President Trump’s health care gyrations reflect a political fact: he and Republicans have to have a health plan to run on in 2020. Faced with resurgent Democrats touting health care issues, other incumbent Republican presidents have come to exactly the same conclusion.
In 1971, Senator Edward Kennedy, a possible challenger to President Richard M. Nixon, was trumpeting a comprehensive single-payer national health insurance proposal. Nixon struck back with a plan of his own that proposed universal coverage based on a more modest, private-oriented approach. After his reelection, Nixon’s plan went down under the Watergate avalanche.
Similarly, in 1991, President George H. W. Bush was blindsided when a Democrat won an upset off-year senatorial election in Pennsylvania, running on the slogan that if the Constitution guaranteed everyone a lawyer, it should also guarantee them a doctor. A shocked Bush directed his staff to produce a comprehensive health insurance plan to defend against the issue in his 1992 reelection bid. Unfortunately for Bush, his plan was largely unsuccessful, brought down by internal Republican policy disagreements.
Trump is undoubtedly aware from the 2018 midterms that his 2020 health care flank is exposed and, as the saying goes, “you can’t fight something with nothing.” So Mulvaney’s promise that Republicans will have a plan of their own makes perfect sense. But Trump faces even greater challenges than his predecessors in shoring up his health care defense.
First, Trump’s decision to challenge the constitutionality of the increasingly popular Affordable Care Act reinforces entrenched stereotypes of Republicans as callously uninterested in health care issues. Second, he seems to expect Congress to participate in producing the plan he needs, something that congressional Republicans appear either unable or unmotivated to do. Third, and most important, Republicans remain deeply divided on critical issues that must be resolved to produce a credible counter-proposal to the Democratic health care drive.
One core question is whether Trump and his allies can commit squarely to guaranteeing that Americans with preexisting conditions will be able to purchase affordable private health insurance. The so called “pre-ex” issue has caught fire with average Americans and Trump must answer to it.
However, insuring people with preexisting conditions raises thorny ideological issues for the increasingly conservative GOP. Private insurance companies won’t cover the sick with high health care costs if plans don’t enroll large numbers of healthy individuals with offsetting lower costs. Insurance rests on the basic principal that low-risk individuals cross-subsidize the care of high-risk ones. But as experience shows, getting enough healthy people to buy insurance requires either mandating or subsidizing them. Both methods expand government involvement in ways that conservatives find unacceptable.
One approach embodied in previous Republican proposals is to leave it to the states to grapple with this and other coverage issues. But given the reluctance of red states to mandate or pay for the purchase of private insurance, this strategy is unlikely to immunize Republicans against charges that they are leaving millions of Americans with preexisting conditions out in the cold.
Other issues will prove challenging for Trump and the GOP as health care debates sharpen in 2020. Perhaps most critical will be where the president and his party stand on universal coverage, which Democrats have fully embraced. In past decades, Republicans have been willing to support universal coverage in principal, so long as it was attained through expansions of private insurance. With the GOP’s fierce opposition to the Affordable Care Act, it is no longer clear the party believes that all Americans should be able to get affordable health care when they need it. Trump will have to confront this issue as he shapes his health care plan.
So, though Trump’s promise of a Republican health plan makes perfect sense politically, it faces considerable practical and political challenges. He would be well advised not to wait for a fractured and demotivated Congress to take on this task. The administration will have to develop the major contours of its own proposal, as Presidents Nixon and Bush did in the past, and the president himself must decide whether he personally supports coverage for all Americans, and for Americans with preexisting conditions in particular.