President Donald Trump has achieved his first major legislative success this week with the passage of health care reform in the House. The bill faces an uncertain future in the Senate and is no one's idea of a perfect solution to repealing and replacing Obamacare. But it's a start. The biggest challenge to actually getting a law in place, however, may be the president, who keeps promising more than he can deliver. Like President Barack Obama's promise to Americans in 2010 -- "If you've got a doctor that you like, you will be able to keep your doctor" -- President Trump's assurance that coverage for pre-existing conditions in the GOP bill will ensure that no one gets knocked off the rolls is a bit of a stretch. Yes, pre-existing conditions will be eligible for coverage, but not necessarily at the same price those with current individual coverage now pay.
The laws of economics -- not necessarily the GOP -- are the problem. Republicans aren't being honest and upfront. They need to explain why no law could fix the current problems with Obamacare without allowing insurers to adjust premiums to recognize that some individuals are more expensive to insure than others. Will fewer people end up uninsured under the GOP proposal as it stands? Probably, though over time the hope is that as the insurance market adjusts, more options will be available for plans that cover at least costs for catastrophic events at a price individuals can afford.
Politicians don't want to admit that you can't cover everyone, including people who are very sick already, without the price of insurance going up for everyone. That was one of the major defects in Obamacare. Yes, the Democrats succeeded in mandating that individuals buy insurance and employers provide affordable options to full-time employees, which expanded coverage and mandated benefits, but it also caused insurers in many states to opt out of the market and made premiums rise faster for many people who were already covered. Without federal subsidies, the system collapses. Cynics believe that the Obama administration knew its program would fail but thought that would make it easier to convince the American people that the only solution would be a single-payer, government-funded health care system, which Democrats have been pushing for decades. But the public has been less enthusiastic.
Unfortunately, this White House is not in a position to make a case to the American people because the president has been all over the place in the debate and, more importantly, seems not to understand the issue or policy specifics well. That leaves House Speaker Paul Ryan as the main advocate, but he comes across as too wonky and in the weeds to make the best case. We'll see which GOP senator emerges as the spokesperson on this issue, but most are wary of wading into the fray.
"Repeal and replace Obamacare" has been the mantra of the GOP for so long now -- since 2010 -- it's a bit surprising the party hasn't invested more time and energy in figuring out how to explain the issues to the American people in ways they can grasp quickly. It begins with admitting that any plan that expands coverage is likely to cost more, especially if young, healthy people can't be persuaded to buy in. It would also help if the party admitted that some health care costs should be borne by individuals out of pocket, just as we expect individuals to pay for routine maintenance on other insurable things, such as cars and homes, especially if they are able to afford it. People also need to understand that their behaviors affect their health, and bad eating habits, smoking, drinking and illicit drug use raise health risks and should raise premiums accordingly. Like cigarette taxes, an unhealthy lifestyle tax on premiums might even encourage individuals to change their patterns.
But elected officials need to make the case to their constituents why such changes are needed. Unfortunately, they won't. Instead, they'll make promises they can't possibly keep and wonder why voters no longer believe anything they say. "Yes, premiums will be coming down," President Trump said from the Rose Garden on Thursday. "Yes, deductibles will be coming down." And when they don't, the GOP in 2018 will be in the same place Democrats were in 2010, facing big losses in the midterm election.