If there was any doubt that Donald Trump and Paul Ryan are now fully conjoined, Trump’s visit to Capitol Hill on Tuesday morning resolved it. After the President tried to cajole and bully the Republican icongressmannto voting for their leaders’ controversial plan to replace Obamacare, Ryan praised Trump lavishly, saying he “came here and knocked the ball out of the park . . . in explaining to our members how it’s important to unify, how it’s important to work together, how we are advancing our principles and we are doing what we told the American people we would do.”
It’s no mystery why Ryan was so expansive. A President who campaigned as an insurgent and a new type of Republican is staking his Presidency on a piece of legislation that reflects the long-established priorities of conservative G.O.P. ideologues. For seven years now, House Republicans and their wealthy donors have been desperate to repeal the Affordable Care Act, which established the principle of universal coverage, and came with new taxes that hit the country’s top earners. To the likes of Ryan and Tom Price, who is now Trump’s Secretary of Health and Human Services, the A.C.A. amounted to a new entitlement program, one that, over the years, was likely to get bigger and bigger. The only solution was infanticide: the A.C.A. had to be killed before it was fully grown.
After Trump won the election, there were still some reasons to doubt whether Ryan and Price would get what they wanted—or, at least, whether they would get it this quickly. To be sure, Trump promised to repeal the A.C.A. during his campaign. But he also promised to renegotiate trade agreements, rebuild America’s decaying infrastructure, construct a wall across the southern border, crack down on Wall Street, and reduce taxes for corporations and the middle class.
As with any incoming President, the key question during the transition was what priorities Trump would set once he took office. Prioritizing trade, the wall, infrastructure, and tax relief would have been consistent with the image he established of himself as a nationalist, a builder, and a populist. But today, two months after the Inauguration, health care is front and center. Practically everything else—renegotiating NAFTA, confronting Chinese mercantilism, the trillion-dollar infrastructure plan, comprehensive tax reform—has been placed on the back burner.
How did Trump get himself into this position? Two days after the election, he said that his Administration would have “A lot of really great priorities . . . We’re looking very strongly at immigration. We’re going to look at the borders, very importantly. We’re looking very strongly at health care and we’re looking at jobs. Big league jobs.”
It was Ryan, in early December, who publicly pushed health care to the top of the list. “Well, the first bill we’re going to be working on is our Obamacare legislation,” he told CBS’s “60 Minutes.” “We want to make sure that we have a good transition period, so that people can get better coverage at a better price.” By the start of this year, Trump had adopted the Ryan timetable, ignoring warnings that he might be making a huge mistake. On January 10th, he told the Times that he wanted to repeal and replace Obamacare straight away, saying, “We have to get to business.”
Since Trump didn’t have a health-care reform plan of his own, or anything that resembled one, his decision to make replacing Obamacare his first priority also amounted to a decision to outsource the job to Ryan. The Speaker had a plan ready, albeit one that clearly violated a pledge Trump made to provide insurance for all—a promise he repeated as recently as mid-January. Still, something always beats nothing. Ryan’s regressive blueprint became the basis of the bill that Trump endorsed and that the House plans to vote upon on Thursday.
Even now, it isn’t entirely clear why Trump and his advisers went down this route rather than, say, first demanding tax reform and an infrastructure bill, which they could have co-branded as a jobs program. Were they responding to polling after the election that showed health care was a priority for voters? Did they think targeting Obamacare immediately was necessary to get Republicans to support the rest of their agenda? Did Ryan sucker Trump?
Whatever the answer is, going all in on health care was a high-risk strategy. Even if the House passes its bill on Thursday, its prospects in the Senate are uncertain. Republicans can afford to lose just two votes in the upper chamber. Already, four G.O.P. senators have said that they don’t support the current bill, and more opposition may be on the way. A number of Republican senators are rightly concerned that the bill will reverse Obamacare’s expansion of Medicaid, which has provided health insurance to millions of low-paid and poverty-stricken Americans. Ryan tried to assuage some concerns by introducing some amendments to the bill earlier this week—but they won’t put an end to these concerns.
If Ryan’s bill goes down, it would be a grave embarrassment for Trump, but, in the long term, enacting the legislation could be much more damaging. According to a tally of recent polling by Five Thirty Eight’s Nate Silver, about thirty per cent of Americans support the G.O.P. bill, and forty-seven per cent oppose it. Even among self-identified Republican voters, who make up about a third of the electorate, there are reservations. In a survey by YouGov, forty-nine per cent of Republicans said that they favored the G.O.P. bill, twenty per cent said that they opposed it, and thirty per cent said that they weren’t sure. Just fifteen per cent of Republicans said that they strongly favored the proposal.
These figures could change, of course. But how likely are they to get better for Trump? According to the Congressional Budget Office, the G.O.P. legislation, in its unamended form, would raise premiums in the individual insurance market by up to twenty per cent over the first couple of years. About fourteen million people would lose their coverage almost immediately. (The C.B.O. hasn’t fully scored the amended bill, but experts say the changes wouldn’t make much of a difference to these figures.)
During the transition to a new system, which would inevitably be somewhat chaotic, dry numbers like these would be converted into real people. There would be stories of the sick and the old and the poor—some of them Trump supporters—getting priced out of coverage. And Trump, despite his obvious distaste for the label “Trumpcare,” would have his name on the legislation once he signed it into law.
Either he is oblivious to the dangers or he is putting on a brave face. “Big day for healthcare,” he tweeted on Wednesday morning. “Working hard!”