Trump's Big Health-Care Gamble

Why has the president decided to go all in on the Republican insurance plan, and what will he do if it fails?

President Trump meets with the House Republican deputy whip team at the White House on Tuesday.
President Trump meets with the House Republican deputy whip team at the White House on Tuesday. (Carlos Barria / Reuters)

It’s health-care time, and the legislating is not easy. Congressmen are jumping away from the plan, and Tom Cotton is skeptical of the House Republican approach to replacing Obamacare. Thursday morning, the GOP senator from Arkansas tweeted:

Cotton’s declaration is ominous for the bill’s hopes, which were already sagging. The bill has come under fire from multiple conservative factions, and it’s unclear whether it can even pass the House, let alone survive the Senate.

The bill’s precarious status makes President Trump’s approach all the more interesting. At the beginning of the week, Secretary of Health and Human Services Tom Price was cautiously declining to call the proposal “Trumpcare.” But over the last two days, the White House has decided to drive hard, putting as much muscle as it can behind the bill. Trump has met with House Republican deputy whip team. He has been meeting with and courting the bill’s skeptics. He’s promising he can get enough votes to pass the plan. Mike Pence is traveling the country to drum up support, and the president reportedly plans to hit the road soon, as well.

The sudden sprint has encouraged reporters to bring out terms redolent of Trump’s past career: “Trump goes into dealmaking mode,” says The Washington Post. “Trump in ‘sell mode’ on health care,” adds ABC News. The best metaphor might go back to Trump’s days running casinos, though. The president is making a big bet.

One side of the wager is the idea that he has enough political capital to push through some sort of repeal bill. The problem is, as my colleague Russell Berman reports, that Congress has a narrow window in which to push through the new health plan. So what happens if Cotton proves correct, and the bill fails?

According to CNN, Trump has a contingency plan:

In an Oval Office meeting featuring leaders of conservative groups that already lining up against House Republicans' plan to repeal and replace Obamacare, President Donald Trump revealed his plan in the event the GOP effort doesn't succeed: Allow Obamacare to fail and let Democrats take the blame, sources at the gathering told CNN.

Even if that is Trump’s hedge, he’s charting a precarious path, which is premised on his own ability to separate himself from Republicans in Congress.

Actually, every path is daunting. Let’s say that Trump gets Republicans to coalesce around the replacement plans. That could be, as Democrats can well attest from their experience passing the Affordable Care Act in the first place, a dicey proposition. Millions of people, many of them Republican voters in November, would likely lose their coverage or see the price go up. For the first time in its life, Obamacare has a net favorable rating with voters, but it struggled as long as Democrats were in control. Voters seem to hate anyone messing with their health care, even when they don’t like it that much, and will penalize the party that does that.

Now, let’s say that the bill fails, and GOP leaders can’t salvage something. That would certainly be embarrassing for them. The Republican Party has spent the last seven years railing against Obamacare and promising to eliminate it at the earliest chance. Voters have now given them a chance, with unified control of the White House, House, and Senate. As Speaker Paul Ryan put it Thursday, “This is the closest we will ever get to repealing and replacing Obamacare.” How can they justify not getting it done?

One answer is to leave Obamacare in place and let it fail. That plan depends on Obamacare actually failing. While the law would struggle without the marketing the Obama administration put behind it, it’s unclear that it would collapse outright. In any case, the liberal journalist Greg Sargent sees this as an effective strategy:

If the law survives, Trump can spend the next couple of years claiming that it is collapsing all around us—or rather that it continues to collapse, since it is already collapsing as we speak. And Republican voters will of course believe that this is the case, since it is an unshakable truism for them that the law has already failed in spectacular fashion.

Accepting this requires a very cynical view of Republican voters, and of Republican members of Congress, believing that they don’t actually care about repealing the law and that, in the case of the voters, they won’t have been following the news. One lesson of the fights over the debt ceiling in the last few years is that conservative members really care about their priorities, even when misbegotten. One needn’t agree that repeal is good to believe that many Republicans sincerely want to get rid of the law. If the GOP Congress fail in its repeal effort and then just gives up and moves on, it’s reasonable to expect that some of its members will face primary challenges in 2018, and that voters will penalize some of them, though it’s tough to know how deep the impact would be.

Now, perhaps Trump thinks he can separate himself from congressional Republicans and let them take the backlash. He’s not on the ballot in 2018, after all, and he has shown repeatedly that he has little loyalty to the Republican Party except insofar as it is advancing his interests.

That might work, but it might not. If Trump wasn’t busy burning his bridges with Barack Obama, the former president might provide a cautionary tale. Obama decided to push through the Affordable Care Act at the start of his term, at political cost. Trump has opted to make repeal his top priority at the outset, which both marries him to the effort and also means he isn’t notching other political victories. Trump, even more than Obama, comes across as cavalier about his party’s fate in the House, but he will miss it if it’s gone or depleted, just as Obama did.

Trump has always loved big gambles, and they’ve also sometimes blown up in his face. In the business world, he showed a remarkable knack for bouncing back. But the presidency is different, and if his health-care wager comes out poorly, though, he won’t have the option of declaring bankruptcy and laying low for a few years.