Wednesday, March 15, 2017

Trumpcare and the Lost Art of Governing

In spite of what the Republicans have been telling us for the past 25 years, government is not an evil to be feared and avoided. To the contrary, government is hardwired into our Constitution as the means by which we promote our general welfare and maintain a civilized, democratic society. There can and should be healthy debates about the appropriate size and scope of government. Such debates, which otherwise are known as "governing," ideally involve bringing intelligence, integrity, and skill to solving societal problems through a rational process that allows for consideration and reconciliation of different viewpoints. When held to that standard, the Republicans' Trumpcare proposal, which suffers from the mutually reinforcing problems of being ill-conceived and virtually unvetted, isn't an example of governing but rather a mockery of it.

After categorically criticizing Obamacare for seven years, it turns out the Republicans did not actually have an alternative to it. It seems they didn't see the need for one until Mr. Trump unexpectedly won the presidency after promising to "repeal Obamacare and replace it with something great." House Republicans then hastily drafted something behind closed doors, which they now want to enact even more hastily without any meaningful consideration of the bill's potential human and economic consequences and without any regard for the views of citizens, the health care and insurance industries, and other experts.

Apparently, fulfilling their campaign promise to rid us of Obamacare is more important to them than the substance of what they are doing. House Speaker Paul Ryan all but admitted this on Sunday, when he said that if Republicans fail to repeal and replace Obamacare then they will be breaking a campaign promise to their voters. Perhaps they will, but if what they replace Obamacare with destabilizes health insurance and health care markets and negatively affects wide swaths of the American public, including in many cases their own constituents, then they will be betraying the public trust. That is a fate far worse than breaking a campaign promise, but they appear to either not understand this or not care. By prioritizing fulfillment of their campaign promise over substantive results and due process, their behavior ranges from merely hypocritical to downright reckless.

First the sheer hypocrisy. After all their criticism of Obamacare as a complete disaster, their proposed replacement essentially adopts the basic Obamacare framework, only without some of the key elements that are necessary to sustain it. After Mr. Trump's promise of "healthcare for everyone," the nonpartisan Congressional Budget Office estimates that the Trumpcare proposal would not expand coverage but rather strip existing coverage from 24 million Americans over 10 years. After criticizing Democrats for rushing passage of Obamacare -- a claim that was thoroughly debunked in yesterday's Washington Post Fact Checker -- they propose to go from having no bill to having an enacted law in a matter of weeks, virtually ignoring the "regular order" of legislative process that traditionally applies to a proposal of this magnitude.

Then there's the substance of their proposal. What they seek to accomplish in this bill is not only reckless but also cruel.

Mr. Ryan says that the Trumpcare plan will allow people to choose the level of coverage that is right for them, which implies that some people will be free to not buy coverage at all. Indeed, Trumpcare would replace the Obamacare coverage mandate with a penalty that would be assessed when a person signs up for coverage after letting it lapse, which would likely incentivize younger and healthier people to postpone purchasing insurance. Their absence from the insurance pool would be expected to drive premiums up for those who do participate. Moreover, Mr. Ryan apparently has forgotten that having uninsured people, voluntary or otherwise, is what brought the health insurance and health care markets to such a problematic state in the first place. Uninsured people, even those who are young and appear healthy, nonetheless sometimes get deathly ill and have accidents. When they do and can't afford their care, the cost is shifted to the rest of us. Mr. Ryan's underlying assumption that people should be free to remain uncovered (or undercovered) and the incentives Trumpcare provides for them to do so are therefore reckless.

A further implication of Mr. Ryan's logic is that all those who opt out of coverage will do so by choice. As details of the bill emerge, most notably the CBO estimate, it is increasingly clear that millions of people who want and need coverage, including many who now have coverage because of Obamacare, will not be able to afford coverage under Trumpcare. Trumpcare would replace need-based subsidies with flat tax credits based on age, increase the premium surcharge insurers could charge older people, gut the Medicaid expansion that helps the needy, and give a tax break to the wealthy, who would no longer be asked to chip in to assist the less fortunate. In combination this would effectively redirect the assistance now received by older, sicker, and poorer people to richer and healthier people who have a lesser need. This sets a new bar for legislative cruelty. It also falls abysmally short of Mr. Trump's promise to provide good health care for everybody, but he nonetheless inexplicably appears prepared to push for the bill's swift enactment.

