How the public, bad process and a disengaged president killed Trumpcare

President Donald Trump speaks in the Rose Garden at the White House after the House pushed through a health-care bill in May. Jabin Botsforth | The Washington Post

Trumpcare seems to be dead, but what killed it? Three dynamics mattered, including President Trump himself.

First, the public strongly opposed all versions of Trumpcare and vocally said so.

Every poll showed that the House and Senate versions of Trumpcare were deeply unpopular. As time went on, Obamacare got more popular and tended to poll at least twice as strongly as Trumpcare.

The reason for Trumpcare’s unpopularity was simply that the bill didn’t do what the public wanted.

Americans want more and better coverage. Trumpcare would have delivered less and worse coverage.

Medicaid was a lot more popular than Trumpcare advocates thought. It’s deeply embedded in the United States.

The parents of medically needy kids opposed Medicaid cuts as did the children of parents in nursing homes.

But public opinion mattered because people were vocal. They organized and they spoke up. Opposition cut across party lines because the law would affect so many people in real ways.

In Maine, Sen. King and Rep. Pingree opposed Trumpcare from the start. Sen. Collins heard the public when she marched in the Fourth of July parade in Eastport and when they visited and called her office.

In red states where Mr. Obama and Democrats remain highly unpopular, the law’s reach into American lives could not be denied. This was true for communities ravaged by the opioid crisis, which health care money helped treat; for rural states where hospitals had become all but dependent on increased Medicaid payments that covered the bulk of their patients; and for poor constituents with chronic medical conditions who had come to take it as an article of faith that their insurance companies could not deny them coverage for pre-existing conditions.

Senator Susan Collins, Republican of Maine, said she was besieged by constituents who urged her to oppose the Republican plan: a conservative Republican who was worried about the impact on her grandson, who has cystic fibrosis; a small-business owner in a town where the hospital depends on Medicaid for more than 60 percent of its revenues and is the second-largest employer; a working single mother and her 9-year-old daughter who, for the first time in the girl’s life, were both able to get affordable insurance. [source]

In contrast, Rep. Poliquin, who voted for Trumpcare, cut out the public and stopped up his ears. He also misled by lowballing the number of Maine people who would lose coverage.

Second, Trumpcare failed because the process excluded experts and stakeholders.

A decision was made by Republican leaders to write a bill in secret and then try to push it through. This was very different from the process used to pass Obamacare.

While this seems to have been done in order to prevent resistance from organizing, it meant legislators didn’t use a good process as an opportunity to build support from the public and to craft a bill that had been vetted by experts and that stakeholders would support.

The result was a lousy bill cutting coverage for tens of millions and a lack of support from patient groups and hospitals, all of which could point to the damage Trumpcare would cause. Their opposition hurt the bill among the public, some of whom look to groups and experts for cues, and some legislators.

Coverage about lies about the bill’s effects — as Sec. Price and Vice-President Pence did — created a backlash among people who followed policy details. Pence caused damage by lying to governors (and especially about Ohio) at the National Governors Association.

Third, Trumpcare failed because Trump was a disengaged president who didn’t understand health policy and never tried to sell the bill to the public.

There has never been a time when Trump said more than vague generalities about health policy, not during the campaign and not since. He didn’t run on a plan and he didn’t engage once in office. That made it very hard for Trump to get anything passed.

The history of health politics shows that one needs an engaged president working with Congress to pass major legislation.

That’s what happened when Lyndon Johnson passed Medicare and Medicaid. It’s also what happened when Obama passed the Affordable Care Act.

Interestingly, when the president drives the legislation pretty much alone — as Bill Clinton did — that doesn’t work either. But that wasn’t the issue this time.Trump never engaged and still shows little understanding of the policy and process.

That and Trump’s very poor job approval ratings bode poorly for Trump’s ability to pass other major legislation.


Amy Fried

About Amy Fried

Amy Fried loves Maine's sense of community and the wonderful mix of culture and outdoor recreation. She loves politics in three ways: as an analytical political scientist, a devoted political junkie and a citizen who believes politics matters for people's lives. Fried is Professor of Political Science at the University of Maine. Her views do not reflect those of her employer or any group to which she belongs.