no obligation to release any record of his financial entanglements, with the bold repeated lie that an “audit” – whose existence can’t be confirmed and wouldn’t matter anyway – prevents him from doing so, is simply and mutely accepted. The collapse – motivated for some by opportunism, for others by the intimidation of the mob – is complete.

No, the collapse is total. And at that terrifying first press conference of Trump’s, on Wednesday, we saw the looming face of pure authoritarianism. Rewards are promised to the obedient: those good states that voted the right way, the “responsible” press. Punishments are threatened to the bad: “They’re going to suffer the consequences!” Intimidation is the greeting to any critic. And look! There’s a claque alongside to cheer the big boss and deride his doubters. This is what was once called Bonapartism: I won and I can now do anything I choose. Victory, however narrow, is license for all.

That may seem a bit off-topic, but now they’ll also destroy Obamacare for no good reason, because they can. They won.

Gopnik can offer only this:

In such a moment of continued emergency, the most important task may be to distinguish as rigorously as possible between new policies and programs that, however awful, are a reflection of the normal oscillation of power, natural in a mature democracy, and those that are not. To borrow from Woody Allen’s distinction between the miserable (something we all are) and the horrible (fortunately suffered by only a few), we must now distinguish resolutely between the sickening and the terrifying. Many programs and policies with which progressive-minded people passionately disagree will be put forward over the next few years. However much or strongly one opposes them, they are, like it or not, the actual agreed-on platform of a dominant national party. On the issue of gun control alone, we’ll get a Supreme Court that won’t reverse the bad decision of Heller, a legislature that will only further diminish sane controls on military weapons in private hands, likely an increase in open-carry laws, and all the murderous rest. All of this will cost kids’ lives and bring much misery.

One may oppose these things – and one should, passionately and permanently – but they are in no sense illegitimate. They are just wrong. They are also reversible by the same laws and rules and norms and judicial and, perhaps most of all, electoral processes that created them. If we want gun control, we need to get more people caring about it and more people in more places voting for it; we cannot complain because people who don’t want gun control don’t give it to us.

That would also mean that we cannot complain because people want to get rid of Obamacare and we don’t want them to. No one likes a whiner. They don’t believe that it is the job of the federal government to guarantee that everybody has health insurance. Fine – engage the public on that. What they reverse can be reversed again.

On the other hand, they’re not making that argument. They never bring it up. Perhaps they really are running on pure spite – but luckily that spite has just been tempered by the rather dimwitted musings of the man they find that they have to accept as their leader. They can’t do anything that they had planned about Obamacare now. Some good may come of his presidency after all.


About Alan

The editor is a former systems manager for a large California-based HMO, and a former senior systems manager for Northrop, Hughes-Raytheon, Computer Sciences Corporation, Perot Systems and other such organizations. One position was managing the financial and payroll systems for a large hospital chain. And somewhere in there was a two-year stint in Canada running the systems shop at a General Motors locomotive factory - in London, Ontario. That explains Canadian matters scattered through these pages. Otherwise, think large-scale HR, payroll, financial and manufacturing systems. A résumé is available if you wish. The editor has a graduate degree in Eighteenth-Century British Literature from Duke University where he was a National Woodrow Wilson Fellow, and taught English and music in upstate New York in the seventies, and then in the early eighties moved to California and left teaching. The editor currently resides in Hollywood California, a block north of the Sunset Strip.
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