Affordable Care Act

The GOP's Obamacare Repeal Bill Is Dead Because Trump Doesn't Understand How Health Policy Works

It's hard to make a deal on a policy deal when you don't care about the policy.


Nobody knew health care could be so complicated!
Molly Reilly/SIPA/Newscom

The House bill to partially repeal and replace Obamacare is officially dead.

The American Health Care Act (AHCA), which was scheduled for a vote this afternoon, has been pulled from consideration. The move means that GOP's years-long quest to repeal and replace the health care law has failed. For the foreseeable future, at least, Obamacare will stay on the books.

President Trump stumped for the bill aggressively over the last several weeks, and White House Press Secretary Sean Spicer said today that the president "left everything on the field when it comes to this bill." But in the end Trump couldn't make it happen.

The GOP legislation was ill conceived from the start. Partly as a result of the need to follow a special process that would allow the bill to pass with a simple majority in the Senate, it left much of Obamacare's essential structure in place—including insurance regulations, subsidies paid through the tax system for individuals purchasing coverage on the individual market, and a mandatory penalty, assessed by insurers, for those who go without coverage and seek to regain coverage.

The bill would have transformed Medicaid into a per-capita block grant system, but not until the next decade, and in its initial form would have created incentives for states to expand the health program. It also would have resulted in individual insurance premiums rising 15 to 20 percent in the short term, and some 14 million people losing their insurance as of next year, according to the Congressional Budget Office. A final amendment to the bill, released late last night, might have sent the individual market into a complete and immediate meltdown.

The bill failed in part because it could not establish a balance between the concerns of moderate Republicans, particularly with regard to the way it treated the Medicaid expansion, and more conservative members of the House Freedom Caucus, who argued that the bill was too much like Obamacare, retaining its core scheme of subsidies and regulations.

But it also failed because Trump proved himself an ineffective negotiator and dealmaker—one whose preference for shallow political victories over substantive policy wins ultimately proved insufficient in a complex policy negotiation.

Throughout his life, Trump has portrayed himself as a master dealmaker. As far back as 1984, for example, he argued that the U.S. government should let him manage the nuclear arms negotiations with Russia. "It would take an hour-and-a-half to learn everything there is to learn about missiles," Trump, who on the campaign trail did not know what the nuclear triad was, told The Washington Post at the time. Trump has never been focused on details. The deal itself was always more important than what was in it.

As House Republicans moved towards a vote on the health care bill, GOP lawmakers characterized his role similarly. This week, in advance of meetings with Republicans who opposed the bill, Rep. Patrick McHenry (R-North Carolina) called Trump "the closer." Final support for the bill would be won by Trump, who would use his skills as a dealmaker to push it over the finish line.

Trump repeatedly promised to repeal and replace Obamacare with "something terrific." But he never described the policy mechanisms of the replacement he preferred. And the outcomes he described—coverage for everyone, lower premiums, no changes to Medicaid—had little or no connection to the bill that House Republicans eventually drew up.

That didn't seem to matter to the president. As has always been the case with Trump, making a deal—any deal—was all that mattered.

In the end, though, the bill died. Trump couldn't close the deal. And one of the biggest reasons that Trump couldn't close the deal is that he didn't understand or care about the details.

There was little evidence that Trump understood the bill, or that he cared much about what was in it.

"[Trump] is more interested in a win, or avoiding a loss, than any of the arcane policy specifics of the complicated measure, according to a dozen aides and allies interviewed over the past week who described his mood as impatient and jittery," The New York Times reported today.

Trump spent the last two weeks selling the House plan. He met with specific individuals and with various congressional factions opposed to the bill. He personally called the offices of more than 100 legislators. He has cajoled and threatened, telling those who refused to back the legislation that they would lose their seats. He threw the entire weight of his personality and the office of the president behind the vote, saying that he backed the bill "one-thousand percent."

But he never took the time to explain to either the public or congressional Republicans what the bill actually did. He did not make a case for the bill's policy merits, preferring instead to describe it using generic superlatives. Contrast that with President Obama, who traveled the country making the case for his health care overhaul, and made a major prime time address outlining its provisions.

Trump, in contrast, was, by virtually all accounts, indifferent to the policy content of the bill so long as it passed and he could say that he had fulfilled his promise to repeal and replace Obamacare.

Even that claim, however, would have glossed over important details. The bill only repealed parts of Obamacare, and it left many of its fundamental assumptions about the nature of health policy firmly in place. If anything, it made those assumptions even more difficult to upend by giving them bipartisan cover.

The bill Trump backed made no attempt to balance either the policy or political interests of the legislators, influence groups, or stakeholders involved. Trump spent the week negotiating changes to the bill, but because he neither cared nor understood what was in it, and what lawmakers wanted from the bill, he couldn't act as an effective negotiator. A handful of last minute updates to the bill intended to pick up holdout votes backfired: One reduced the bill's projected deficit reduction, while another was so imprecisely drafted that it ran the risk of killing the individual insurance market entirely, while leaving the federal government in control of the regulations it was supposedly devolving to states.

Trump, of course, shares some blame with Speaker of the House Paul Ryan. Ryan led the drafting of the bill, and the legislative process. The bill he put together didn't really make sense, in large part because it was never really a health policy bill. The AHCA was a setup for tax reform designed to make it easier to permanently cut taxes in a future piece of legislation.

But it was Trump who managed the negotiations. It was Trump who was expected to seal the deal. And it was Trump who ultimately couldn't make it work.

Health policy is hard because all of the policy pieces are interconnected. The various policy pieces, meanwhile, are just as interconnected with the politics, which is just as complex. You can't separate any of it, and adjusting any one part of the system inevitably means a cascade of additional adjustments will be necessary further down the line. It's a system of trade-offs, and Trump didn't know or care what those trade-offs were.

This is the danger of a president who is so disinterested in policy particulars, especially when, like Trump, he expects to maintain a central role in the process. Trump's character—his personal style and his habits of mind—prevent him from effectively negotiating complex legislation. And in this case, it meant that even with control of the White House and both chambers of Congress, Republicans couldn't put together an Obamacare repeal bill that could pass, or was worth passing. It's a problem that is likely to continue to haunt conservative policy goals for as long as Trump is president.

Trump didn't care about the details. But health policy is all details. And it turns out it's hard to make a policy deal when you don't understand the policy.