Sunday, November 20, 2016

Maybe the Democrats Should Help Trump Abolish Obamacare

Andrew Koppelman

One area of common ground between President-elect Donald Trump and the Congressional Republicans is that they’re both eager to do away with Obamacare.  Trump just has one little proviso: he doesn’t want to get rid of the protection for preexisting conditions.  More generally, he doesn’t plan to take health insurance away from 20 million people.  For years, he has said that he supports universal coverage.  He wants to replace Obamacare with “something terrific.”

That means there’s a potentially huge gap between him and Republicans who want radically constrict coverage.  He wants to be able to say he destroyed Obamacare, but he also can’t screw the millions of working class voters – many of whom are already benefitting from the Obamacare subsidies – to whom he owes his election (and who, he hopes, will vote for him again).

That creates a political opportunity for those of us who don’t like letting people die or be bankrupted by treatable diseases.

I’m not thrilled that Trump will be President.  I was depressed about it for days.  But the man is too mercurial to confidently forecast that he will be a disaster.  It is of course no great blessing to have a President who is a stupid, ignorant, habitual liar.  On the other hand, he isn’t an ideological Ayn Rand libertarian, because he isn’t an ideological anything.  Ideology is beyond him. 

If he finds that the Democrats are the only ones who offer him a path to benefit his voters, then he could be persuaded to follow that path.  Obama himself has said that all he really cares about is universal coverage, and that if the Republicans “can come up with something better that actually works, a year or two after they’ve replaced the ACA with their own plan, and 25 million people have health insurance and it's cheaper and better and running smoothly, I'll be the first one to say that's great.”

Obama’s huge achievement, an achievement that may last, is the extension of coverage to a huge population that was previously uninsured.  (That was the principle that the Supreme Court health care case was really about.)  In order to accomplish that, Obama had to make lots of nasty compromises with lots of nasty interests.  Those were worth it at the time: the political opportunity to expand coverage was unlikely to come again.  But the nasty details can and should be revisited.  There are of course lots of ways in which a revision could end up hurting consumers.  That’s why the Democrats ought to be at the table when the details are worked out. 

There have been some Republican suggestions for an Obamacare overhaul that doesn’t diminish coverage.  The Republicans are split on the coverage question, though.  Paul Ryan likes having lots of uninsured people:  “I’d go back to the pre-Obamacare baseline . . . we shouldn’t assume we’re going to have an explosive entitlement and then just replace it with our own.”  (Quoted in Philip Klein, Overcoming Obamacare:  Three Approaches to Reversing the Government Takeover of Health Care 87 (2015).)  Ryan’s political judgment leaves something to be desired:  he appears to be dumb enough even to try to privatize Medicare.  Some Republican proposals could reduce costs, and they certainly would make it easier for individuals to remain uninsured if that is what they want.  But they would also take coverage away from millions.

If Trump isn’t willing to do that – if he’s really willing to insist on universal coverage - then on this issue, maybe we can be friends. 

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