President Trump thought he could use his skills as a salesman to bridge a divide in the Republican Party over the bill to repeal and replace Obamacare. There was a problem, though. As the FRONTLINE documentary “Trump’s Takeover” reports, the president didn’t seem to understand or care about the details of the bill he was selling.
“The president was not particularly engaged in the policy details. That was pretty apparent,” Rep. Charlie Dent (R-Penn.) tells FRONTLINE. “The president seemed to defer to Congress, largely, and basically, ‘Whatever you guys pass, I’ll sign.’”
This scene is an excerpt from the new documentary, “Trump’s Takeover,” which goes inside President Trump’s high-stakes battle for control of the Republican Party.
It examines how the president, who vowed to defeat the Washington establishment, has worked to remake the party in his own image — counter-punching when criticized, and publicly attacking Republicans who defy him.
From Trump’s attacks on party leaders on Twitter after the repeal-and-replace bill died, to a split over what many in the party said was the president’s inadequate response to deadly violence at a white supremacist rally in Charlottesville, to when Congress ultimately delivered a major legislative victory for Trump with the passage of tax reform, the documentary traces the president’s takeover of the party, from the perspective of Republican lawmakers.
“Trump’s Takeover” premieres Tues., April 10 at 10/9c on PBS & online: https://to.pbs.org/2GNBtMc
FRONTLINE is streaming more than 200 documentaries online, for free, here: http://to.pbs.org/hxRvQP
Funding for FRONTLINE is provided through the support of PBS viewers and by the Corporation for Public Broadcasting. Major funding for FRONTLINE is provided by the John D. and Catherine T. MacArthur Foundation. Additional funding is provided by the Abrams Foundation, the Park Foundation, The John and Helen Glessner Family Trust, and the FRONTLINE Journalism Fund with major support from Jon and Jo Ann Hagler on behalf of the Jon L. Hagler Foundation.
Medium-size reform creates the conditions for bigger things.
Recent state elections — the Democratic landslide in Virginia, followed by Democratic gubernatorial victories in Kentucky and Louisiana — have been bad news for Donald Trump.
Among other things, the election results vindicate polls indicating that Trump is historically unpopular. All of these races were in part referendums on Trump, who put a lot of effort into backing his preferred candidates. And in each case voters gave him a clear thumbs down.
Beyond offering a verdict on Trump, however, I’d argue that the state elections offered some guidance on an issue that has divided Democrats, namely health care. What the results suggested to me was the virtue of medium-size reform: incremental enough to have a good chance of being enacted, big enough to provide tangible benefits that voters don’t want taken away.
Remember, there was a third governor’s race, in Mississippi, in which the G.O.P. held on. True, Mississippi is a very red state, which Trump won by 18 points in 2016. But Louisiana and Kentucky are or were, if anything, even redder, with Trump margins of 20 and 30 points respectively. So what made the difference?
Personalities surely mattered. Louisiana’s re-elected John Bel Edwards was widely liked, Kentucky’s defeated Matt Bevin widely disliked. Demography probably also mattered. Urban and especially suburban voters have turned hard against Trump, but rural voters haven’t, at least so far — and Mississippi is one of the few states left with a majority-rural population.
But there’s another difference among the three states. Kentucky and Louisiana took advantage of the Affordable Care Act to expand Medicaid, leading to steep drops in the number of uninsured residents; Mississippi hasn’t. This meant that voting Democratic in Kentucky and Louisiana meant voting to preserve past policy success, while the same vote in Mississippi was at best about hope for future reform — a much less powerful motivator.
Back in 2010, as Obamacare was about to squeak through Congress, Nancy Pelosi famously declared, “We have to pass the bill so that you can find out what is in it.” This line was willfully misrepresented by Republicans (and some reporters who should have known better) as an admission that there was something underhanded about the way the legislation was enacted. What she meant, however, was that voters wouldn’t fully appreciate the A.C.A. until they experienced its benefits in real life.
It took years to get there, but in the end Pelosi was proved right, as health care became a winning issue for Democrats. In the 2018 midterms and in subsequent state elections, voters punished politicians whom they suspected of wanting to undermine key achievements like protection for pre-existing conditions and, yes, Medicaid expansion.
And this political reality has arguably set the stage for further action. At this point, as far as I can tell, all of the contenders for the Democratic presidential nomination are calling for a significant expansion of the government’s role in health care, although they differ about how far and how fast to go.
Which brings me to the latest development in intra-Democratic policy disputes: Elizabeth Warren’s proposal for a two-step approach to health reform. Her idea is to start with actions — some requiring no legislation at all, others requiring only a simple Senate majority — that would greatly expand health insurance coverage. These actions would, if successful, deliver tangible benefits to millions.
