Dr. Trump has a diagnosis, and it does not look good for the patient.
"ObamaCare is dead," President Trump told CBS News political director John Dickerson a week ago, when the Republican replacement for the Affordable Care Act was taking heat for putting people with pre-existing conditions at risk of being priced out of the insurance market or shunted into high-risk actuarial quarantines. "I'll tell you who doesn't cover pre-existing conditions: ObamaCare," Trump told Dickerson. "You know why? It's dead." On Sunday, as the GOP's American Health Care Act continued to face pointed questions over pre-existing conditions, Trump repeated his prognosis once more:
This is a catchy, effective line, in a Goodfellas sort of way. And, like something out of a mobster movie script, Trump isn't really stating a fact here, he's making a threat. His GOP allies have been talking a lot recently about "death spirals" and spontaneous implosions, as if the law's looming demise were organic as well as inevitable.
If ObamaCare is dead, it isn't because it died of old age or self-inflicted wounds or even a pre-existing condition. It's because Trump and his party are actively killing it.
There was a time when Trump was pretty transparent about this truth. Before he took office, he openly threatened to let the Affordable Care Act die, arguing that starving the beast would bring Democrats to the negotiating table. And it would be much more politically palatable for Republicans if Democrats helped dismember the hostage. But they have so far declined the invitation.
So, starting on his first day in office, Trump began undermining ObamaCare. He signed an executive order to delay or waive all regulations possible. When Health and Human Services Secretary Tom Price was sworn in, he complied with the order. The Trump administration can't scrap the individual mandate for most Americans to buy health insurance, a key mechanism to keep premiums low, without an act of Congress. But no matter: Trump has said his administration simply won't enforce it.
Trump has also publicly toyed with crippling the ObamaCare marketplaces by withholding billions in promised cost-sharing subsidies that insurance companies use to help pay for insurance for lower-income exchange customers. "ObamaCare is dead next month if it doesn't get that money," Trump told The Wall Street Journal in mid-April. Senate Minority Leader Chuck Schumer "should be calling me and begging me to help him save ObamaCare, along with Nancy Pelosi," he added. They didn't call. Trump promised Democrats he would pay the subsidies for May, as part of a large spending package, but it's unclear if he will continue to make the payments after that.
Trump doesn't even have to actively sabotage ObamaCare to leave his mark.
"What's happened since the Trump administration took power is tremendous uncertainty about the future of the ACA," Larry Levitt of the nonpartisan Kaiser Family Foundation told The Washington Post. All businesses dislike uncertainty, but none more than insurers. After three years, the ObamaCare insurance markets were starting to stabilize, according to health-policy experts, but now they are reeling from the chaos. Insurers were supposed to set their 2018 premiums this month, but with all the changes, they've been given a two-month extension. Amid the uncertainty, "they'll be adding in rate increases ... or get out" of the markets, said Brian Webb, manager of health policy for the national Association of Insurance Commissioners.
Republicans used to boast about their efforts to blow up ObamaCare — and they even had several successes when Barack Obama was president. Their attempts to get the bill thrown out in court largely failed, but when the Supreme Court upheld the individual mandate, it also made expanding Medicaid optional, and many Republican governors took the option not to expand health care in their states.
In December 2014, Sen. Marco Rubio (R-Fla.) and his GOP colleagues quietly helped kneecap "risk corridors" intended to keep insurers in the marketplaces by ensuring that they at least break even, inserting a provision in a massive omnibus spending bill that sharply reduced the amount the government could pay insurers, leading several co-ops to go bankrupt and insurers to leave certain markets. Rubio bragged about it in 2015 during his brief run for president. The lack of insurance options in big parts of some states is Exhibit A in the ObamaCare-is-imploding argument.
It's a neat trick — weeding out competition in the marketplace, calling the law doomed because of a lack of market competition, then promising a fix that will drive down prices thanks to free markets. But it's a sneaky trick, too.
Republicans have every right to try and kill the Affordable Care Act. They have been promising to do so for seven years, and that promise helped them win immense power. But they also used to fashion themselves as the party of personal responsibility — like, say, nudging people to buy private health insurance so they don't waste other people's money in the emergency room. If they are still intent on repealing and replacing ObamaCare, they should own up to their responsibility in bleeding and starving the law — even brag about it. They shouldn't blame its death on suicide or natural causes.
Of course, there was always the other option, too: helping fix the law. Democrats opposed former President George W. Bush's 2003 Medicare Part D prescription drug expansion, but when they took over Congress a little over a year after it took effect, they helped make it work. A decade later, Medicare Part D is alive and popular. ObamaCare is finally popular, but apparently it's too late.
The Affordable Care Act isn't perfect and never was, but the GOP-chosen economists at the Congressional Budget Office just pronounced it stable enough to survive in March, and its ailments are probably nothing that a little TLC wouldn't have fixed — as Democrats, apparently naively, expected would happen. Trump and his party now have the power to snuff it out, and they appear set on doing so. But when Dr. Trump finally gives the cause of death, you should probably ask for a second opinion.