Is Trumpcare finally dead? Even now, it’s hard to be sure, especially given Republican moderates’ long track record of caving in to extremists at crucial moments. But it does look as if the frontal assault on the Affordable Care Act has failed.
And let’s be clear: The reason this assault failed wasn’t that Donald Trump did a poor selling job or that Mitch McConnell mishandled the legislative strategy. Obamacare survived because it has worked – because it brought about a dramatic reduction in the number of Americans without health insurance, and voters didn’t and don’t want to lose those gains.
Unfortunately, some of those gains will probably be lost all the same: The number of uninsured Americans is likely to tick up over the next few years. So it’s important to say clearly, in advance, why this is about to happen. It won’t be because the Affordable Care Act is failing; it will be the result of Trump administration sabotage.
Some background here: Even the ACA’s supporters have always acknowledged that it’s a bit of a Rube Goldberg device. The simplest way to ensure that people have access to essential health care is for the government to pay their bills directly, the way Medicare does for older Americans. But in 2010, when the ACA was enacted, Medicare for all was politically out of reach.
What we got instead was a system with a number of moving parts. It’s not as complex as all that – once you understand the basic concept of the “three-legged stool” of regulations, mandates and subsidies, you’ve got most of it. But it has more failure points than, say, Medicare or Social Security.
Notably, people aren’t automatically signed up for coverage, so it matters a lot whether the officials running the system try to make it work, reaching out to potential beneficiaries to ensure that they know what’s available, while reminding currently healthy Americans that they are still legally required to sign up for coverage.
You can see this dependence on good intentions by looking at how health reform has played out at the state level. States that embraced the law fully, like California and Kentucky, made great progress in reducing the number of the uninsured; states that dragged their feet, like Tennessee, benefited far less. Or consider the problem of counties served by only one insurer; as a recent study noted, this problem is almost entirely limited to states with Republican governors.
But now the federal government itself is run by people who couldn’t repeal Obamacare but would clearly still like to see it fail – if only to justify the repeated, dishonest claims, especially by the tweeter-in-chief himself, that it was already failing. Or to put it a bit differently, when Trump threatens to “let Obamacare fail,” what he’s really threatening is to make it fail.
On Wednesday, The New York Times reported on three ways the Trump administration is, in effect, sabotaging the ACA (my term, not The Times’). First, the administration is weakening enforcement of the requirement that healthy people buy coverage. Second, it’s letting states impose onerous rules like work requirements on people seeking Medicaid. Third, it has backed off on advertising and outreach designed to let people know about options for coverage.
Actually, it has done more than back off. As reported by The Daily Beast, the Department of Health and Human Services has diverted funds appropriated by law for “consumer information and outreach” and used them instead to finance a social media propaganda campaign against the law that HHS is supposed to be administering – a move, by the way, of dubious legality. Meanwhile, the department’s website, which used to offer helpful links for people seeking insurance, now sends viewers to denunciations of the ACA.
And there may be worse to come: Insurance companies, which are required by law to limit out-of-pocket expenses of low-income customers, are already raising premiums sharply because they’re worried about a possible cutoff of the crucial federal “cost-sharing reduction” subsidies that help them meet that requirement.
The truly amazing thing about these sabotage efforts is that they don’t serve any obvious purpose. They won’t save money – in fact, cutting off those subsidies, in particular, would probably end up costing taxpayers more money than keeping them. They’re unlikely to revive Trumpcare’s political prospects.
So this isn’t about policy or even politics in the normal sense. It’s basically about spite: Trump and his allies may have suffered a humiliating political defeat, but at least they can make millions of other people suffer.
Can anything be done to protect Americans from this temper tantrum? In some cases, I believe, state governments can insulate their citizens from malfeasance at HHS. But the most important thing, surely, is to place the blame where it belongs. No, Mr. Trump, Obamacare isn’t failing; you are.