Health-Care Reform and Trumpism - The New Yorker
Before Donald Trump came along, there was a lively debate in the Republican Party over the best way to appeal to working-class voters. Mitt Romney’s loss in 2012 energized a faction of conservatives who modestly proposed that a plutocrat running on a message of upper-income tax cuts and deregulation had little to offer voters who were struggling economically. The leading thinkers of the Reformicons, as these conservatives called themselves, included the conservative pundits Yuval Levin, James Pethokoukis, and Ramesh Ponnuru. They argued that “neo-libertarians,” who were too close to the G.O.P.’s wealthy donor class and were obsessed with a Reagan-era agenda, had taken over policymaking in the Republican Party. While the neo-libertarians favored comprehensive immigration reform, further reductions in taxes on the wealthy, and attacks on the welfare state, the Reformicons pointed out that restrictionist immigration policies might help American workers more, that cuts in tax rates were no longer crucial, and that many government programs should be reformed, not ended.
In the 2016 Presidential primaries, the only Republican candidate who came close to this view of the world was Donald Trump, who offered a cartoon-like version of the Reformicon agenda. Trump repeatedly promised that he would not touch Social Security and Medicare. He proposed by far the most restrictionist immigration agenda of any Republican candidate. He deëmphasized tax cuts and occasionally suggested that he would be an enemy of the financial-services industry. After Steve Bannon joined his campaign, in August, Trump’s rhetoric became more sharply populist, and his attacks on corporate power and Wall Street escalated. Though Trump was the Reformicons’ closest ideological ally, many of them despised him. “The catastrophic failure of their party’s primary electorate to select a worthy candidate for president this year has also put many Republican politicians in a horrific nightmare scenario that they did not want and would not choose,” Levin wrote. “But they did have an extended opportunity to struggle against this outcome, including well before the party trapped the country in a lose-lose Trump or Clinton double bind.”
With Republicans controlling Congress and the White House, one of the great political questions of 2017 is what becomes of this ideological debate within conservatism. Paul Ryan, the Speaker of the House, is the standard-bearer of traditional small-government conservatism, while President Trump, aided by a coterie of anti-establishment policy aides, would seem to represent a populist-nationalist challenge to Ryan’s positions. But the health-care debate this week is clarifying what Trumpism actually means. So far, the evidence suggests that, on domestic policy, Trumpism has nothing new to offer the G.O.P.
Trump has said that he wants to transform the G.O.P. into a “workers’ party,” and, along with his commitment not to reduce benefits for Medicare and Social Security, he has promised a health-care plan that would provide “insurance for everybody.” Last month, he told the Washington Post that the White House was writing its own bill that would represent a dramatic break with conservative dogma. “There was a philosophy in some circles that if you can’t pay for it, you don’t get it,” he said. “That’s not going to happen with us.”
None of this turned out to be true. The bill that Trump backs was written by Ryan, and it does not provide insurance for everybody. Under the Ryan bill, millions of Americans who currently have insurance will lose it because they will no longer be able to pay for it. Moreover, as currently written, the Republican health-care plan would actually hurt the Americans who generally voted for Trump. The plan, which includes large tax cuts for the wealthy, is a worse deal than Obamacare for older, poorer, and sicker voters, especially in rural parts of the country, where premiums tend to be high because of a lack of competition in the individual insurance market. “The voters hit the hardest—eligible for at least $5,000 less in tax credits under the Republican plan—supported Mr. Trump by a margin of 59 percent to 36 percent,” according to an analysis by the Times.
In addition to changing the assistance that the government provides to help Americans purchase insurance, the House bill cuts back on Obama’s expansion of Medicaid funding, which would result in many Americans just over the poverty line losing access to the program. Again, if Trumpism represents a new concern with helping those less well off, supporting the House bill is a funny way of showing it.
If the White House ever really considered writing its own, more generous health-care plan, it likely would have found that there is no constituency in the G.O.P. Congress for what Trump promised. In fact, the most vociferous opponents of the Ryan plan are on the right, which wants a dramatically less generous plan. Trump spent this week inviting conservatives to the White House and convincing them that he would try to shape the legislation more to their liking. Though once in favor of single-payer health care, he is now to the right of Ryan on the issue. Conservative policy wonks like Levin, who for years have been pushing the G.O.P. to be serious and creative about health care, have little to cheer for in the current debate. “The House Republicans have managed to propose an approach to health reform that almost no one really likes,” Levin wrote this week.
Trump has been aggressive at defining a new populist nationalism when it comes to immigration, by scapegoating Mexican immigrants and Muslims, and trade, by cancelling the Trans-Pacific Partnership and promising to renegotiate NAFTA. But, when it comes to domestic policy, neither Trumpism nor the Reformicons have done much to affect the neo-libertarian core of the G.O.P. The health-care debate shows that, outside his narrow set of interests, Trump is content to let Ryan and congressional Republicans drive policy. So far, on most domestic policy issues, Trump is not breaking with the Party’s status quo. Instead, he is reinforcing it.
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