When Donald Trump was elected President of the USA, some of those shocked at the result urged incumbent Barack Obama to renounce the usual practice of disappearing from the scene, and allowing the successor space to govern. Stay and fight! They urged. There was even a lunatic plan to draft him as speaker of the House (the speaker does not have to be a member of Congress). Obama made it clear that he would be around, but was planning on taking a long holiday first.
He’s still on holiday, but he’s also around — with the failure last week of the Republican effort to “repeal and replace” the Affordable Care Act, or Obamacare. The American Health Care Act — variously nicknamed “Trumpcare” or “Ryancare” but not with any enthusiasm — was DOA last week, with House speaker Paul Ryan pulling the vote before it even hit the House. That is a major defeat, since the Republicans currently enjoy a stonking 50-seat-plus majority there. Passage through the Senate was always going to be trickier — even with a straight up-down vote, the Republicans could only afford to lose two of their own votes, assuming a total Democratic “no” vote — but to lose it before getting to the House was deemed unthinkable last year.
The problem was — well, the problem was everything about the bill itself. The Affordable Care Act — or the “Kenyan Health Care Act” as some dubbed it retroactively when Ryan’s American Health Care Act was tabled — was more than a year in the making, and had decades of research-hours behind it. Whatever problems it has as a viable, long-term, healthcare funding system, and there are many, its political impact was exactly what was hoped for it. Millions of Americans now have health insurance they could not previously afford, but wanted — something to lose.
The Republicans knew that, and they also knew that there was a cognitive dissonance among some of their supporters, especially those who use Medicaid, the low-income government health scheme, which was expanded under Obama. Trump constructed Obamacare, in his campaign, as something that was destroying America — “when we get rid of it, it’s going to be so beautiful”, at the same time as many of his supporters doubted he would remove it, least of all provisions such as forcing insurance companies to insure people with pre-existing conditions.
The so-called “Freedom caucus” of the Republican Party — the old Tea Party caucus plus other elements — wanted an immediate repeal, arguing that the free market, sorry ferrmark — would step in and guarantee affordable care for all, magically reversing their cartelised conduct of decades. Moderates wanted protection of provisions that Trump had guaranteed would be preserved. “No one’s going to die in the street,” he had said, which many took to be a wider commitment to universal care.
The resulting compromise, written over three weeks, pleased no one. It sharply raised take-up and transfer costs between insurers, which would have reduced the uptake of insurance by healthy young people, thus destroying the “pool” balance that Obamacare had established. To compensate, it proposed to allow for differential pricing between aged and young, up to a multiple of three-to-five times, which would have driven many of the aged middle-low income out of insurance (Medicare, the over-65 plan, only covers part medical costs). On top of that, it proposed to reduce Medicaid funding, and make them block grants to states, which would simply allow them to reduce state spending and cut costs.
The plan was, in other words, three interlocking “death spirals” of costs, relinquishment, and underfunding, and estimates of the number of people it would drive out of healthcare over a decade or so ranged from 10 million to 30 million. The ferrdum caucus hated its retention of Obamacare regulations; the moderates hated the effect it would have on the ground.
The failure is monumental, and being shared around among everyone. Ostensibly, the effect on Trump should be severe. The man who was going to do things quickly, efficiently, straightforwardly, through the art of the deal, has had a worse failure than the Clinton healthcare bill debacle of 1994 (which at least got to a vote — even though it had no chance). The process looks like government as usual. The furrdum caucus is being blamed for intransigence, the moderates for not getting behind a republican President, and Paul Ryan blamed for drafting a terrible bill.
But, of course, it was always going to be a terrible bill — once a simple repeal was taken off the table. Conspiracy theories abound. Did Ryan do the bidding of Trump and the furr(dumm)ies in order for them to have a very public defeat? He could have dug in and insisted that he would not even consider bringing any bill to the floor unless at least six months of drafting and consultation had gone into it. But that would have made him the bad guy, and his speakership may well not have survived the gap. Nor may it yet. Having despatched John Boehner in 2015, in favour of the Ayn-Rand-quoting Ryan, the furr(dumm)ies are in no mood to be blocked again.
Yet what complicates matters for the Republicans is that the idea of a “right” and “moderates” within the party is a misleading oversimplifcaition. Since the victory of Trump and the Breitbart team that attached themselves to him, the Republicans have two rights. The right in Congress is small-government, market-oriented; those round Trump are nationalists, who believe that small-government economics is a fetish, which has impoverished America and led it to fall decades behind, industrial and militarily.
Trump, who spent the weekend following the healthcare defeat playing golf — or, as Fox News put it, “working in the White House” — now says he wants to, in typical style, move on from healthcare to tax, infrastructure and “the wall”. What effect that will have on his support is difficult to say. So much of his hardcore supporters’ fandom has nothing to do with actual policies; while many of the middle-ground supporters who won him the rust-belt states never wanted him to touch Obamacare anyway.
With the chaos of this political failure, encroaching investigation of his campaign’s links with Russia, his wild accusations that Obama bugged Trump Tower, and now, that Hillary was in the pay of the Russians ([email protected]&!?), there is the perpetual sense that the whole show is about to collapse. That is a sentiment in part based on the intensity of the chaos, a feeling that none of us will be able to bear this sort of insanity for four years; it’s also based, in part, on a transfer of a sense of politics transferred from the Westminster system, which has a way to deal with the insanity. But neither captures the full implications of the US system. Unless Trump is impeached (in the House), and tried and convicted (in the Senate, by a two-thirds majority), all he has to do to is to keep breathing, if he wants to be President.
Sorry, Vice-President. Obama is still President, to judge by last week’s debacle, which has left Obamacare firmly in place.