They would not, however, amount to the full Bernie, eliminating private insurance and going full single-payer. Warren still says that this is her eventual intention, and has laid out a plan to pay for such a system. But any legislative push would wait three years, giving time for voters to see the benefits of the initial changes.
Sanders supporters are, predictably, crying betrayal. For them it’s all or nothing: a commitment to single-payer has to be in the legislation from Day 1.
The trouble with such demands, aside from the strong probability that proposing elimination of private insurance would be a liability in the general election, is that such legislation would almost certainly fail to pass even a Democratic Senate. So all or nothing would, in practice, mean nothing.
But is Warren giving up on Medicare for All? After all, what she’s offering isn’t really a transition plan in the usual sense, since there’s no guarantee that Step 2 would ever happen.
The lesson I take from the politics of Obamacare, however, is that successful health reform, even if incomplete, creates the preconditions for further reform. What looks impossible now might look very different once tens of millions of additional people have actual experience with expanded Medicare, and can compare it with private insurance.
Although I’ve long argued against making Medicare for All a purity test, there is a good case for eventually going single-payer. But the only way that’s going to happen is via something like Warren’s approach: initial reforms that deliver concrete benefits, and maybe provide a steppingstone to something even bigger.
Provisions in the Affordable Healthcare Act will give insured American women better access to basic care. How much do you currently pay for contraception? What difference will the new rules mean?
Many basic healthcare options for US women, including birth control and annual “well-woman” check-ups, become free on Wednesday as provisions in the Affordable Care Act come into force.
The new rules mean that many women will no longer have to stump up for “co-pays” or out-of-pocket expenses.
Donald Trump’s government has issued a ruling that allows employers to opt out of providing free birth control to millions of Americans.
The rule allows employers and insurers to decline to provide birth control if doing so violates their “religious beliefs” or “moral convictions”.
Fifty-five million women benefited from the Obama-era rule, which made companies provide free birth control.
Before taking office, Mr Trump had pledged to eliminate that requirement.
The mandate requiring birth control coverage had been a key feature of so-called Obamacare – President Obama’s efforts to overhaul the US healthcare system.
But the requirement included a provision that permitted religious institutions to forgo birth control coverage for their employees.
The Department of Health and Human Services (HHS) said on Friday it was important to expand which organisations can opt out and deny free contraceptive coverage.
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“We should have space for organisations to live out their religious ideas and not face discrimination because of their religious ideas,” said one HHS official, who did not wish to be named.
Why was the decision made?
In announcing the rule change, HHS officials cited a study claiming that access to contraception encourages “risky sexual behaviour”.
The department disputes reports that millions of women may lose their birth control coverage if they are unable to pay for it themselves.
Like prior versions, the latest version of the bill from Senators Bill Cassidy and Lindsey Graham to repeal and replace the Affordable Care Act (ACA) would cut federal funding for health coverage for the large majority of states over the next decade (see Table 1). And the cuts would grow dramatically in 2027, when the bill’s temporary block grant (which would replace the ACA’s Medicaid expansion and marketplace subsidies) would expire and its Medicaid per capita cap cuts would become increasingly severe. We estimate that in 2027 alone, the bill would cut federal health care funding by $298 billion relative to current law (see Figure 1), with the cuts affecting all states.
In fact, starting in 2027, Cassidy-Graham would likely be even more damaging than a straight repeal-without-replace bill because it would add large cuts to the rest of Medicaid — on top of eliminating the Medicaid expansion — by imposing a per capita cap on the entire program. The Congressional Budget Office (CBO) has previously estimated that the repeal-without-replace approach would ultimately leave 32 million more people uninsured. Cassidy-Graham would presumably result in even deeper coverage losses than that in the second decade as the cuts due to the Medicaid per capita cap continue to deepen.
- Eliminate the ACA’s Medicaid expansion and ACA’s marketplace subsidies in 2020 and replace them with an inadequate block grant. Under our estimates, the block grant would provide about $239 billion less between 2020 and 2026 than projected federal spending for the Medicaid expansion and marketplace subsidies under current law, with the cut reaching $40 billion (16 percent) in 2026. The block grant would not adjust based on changes in states’ funding needs, and it could be spent on virtually any health care purpose, with no requirement to offer low- and moderate-income people coverage or financial assistance. And, as noted, the block grant would disappear altogether in 2027.
- The enormous cut in 2027 reflects two factors. First, the block grant would disappear in 2027. The bill’s sponsors have claimed that the rules that govern the budget reconciliation process, which allows the bill to pass the Senate with only 50 votes, necessitated that the proposed block grant be temporary. In reality, however, nothing in those rules prevents the bill from permanently funding its block grant. Furthermore, the expiration of the temporary block grant would create a funding cliff that Congress likely couldn’t afford to fill. Even if there were significant political support for extending the inadequate block grant in the future, budget rules would very likely require offsets for the hundreds of billions of dollars in increased federal spending needed for each additional year.