In sum, as several commentators have already noted, Trumpcare is essentially a tax cut for the rich masquerading as a health care bill. If you ever wondered which segment of their base the Republican leadership really cares about, this bill should remove all doubt.

Not surprisingly, numerous affected constituencies oppose the current Trumpcare proposal. Within the health care establishment, critics include the American Medical Association, the American Hospital Association, the American Nurses Associations, and the American Academy of Pediatrics. The AARP is opposed. Conservative Republican lawmakers and media outlets are opposed on the theory that it is too much like Obamacare and still represents a government entitlement. On the other hand, more moderate Republican lawmakers, including a number of US Senators and governors, have expressed particular concern about the proposed gutting of the Medicaid expansion. Democrats oppose the bill because it throws the baby out with the bathwater instead of identifying and addressing the gaps and flaws in Obamacare.

Mr. Ryan's apparent intent to rush the bill through the House in spite of these objections is arguably worse than the problematic content of the bill. Legislation expected to have significant national consequences ordinarily is preceded by preliminary hearings and meetings with stakeholders to help lawmakers understand the issues. Once lawmakers craft a bill that takes this preliminary input into account, there then are hearings and meetings about that specific bill. The goals of this stage are to develop a full understanding of the bill's likely consequences should it become law and identity desirable changes. Only after a reasonable period of study and analysis does a bill proceed to amendment by relevant committees and the full chamber.

This process of regular order serves at least two important purposes. First, it enables both the lawmakers and their constituents to assess and weigh in on the merits of the proposal in reasonable time to influence it. Second, it lends legitimacy to the ultimate product. Even if you don't like a final law, it is much harder to argue with it when it was produced through a transparent, thorough, and fair process. Both of Mr. Obama's signature legislature achievements, Obamacare and the Dodd-Frank Act, were the product of such a process. In each case that process took many months, because understanding a significant and complicated problem and crafting a sound response takes time.

Trumpcare, by contrast, was written with little in the way of outside input. According to the Washington Post fact checker mentioned above, there were a handful of general subject matter hearings that preceded drafting of the bill, but that is inadequate for an issue of such complexity and a bill of such consequence. Moreover, there were no hearings to examine the actual text of the bill, and two committees rushed to mark it up within days of its release. Without the benefit of legislative hearings and other traditional forms of outside input, those markups were little more than charades. In his continued push to go the House floor as quickly as possible, Mr. Ryan told his troops that the bill he has proposed is their last and only chance at enacting health care reform, which indicates that he is not interested in significant amendments to his proposal let alone alternative approaches. This is a reprehensible way to handle a proposal that would have such wide-ranging effects on human health, health insurance and health care markets, and the economy more broadly.

To be clear, Obamacare is far from perfect. It was an important first step toward 100% insurance coverage and better health care, but very real challenges remain regarding participation levels, participation cost, and access to care. These very real problems deserve thoughtful, thoroughly vetted solutions. The Trumpcare proposal doesn't even pretend to be a coherent solution to these problems; if anything, it appears designed to make them worse.

One hopes the Senate, which thankfully includes a handful of Republicans who are at least as interested in the longer-term consequences of their actions as they are in scoring quick public relations points, will save us from this slapdash proposal. In a best case scenario, they reject Trumpcare, admit that Obamacare, which after all began as a Republican idea, is a reasonable but imperfect approach, and work in good faith to address the shortcomings of the current law. If that occurs, then there will be some hope that the art of governing -- and it is an art -- has not been entirely lost. If instead Mr. Ryan's Trumcpare proposal carries the day and becomes law in short order in spite of considerable objection, then the art of governing will have been abandoned. Once the consequences of such a miscarriage of public duty become apparent to the governed, it will be long past time for the Republicans who so callously forced this damaging plan upon us to go.

*This blog post consists solely of the view and opinions of its author.