Trump: Maybe we can amend ObamaCare instead of repealing and replacing it

I remember reading somewhere in September, during Trump’s brief “softening” phase on immigration, that one possible explanation for his tentative change of heart on mass deportation is that he tends to repeat whatever the last advice was that was whispered in his ear. He had met with his Hispanic Advisory Council shortly before that and they had made the pitch to him that comprehensive reform is a winner. Trump seemingly decided to run the idea up the flagpole in his interviews that week to see how it flew. If so, that could explain this surprising hedge on ObamaCare, which is numero uno on the right’s legislative kill-list next year. Except this time the guy whispering in his ear was … Barack Obama.

Amended ObamaCare will be the best ObamaCare, that I can tell you.

Mr. Trump also showed a willingness to preserve at least two provisions of the health law after the president asked him to reconsider repealing it during their meeting at the White House on Thursday

Mr. Trump said he favors keeping the prohibition against insurers denying coverage because of patients’ existing conditions, and a provision that allows parents to provide years of additional coverage for children on their insurance policies…

On health care, Mr. Trump said a big reason for his shift from his call for an all-out repeal was that Thursday meeting at the White House with the president, who, he said, suggested areas of the Affordable Care Act to preserve. “I told him I will look at his suggestions, and out of respect, I will do that,” Mr. Trump said in his Trump Tower office.

“Either Obamacare will be amended, or repealed and replaced,” Mr. Trump said.

Let’s be fair. Many Republican pols, not just Trump, have said over the years that they’d like to keep the “good parts” of ObamaCare — although that usually involves including them in whatever replaces O-Care after it’s repealed, not keeping the law in place and amending it. Like it or not, as a matter of pure symbolism, righties would chafe at the idea of amending it even if that approach is more likely to win Democratic support. They want Obama’s legacy obliterated and that starts with repeal, even if some ideas driving the current law end up being reinstituted in the new program. The two “good parts” of the law worth keeping that are typically named by Republicans are the two Trump identified, compulsory coverage for preexisting conditions and the right of young adults to stay on their parents’ insurance until they’re 26. Not coincidentally, both are popular with the public. The sick get covered and the young, who might be struggling to find work, get covered. Like the man said, he’s not gonna let people just die in the street.

But … what if I told you that policies involve trade-offs, and that the “good parts” require “bad parts” to pay for them? That’s been the left’s defense of ObamaCare since day one. You like coverage for preexisting conditions? That’s nice — but if you want to pay for it, you need the individual mandate. Only by forcing people to buy insurance, especially healthy young people who won’t cost much to insure, will you generate the revenue stream needed to pay for treatment for the very sick. Gotta take the bitter with the sweet. Relatedly, one of the reasons ObamaCare’s costs are soaring is because there are too many under-26ers using mom’s insurance instead of being forced into the marketplace to buy their own. That lost revenue forces insurers to make up the difference somewhere, which means higher premiums for everyone else. If you want to stabilize the law fiscally, kicking the under-26 crowd off their parents’ insurance and into the pool with the rest of us would help do that. But that’s unpopular, so we haven’t and probably won’t.

The preferred GOP alternative to mandates in paying for coverage of preexisting conditions is to subsidize high-risk pools at the state level. Paul Ryan likes the idea, and various states tried it out before O-Care was passed. But there were problems:

High-risk pools “are basically targeted welfare, which is a lot better approach than distorting entire markets with mandates and price controls,” argued Dean Clancy, a policy consultant at Adams Auld, and a former senior health policy advisor to congressional Republicans and the George W. Bush administration.

But there are widespread doubts about the viability of high-risk pools. A December 2014 Commonwealth Fund study concluded that the pools are not a workable alternative to the ACA’s rules for covering those with pre-existing conditions because they are prohibitively expensive to administer, the coverage is too expensive for consumers, and they offer skimpy benefits. The report predicted that a switch to high-risk pools would result in higher state and federal costs, fewer people with coverage, and plans that don’t meet the medical needs of those with chronic conditions

Holtz-Eakin acknowledged that effective high-risk pools would be expensive and tricky to design, and many Republicans wouldn’t like having billions of dollars of their cost passed on to taxpayers. “But you have to subsidize the care of these individuals,” he said. “You can make the case that we’re spending a lot on the ACA for not good effect, so let’s spend it instead on high-risk pools. There’s no way around it.”

“Sometimes the pools got so expensive for states that they had to impose waiting lists for coverage,” noted a recent Kaiser Health News report. You can see how this is likely to go politically if the GOP replaces O-Care with that. Either the high-risk pools will be very lavishly funded to address some of the problems they had in their previous pre-ObamaCare incarnations, which will alarm fiscal conservatives, or they’re likely to end up being more expensive and less comprehensive for the very sick, which will generate lots of attack angles for the left. A president who’s devoutly fiscally conservative might be willing to take that heat in the name of budget discipline. A president who’s not as devout might not. If the left hits Trump with a barrage of studies showing that his program might make it more likely that people will “die in the street,” or at least not enjoy benefits as lucrative as Barack Obama gave them, what does he do with that information? He’s supposed to be the hero of blue-collar America, the guy who won’t touch entitlements because he’s looking out for the little guy. The little guy with a genetic illness has to make do with worse coverage from Trump than what he got from Obama?

Hey. He said all along he’s a dealmaker. Soon we’ll find out what “the best deals” look like in practice. Your exit quotation comes from Newt Gingrich, hedging on another signature Obama policy: “He’ll spend a lot of time controlling the border. He may not spend very much time trying to get Mexico to pay for it. But it was a great campaign device.”