Has Donald Trump spent months secretly crafting a top-to-bottom transformation of our broken health system that will patch up America’s scrapes and bruises and straighten the nation’s teeth? All signs point to no. A week ago, Trump told the Washington Post that he was putting the finishing touches on a new health reform plan that would guarantee “insurance for everybody.” Alas, he offered no details other than to say that his plan would offer “much lower deductibles” and that it would be released very soon. In a detailed account of intra-Republican wrangling over the future of Obamacare, Yuval Levin reports that “the conservative health-care universe, including some people on Trump’s own team, quickly concluded that the separate administration plan he described was entirely a figment of Trump’s imagination.”
Considering it doesn’t exist, Trump’s imaginary health care proposal has accomplished a great deal. For one, it has tempered the enthusiasm of congressional Republicans for unraveling Obamacare too quickly. It’s reminded them that the road to replacing Obamacare is fraught with peril for the GOP, and that “insurance for everybody” is a message that appeals not just to Democrats but to a growing number of Republicans.
First, let’s consider the argument that there is nothing for Republicans to worry about, and that to delay Obamacare repeal would be to play into the hands of Democrats. The basic idea here, perfectly distilled in a recent Wall Street Journal op-ed by Betsy McCaughey, is that Obamacare didn’t really do anything of value, so getting rid of it won’t make much of a difference.
One of the chief political arguments in favor of passing (and now keeping) Obamacare was that millions of Americans faced the prospect of being denied insurance coverage because of pre-existing conditions, and that Obamacare would eliminate that possibility. But according to McCaughey, having a pre-existing condition was only an issue for individuals seeking insurance coverage in the individual market. Since roughly half of Americans (49 percent) are covered by employer-based insurance and another third are covered by Medicare (20 percent) and Medicaid (14 percent), pre-existing conditions were irrelevant for most people. We didn’t need Obamacare to tackle this problem, she insists. Rather, we needed to establish high-risk pools for the small number of people who fell through the cracks. McCaughey argues that while Obamacare premium subsidies will cost $56 billion this year, fully funded high-risk pools would cost something on the order of $16 to 20 billion. Sounds simple, right? Roll everything back to the pre-Obamacare status quo, add some high-risk pools, and you’re good to go.
There is a problem with McCaughey’s line of analysis, however. It’s true that the political case for Obamacare rested in no small part on the fear that pre-existing conditions would render tens of millions of people uninsurable. But the deeper problem, then as now, is that half of U.S. adults have at least one chronic health condition, such as heart disease, cancer, diabetes, and arthritis, among many others. Most people with these conditions can’t come close to covering all of the costs associated with their medical care, which means that other people—family members, employers, or taxpayers at large—have to cover the rest. Yes, the pre-existing condition problem is a relatively narrow one that affects working-age adults who are too young for Medicare, who earn too much money to qualify for Medicaid, and who don’t receive health insurance from an employer, as James Capretta and Tom Miller explained back in 2010. The chronic disease problem, on the other hand, is far broader and more profound, and Republicans ignore it at their peril.
When families are left to bear the financial burden of chronic disease, their economic well-being is endangered, as millions of Americans can tell you based on first-hand experience. As health care costs for employers rise, an ever-larger share of compensation comes in the form of health benefits rather than wages, which partly explains why wage growth has been so sluggish for middle-income workers. Soaring health costs led many employers to drop coverage in the pre-Obamacare era, and they’re the reason why at least some have reduced the work hours of their employees to skirt Obamacare’s employer mandate. What if we let state governments carry the load? When that happens—and it is already happening—spending on other government services, from public education to transportation, gets crowded out. Unlike the federal government, states are constrained by the need to balance their budgets, which is why they’re left to beg for federal bailouts when the economy takes a dive and tax revenues plummet.
One way or another, and whether we like it or not, voters are going to look to the federal government to do something about the cost of chronic conditions. So does that mean Republicans should give up on moving beyond Obamacare? Not at all. But they need to accept that the federal government will always be the payer of last resort for the chronically ill.
There is at least one Republican who understands this instinctively. In his 2000 manifesto The America We Deserve, Donald Trump offered the following riff on universal coverage, which Avik Roy recently quoted on his blog:
I’m a conservative on most issues but a liberal on this one. We should not hear so many stories of families ruined by healthcare expenses. We must not allow citizens with medical problems to go untreated because of financial problems or red tape. … Working out detailed plans will take time. But the goal should be clear: Our people are our greatest asset. We must take care of our own. We must have universal healthcare.
If Trump did have a plan that would offer “insurance for everybody,” what might it look like? It’s hard to say. My suggestion is that he declare an Obamacare truce: Keep the Obamacare exchanges as a safety net for those who need comprehensive coverage and can’t afford it without premium subsidies, but also tweak the law to allow the young and healthy to buy cheap non-Obamacare-compliant plans if they’re willing to go without subsidies. But as I’ve written, it’s not really Trump’s job to come up with detailed policy proposals. His job is to hector Congress into doing his bidding, and shilling for an imaginary health care plan was as good a way as any to get real policy ideas rolling in. Trump is saying, essentially: This is what I want, this is what the American people want, now go figure out a way to do it, and if you don’t, I’m going to call you horrible names on Twitter.