All of Washington is convulsed by the debate over the future of American health care, but the combat is far less about the medical options available to patients than it is about politics, economics – and the emerging character of the Donald J. Trump presidency.
There no longer is any question that the Republican-controlled Congress, with the ardent support of the Trumph administration, is on the verge of bringing the "Obamacare" health-insurance plan to an ignominious end. But larger political questions still are in flux, and their resolutions will reflect tectonic transformations in the American political landscape – and will prompt significant changes in the delivery of health care to Americans as byproducts.
"Politics is having more influence than patient needs," said Allen V. Koop, a Dartmouth College historian of American health care. "Our policies are governed more by who is in power than by a careful assessment of the health needs of Americans, and it's politics rather than treatment procedures that prevails."
Indeed, the fight over the destruction of Obamacare, and the even more baroque debate over the future of American health care, reflect the changed circumstances of Washington politics in the wake of a formidable set of significant events: the emergence of a hard-right faction of Republican lawmakers who generally fall under the umbrella description of the Tea Party; the astonishing triumph of Mr. Trump in the November election; the ascendancy of white working-class voters as the coveted prize of American politics and the engine of the new Trump political coalition; the eclipse of the establishment wing of the Republican Party; and the emerging style of the Trump administration.
The result is a stunning rush to redeem Republican campaign promises to overturn Obamacare and a pre-emptive dismissal of the customary order of congressional politics, which includes a sober reckoning of the costs of pending legislation that, until this month, was considered a best-practices if not a de rigueur preliminary. The zeal to eliminate Obamacare – the hurry to press the repeal through both the House Energy and Commerce and the Ways and Means committees, both ordinarily known for comprehensive, even dilatory, hearings and deliberations – has swept away the formalities that have governed Capitol Hill for decades.
Moreover, the effort to repeal Obamacare and replace it with an alternative fashioned in the House and supported by House Speaker Paul Ryan of Wisconsin reflects another major departure in American political life – a barrier that actually was broken by the Democrats in the Obama years and now simply is being reinforced by the Republicans in the Trump years.
Until Obamacare, every major expansion of American social policy – beginning with the Social Security Act of 1935, but including three major civil-rights acts in the late 1950s and mid-1960s and the creation of Medicare in 1965 – had support from both parties, rendering them American initiatives rather than partisan achievements. The last of those measures, Medicare, was a product of Lyndon B. Johnson's Great Society program that won the support of 70 Republicans along with 237 Democrats in the House; the Senate vote in favour of the measure included 57 Democrats and 13 Republicans.
By contrast, not a single Republican in the House or Senate voted for Obamacare – and not a single Democrat in either chamber will vote to eliminate it. The bipartisan consensus on social policy that prevailed for three-quarters of a century has been eviscerated.
Meanwhile, Washington is witnessing a heretofore unknown side of Mr. Trump, whose art of the deal on the campaign stump consisted largely of random assertions and whose social-media manner on Twitter was more intuition than reflection. His critics have characterized the President much the way the towering 19th century lawmaker Daniel Webster once described his great rival, Henry Clay: "He is irritable, impatient, and occasionally overbearing; and he drives people off."
But in this capital fight Mr. Trump has employed more subtle means, including White House receptions and even a bowling outing.
This new style – you might call it ten-pin diplomacy – has been more courtly than combative, and it has been highly effective. A year ago Mr. Trump was characterizing Senator Ted Cruz of Texas, an opponent for the Republican nomination, as "Lying Ted," and the senator said Mr. Trump was a "snivelling coward," a "pathological liar" and a "serial philanderer" who was "utterly amoral." Last Wednesday night Mr. Cruz, his two daughters and his wife – whom Mr. Cruz said his rival had "slandered" – were at dinner with Mr. Trump at the White House. Catherine Cruz brought along a stuffed giraffe from her kindergarten classroom, and the two girls and the giraffe posed for a photo with the President at his Oval Office desk. Mr. Cruz still retains skepticism about the House measure.
Saturday, Mr. Trump dispatched his Vice-President, Mike Pence, to Kentucky, where the Republican governor, Matt Bevan, and a Republican senator, onetime Trump rival for the GOP presidential nomination Rand Paul, have been vocally critical of the new health-care plan being rushed through Congress. Mr. Pence said the administration needed strong Republican backing to, as he put it, "make sure that the Obamacare nightmare is about to end."
As if the health-care issue were not arcane enough, Republicans remain split over the virtue of using tax credits as part of their new insurance scheme; many conservatives, including Mr. Cruz, are wary of tax credits, regarding them as a form of welfare or an entitlement. Democrats, meanwhile, are arguing that the very blue-collar voters who defected from their party to back Mr. Trump in November will be the biggest victims of the new health-care style.
But nobody can be sure of the consequences, nor of the shape of American health care, in the new era.
"Obamacare started out as insurance reform but it swiftly became something else entirely," said David M. Shapiro, the Florida-based past president of the Ambulatory Surgery Center Association, a member of several accreditation boards and a respected veteran of Washington health-care politics. "We still don't know the effects of Obamacare, and health-care politics is so complicated that the effects of changing Obamacare can't really be anticipated either."