The basic economics of U.S. health care makes that easier said than done. Before the ACA, the U.S. stood out from the international pack on health care in two very unpleasant ways. First, it spent a far larger share of gross domestic product on health care. Second, it was the only advanced industrial nation that left vast swaths of its population uninsured. These two doleful facts remain true, although the fraction of Americans without health insurance fell from 13.3% in 2013 to 8.8% in 2017, according to Commerce Department data.
There are several ways to get more people covered. One is to adopt a system in which the government provides or pays for universal coverage—the British or Canadian model. This won’t happen soon in the U.S., not even as Medicare for All.
A second route, advocated unsuccessfully by President Clinton in 1993, is to mandate that every employer provide health insurance to its workers. This approach might seem natural in the U.S. context because so many workers already receive health insurance that way. But the employer mandate has fatal flaws. It wouldn’t cover the nonworking population, and it would impose heavy burdens on small businesses.
For these and other reasons, many economists in the Clinton administration—including me—favored an individual mandate. But that idea was dead in the water in 1993 because it had been advocated by the Heritage Foundation starting in 1989. It was therefore a “right wing” idea.
There are problems with an individual mandate, too. For one, the high cost of U.S. health insurance means that many low- and moderate-income families cannot afford to buy policies on their own. For another, if for-profit insurance companies are made to lose money by covering people with pre-existing conditions, the government must also force young healthy people, who tend to have limited medical expenses, into the insurance pool.
Fortunately, both problems are easily solved—conceptually, that is, not politically—by mandating that everyone buy a policy and providing subsidies to the needy. Massachusetts legislators understood this in 2006. They also knew they were not writing on a blank slate; many citizens received health insurance through their jobs and didn’t want to lose it. Hence the hybrid system that became known as RomneyCare.
If this short description reminds you of the ACA, it should. The two plans are not identical twins, but there is a family resemblance. In 2010 Democrats didn’t follow in the footsteps of Romney Republicans to make them look good; they designed their plan that way because under the constraints of precedent, the underlying logic practically forces you there.
Keep that in mind: If there ever is a TrumpCare, an unlikely proposition, it’s bound to resemble RomneyCare and ObamaCare—no matter what the president claims.
A surprise move by the Trump administration aimed at striking down the Affordable Care Act thrust the partisan battle over health care into the middle of the 2020 campaign on Tuesday, handing Democrats a potential political gift on an issue that damaged Republicans badly in last year’s midterm elections.
In a new court filing, the Justice Department argued that the ACA, also known as Obamacare, should be thrown out in its entirety, including provisions protecting millions of Americans with preexisting health conditions and allowing young adults to stay on their parents’ health-care plans.
President Trump praised the move during a lunch with Senate Republicans, and suggested the GOP should embrace a new congressional battle over health-care policy ahead of the 2020 elections.
“Let me tell you exactly what my message is: The Republican Party will soon be known as the party of health care,” he told reporters before the lunch. “You watch.”
.. Trump spent much of his time at the Senate lunch talking about health care, according to several senators present.
“If there’s a message to be learned from 2018 on policy, it’s health care,” Sen. Lindsey O. Graham (R-S.C.) told reporters after the lunch Tuesday. “Let’s become the party of health care.”
“He thinks that that’s the one area where we’ve fallen short and he wants to see us address it,” said Sen. John Neely Kennedy (R-La.). “He made that very clear.”
“If you’re a Republican thinking about 2020 right now, you want to be on offense on health care, not defense,” she said. “And the only way to do that is to make the focus on what Democrats want to do — on Medicare-for-all — rather than making it on what the president and the White House are suggesting.”
.. A federal judge in Texas ruled in December that the law’s individual mandate “can no longer be sustained as an exercise of Congress’s tax power” and further found that the remaining portions of the law are void. He based his judgment on changes to the nation’s tax laws made by congressional Republicans in 2017.
.. “It is highly unusual for the Department of Justice not to defend duly enacted laws, which the Affordable Care Act certainly was,” Collins said. “This decision to even go more broadly in failing to defend the law is very disappointing.”
.. “I think Obamacare should be gone,” he said. “We’ve got to cover people with preexisting conditions apart from Obamacare, which is what I talked about a lot.”
.. There would be ripple effects throughout the health-care industry and insurance landscape as well. Those with workplace plans could be affected, as employers would be allowed to scale back certain medical benefits, and people with preexisting conditions buying coverage on their own would no longer be guaranteed access to coverage at no extra cost.