Donald Trump has finally discovered that health policy isn't easy. Speaking to reporters yesterday, he shared his revelation. "It's an unbelievably complex subject. Nobody knew that health care could be so complicated."
Nobody knew! Nobody, except, perhaps, President Obama, congressional legislators, health insurance executives, hospital administrators, doctors who manage practices, individual humans trying to navigate the system, or literally-in-the-Joe-Biden-sense anyone who has ever interacted with American health care in any way whatsoever. The complexity of both the health care delivery and policy is the defining aspect of the system.
On the one hand, Trump's statement is yet another reminder of both his deep aversion to specific policy knowledge, and his habit of describing any new piece of knowledge or understanding he gains as a unique personal revelation.
At the same time, it also reveals the very real problem that Republicans are encountering as they attempt to repeal, replace, and reform Obamacare. The policy issues are complex, and the politics are, if anything, even more complicated, and the interaction between the two creates an additional layer of complexity that Republicans have yet to really solve.
Just to take one example: One of the biggest parts of Obamacare was an expansion of Medicaid. A 2012 Supreme Court decision gave states a choice about whether to expand the program, which provides coverage for the poor and disabled, and 31 states said yes. A full repeal, or even a repeal of all the spending in the law, would roll back that expansion.
But Trump himself has repeatedly promised not to touch Medicaid, one of the nation's biggest entitlements. And just this weekend, Trump's Treasury Secretary, Steve Mnuchin, also said that the administration's budget plan won't touch entitlements. And as Trump found out at a meeting with state governors over the weekend, lots of governors, including some Republicans, are wary about rolling back or Medicaid as well. Hospitals, which get a lot of money from the Medicaid expansion, have also pushed for caution when it comes to repeal. And that's just the inside-Washington forces.
In any case, if Trump agreed to a full repeal of Obamacare, he would be going back on his promise to not cut entitlements, and if he agreed to leave some version of the Medicaid expansion in place, he would be reneging on his promise to repeal Obamacare. Trump has stayed away from embracing any specific plan so far, allowing him to maintain this contradiction. But at some point, he'll have to make a decision.
Of course, a full repeal isn't really what's on the table. That's because Republicans are planning to use the reconciliation process to repeal the law, and that process only allows them to touch provisions with a non-trivial budgetary impact. That means that the subsidy spending and the mandate can go, but the rules prohibiting insurers from discriminating against people with preexisting conditions stay on the books.
Now, there are some reasonably strong arguments that the GOP could repeal the law's insurance regulations through the reconciliation process if they wanted to. As the Mercatus Center's Charles Blahaus recently pointed out, the Congressional Budget Office has said in the past that those provisions have a clear budgetary impact. In theory, Republicans could use this as evidence when making the case for including the repeal of those rules. At the very least, they could try. But so far they haven't.
One problem is that those regulations are among the most popular parts of the law. Another related problem is that Trump said after the election that he wants to preserve Obamacare's preexisting conditions protections. Even some Congressional Republicans are on board. GOP Sen. Chuck Grassley recently told a townhall questioner that, "There are a lot of consensus in Washington that the one issue that you brought up — pre-existing conditions — should not be changed."
Trump and his top advisers have also said that he wants to preserve coverage for everyone who currently has it under Obamacare, but the GOP plans currently being drafted wouldn't do that. And even if they eventually led to a system with roughly equivalent coverage numbers, there would be a huge amount of short-term disruption.
These sorts of difficulties are why the repeal effort has bogged down, and why Republican leadership is, according to a Wall Street Journal report, now intent on holding a vote on the reconciliation bill, and essentially daring their fellow Republicans to oppose it. That's a high-risk strategy, because there isn't much margin for error: The GOP can sustain just two defections in the Senate, and 22 in the House, so any sizeable opposition could derail the plan. In fact, it may already have been derailed: Last night, Rep. Mark Meadows, who heads the House Freedom Caucus, has said his faction cannot support the current legislative draft. Presuming no support from Democrats, the bill won't survive without them.
The interlocking complexity of the system is one of the reasons that Obamacare is such a frustrating law: It built on top of an already-labyrinthine system that had been created and modified over years, and it was crafted and influenced by an array of factions with competing interests.
It's also why, with Trump's big address to the joint Congress looming, some Republicans are now looking to Trump to guide them out of this mess. "The president can play a major role in endorsing a plan he wants to sign into law, and I think it's absolutely essential that he takes a lead role," Rep. Chris Collins told Politico. Given Trump's near total lack of engagement with the various policy mechanisms and trade-offs involved, I wouldn't raise expectations too high. Even if he does endorse some specifics in his speech, it's always possible he'll reverse himself.
In any case, though, Trump's essential point is right: Health care is indeed complicated. And not only is it complicated, Trump's inconsistent and uninformed statements on the matter have made it even more so.