the national interest

Why Trump Thinks Passing a Terrible Health-Care Bill Makes Sense

Donald Trump, selling the Republican health-care plan. Photo: Bill Pugliano/Getty Images

Almost every great vote-wrangling drama in Congress, especially on a high-profile issue in the first year or two of a new presidency, is eventually reduced to a simple test of strength. Like a bad war, the original objective falls by the wayside and is replaced by the conviction that defeat will lead to a collapse of all credibility. This dynamic has defined the Republican push to pass the American Health Care Act, perhaps more than any other legislative set piece in memory.

President Trump can barely muster any enthusiasm at all for the bill. His public defenses are vague and grudging, and he is reportedly even less keen in private. “He is tired of seeing it criticized on TV,” one source tells Politico. What fires up Trump’s passion is not the bill itself, but the prospect of winning. “A loss is not acceptable, folks,” he reportedly told a caucus meeting.

Rather than advocate for the alleged benefits of the bill — if anybody even alleges them any more — Republicans have staked their case on a series of reasons unrelated to its direct effects on the health-care system:

1. They promised. “We made a promise and now it is the time to keep that promise,” says Paul Ryan. “If we keep that promise, the people will reward us. If we don’t keep our promise, it will be very hard to manage this.”

It is true that Republicans have promised for seven years to repeal Obamacare, which they have described to their base as irredeemably evil. At the same time, Republicans made other promises: to provide affordable coverage to everybody, including people with preexisting conditions, and with lower premiums and lower deductibles. “Nobody will be worse off financially,” promises Tom Price.

Overpromising is common for politicians. But Republicans didn’t merely stretch the truth. They have promised something diametrical to their actual agenda. Republican plans would reduce coverage subsidies, foisting people onto cheaper plans with much higher deductibles. All the while, they promised the precise opposite. Whatever they do, they are going to break their promises.

A related argument maintains that Republicans would somehow take the blame for the status quo if they failed to pass the bill. “I’m optimistic that none of my members in the end want to be responsible for the status quo on Obamacare,” says Mitch McConnell. Of course, Republicans will be held responsible for the status quo regardless of whether they pass a health-care bill.

2. Losing will embolden our enemies. “[Trump] told us if we don’t pass this bill on Thursday, it will put everything in jeopardy that he wants to do, his agenda,” Republican Representative John Duncan of Tennessee told The Hill. “If we are not able to move forward with health-care reform, it endangers tax reform,” Representative Bill Flores of Texas, a former chairman of a House conservative caucus, tells Sahil Kapur. “The folks that were able to tear this down would feel like they’re empowered to tear the next big project down.” This is, essentially, the domino theory of legislation. But, really, think about it rationally: The folks who are tearing down Trumpcare are fellow Republicans in Congress. If Trumpcare fails, are they going to turn against tax cuts?

3. But think of the tax cuts! The manic drive to pass the health-care bill follows from a legislative strategy that was designed to culminate in a huge tax cut that would not have to be phased out after a decade. Republicans continue to insist health reform must be passed for this reason.

The trouble with this argument is that, for reasons I’ve explained before, the strategy is hopelessly overambitious. In a nutshell, Republicans want to repeal Obamacare and the taxes that finance it in order to enable their next big tax cuts to appear “revenue-neutral.” But their strategy also requires passing a border-adjustment tax, which is supposed to provide a trillion dollars they can use to offset the costs of the big tax cuts for rich people that they crave. But that tax is wildly complex and enormously controversial among Republicans in Congress and stands almost no chance of enactment.

So, if and when this strategy fails, they’re going to give up on passing a revenue-neutral tax “reform” and instead pass a huge tax cut that doesn’t bother pretending to be revenue-neutral. And when that happens, it won’t matter whether or not they have already repealed the taxes that finance Obamacare. They’ll look back and wish they hadn’t bled time and political capital on a reach goal that they wound up abandoning anyway.

4. We’ll lose Congress if we fail. “If we get this done, and tax reform, [Trump] believes we pick up ten seats in the Senate and we add to our majority in the House,” says Republican Representative Chris Collins of New York. “If we don’t get it done, we lose the House and the Senate.” Trump has reportedly emphasized the same point to his party.

It is a bit strange to argue that a party can consolidate or even expand its base of support by passing a deeply unpopular bill. To be sure, if Republicans believe that the public has simply been misled about its bill, and will like the result once it has been enacted, they might have reason to think a vote could help them in the long run. But it is almost impossible to find a policy advocate of any ideological persuasion who believes that. The GOP plan does create some beneficiaries: Very wealthy people will enjoy lower taxes, and some healthy, high-income people will get lower insurance premiums. But many millions of people will lose their coverage or face enormous premium hikes. And those people are disproportionately Republican. So if House Republicans do pass the bill, they’ll take a hit in public opinion for backing a highly unpopular piece of legislation, and then, down the road, a much larger hit as the real-world consequences of their vote take effect.

The AHCA is the fruit of a failed strategy. The law’s design was dictated by a legislative schedule that initially assumed Republicans would simply defund Obamacare, move on to tax cuts, and return to health care at their leisure later on. They have instead been forced to craft an actual health-care bill on a manic time frame, using a legislative mechanism that is not designed for major social legislation. Like people leading a country into a losing war, they demand to push on and invent new reasons to justify the cost, because they can imagine nothing worse than admitting they failed.

Why Trump Thinks Passing a Terrible Health Bill Makes Sense