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What the Trump administration can learn from Obama

From the January ACP Internist, copyright © 2017 by the American College of Physicians

By Robert B. Doherty

Whenever there is a presidential election, it brings with it new priorities and policies. This is especially so when the election results in a change in which political party controls the White House and/or Congress.

In 2008, when President Obama was elected and rode into office along with a new Congress controlled by the Democrats, it signaled a shift in health care policy, from then-President George W. Bush's more incremental approach to closing gaps in coverage (e.g., creation of the Medicare Part D prescription drug benefit) to a wholesale overhaul of health care, with the goal of extending coverage to everyone and regulating insurance practices that denied coverage to people with preexisting conditions. This change in priorities and polices ultimately culminated in the enactment of the Affordable Care Act (ACA) in 2010; in the years since then, the ACA has extended health insurance coverage to 22 million people, driving down the uninsured rate to the lowest ever.

Now, with the election of Donald J. Trump and continued GOP control of Congress, we are entering a time when we will again see new priorities and policies, and as under President Obama, a major emphasis will be a wholesale overhaul of health care. The difference is that President-elect Trump and the congressional leadership want to repeal the ACA and replace it with a conservative market-based alternative.

The details of a GOP replacement plan still need to be determined, and Congress and the Trump administration may give themselves a couple of years to figure something out, while putting an expiration date on as much of the ACA as possible. The eventual alternative likely would greatly scale back federal subsidies to buy coverage, eliminate benefit mandates and the requirement that people buy coverage, ease preexisting condition regulations on the insurance industry, and give states more control over Medicaid with fewer federal dollars. Independent experts believe that as a result, many millions of people will lose coverage. Some (particularly younger adults) may benefit from lower premiums, although the plans available to them will probably have less comprehensive benefits than those required by the ACA. Older and sicker patients would likely face higher premiums.

President-elect Trump and the GOP Congress would be well advised to take some lessons from the Obama administration. As one example, they should be careful in assuming there is a broad mandate to overhaul health care. President Obama ran in 2008 partly on a pledge to achieve universal coverage, but this was just one of many reasons most people voted for him (the collapsing economy was a bigger factor). When he tried to deliver on his promise, he found that many people really didn't want anything that would shake up their choice of health plans or doctors.

President-elect Trump emphasized repeal of “Obamacare” in the waning months of his campaign, but this too was one of many reasons that people voted for him, with trade, the economy, immigration, and terrorism probably mattering more. And unlike President Obama, who won over 50% of the popular vote, Mr. Trump lost the popular vote to Hillary Clinton by more than 2.5 million ballots cast, and his Electoral College advantage in the four states that swung the election to him was fewer than 80,000 votes at last count.

It is hard to claim a broad mandate for ACA repeal when millions more votes were cast for the candidate who promised to keep and expand it. And the most recent postelection polling by the Kaiser Family Foundation shows that only 26% of voters want the ACA completely repealed, and even among Republicans, barely over 50% favor repeal, down from 69% in October. Many more people prefer to keep it, expand it, or scale it back, not get rid of it. The point isn't to suggest that the new president won't try to come up with a conservative alternative as promised, only to recommend caution in assuming that this is what most voters really want.

Once you overhaul health care, you own it. Changes in health care financing, regulations, insurance offerings, and cost controls create winners and losers. Some people will pay more, others less. Some will find that they have access to more affordable plans, others less access. This is why the ACA has never been particularly popular. Although over 20 million gained coverage, and many more benefited in other ways (e.g., from the ban on annual and lifetime limits on coverage), others paid higher taxes or premiums, or penalties because they didn't buy a qualified plan, and about 4 million people were forced in 2013 to buy new insurance plans because they didn't meet the ACA's requirements. Remember the headlines about people losing their plans and the backlash against President Obama for not keeping his promise that “If you like your insurance plan, you can keep it”? Well, multiply that at least fivefold and you can imagine the political headaches ACA repeal will create for the GOP if people lose coverage or end up having to choose from inferior plans.

Agreeing on a replacement will be difficult. Even with solid Democratic majorities in Congress and some overall idea of how they wanted to change the health care system (income-based subsidies to buy coverage, expansion of Medicaid, bans on insurers from excluding or charging more to people with preexisting conditions), President Obama and Congress struggled to agree on a plan. It ended up taking some 15 months before Congress coalesced around what became the ACA. The idea that the GOP can come up with a quick and easy plan to replace the ACA is just not realistic. It is going to be a hard slog, not a sprint.

Finally, if Congress passes an overhaul solely with the votes of one political party, it guarantees that members of Congress from the other party won't come to their rescue when things go wrong (and they will) and will instead oppose the overhaul at every opportunity. Republicans railed when the Democrats used budget reconciliation to pass the ACA without a single GOP vote, yet the GOP seems ready to do the same to repeal the ACA. While turnabout may seem like fair play, it inevitably comes with a huge political cost.

I don't really expect the new administration and Congress to take lessons from President Obama's health care overhaul. But consider the possibilities: If President Trump and the GOP were appropriately cautious in assuming a voter mandate for ACA repeal, tried to avoid disrupting how people get coverage, and took the time needed to come up with a plan that could win Democratic votes, wouldn't the outcome be far better, not just politically for them, but for the American people?

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