Understanding a New Presidency in the Age of Trump. Joseph A. Pika

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СКАЧАТЬ a funny thing happened on the way to repeal: Americans began to rally around some of the law’s basic tenets. Though not widely loved (even its advocates argued for revision), the Affordable Care Act nonetheless had many specific provisions that proved very popular, such as the requirement that insurers cover individuals even if they had pre-existing medical conditions. On the campaign trail, Trump had seemingly embraced those provisions, and declared that as president he would replace Obamacare with “something terrific”; indeed, he told the Washington Post the week before his inauguration that “we’re going to have insurance for everybody. There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” He added that the new plan would provide “great health care…. Much less expensive and much better.”⁵⁹

      As president, Trump did not back up those promises for “something terrific” with a specific legislative proposal. Meanwhile, Republicans in Congress ran headlong into deep divisions within their own caucus about how to proceed on the issue. While many, including Trump, took the stand (at least early in 2017) that Obamacare had to be repealed and replaced, others thought repeal sufficient. The conservative House Freedom Caucus wanted to deregulate the insurance marketplace and slash federal spending on health care; the more moderate Tuesday Group of representatives preferred providing tax credits to offset insurance costs and worried about rolling back coverage, including the expansion of Medicaid that Obamacare had funded (money on which more than thirty states now depended). To avoid having to win over votes from Democrats in the Senate, the Republicans sought to use a process called “reconciliation,” which prevented legislation from being filibustered in the Senate but could only be used to change provisions that had a monetary impact (meaning that most regulatory change could not be passed in this manner). But even getting support from fifty-one Republican senators would be a hard sell given a party caucus that ranged from Ted Cruz of Texas on the far right to the more purple Susan Collins of Maine.

      On March 6, Speaker Ryan unveiled the American Health Care Act (AHCA), a bill crafted by the House Republican leadership and quickly shepherded through committee, even before the Congressional Budget Office (CBO) had the opportunity to analyze its costs. The bill eliminated the Obamacare individual mandate and the law’s taxes on high earners, established tax credits to replace the law’s premium subsidies, and cut $880 billion from projected Medicaid spending over ten years. When the CBO did report, it predicted that federal spending under the bill would decline $337 billion over the next decade—but also that 24 million fewer people would have insurance coverage after that time, and that many (especially those over 50 years old in rural areas) would see huge and immediate increases in their out-of-pocket health costs. Democrats pounced and Republicans split; some among their ranks were nervous about cuts to coverage, others were angry that the bill maintained health care entitlements at all.

      Though many of the House bill’s provisions seemed to contradict his past promises, Trump fully endorsed the measure. Yet White House lobbying initially failed to persuade House members feeling the heat from constituents. Moves to the right alienated Republican moderates; moves to shore up subsidies caused the Freedom Caucus to scoff at “Obamacare Lite.” Meanwhile, public support surged for the existing law as fears of losing even imperfect health coverage rose.⁶⁰

      As a result, Ryan pulled the AHCA from the floor on March 24. Although Ryan initially said that the United States would “be living with Obamacare for the foreseeable future,”⁶¹ he mounted a renewed push to repeal and replace it later in the spring. In early May, amendments pushing both to the right (allowing states to waive key insurance requirements) and the center (placing $8 billion in a fund subsidizing “high-risk pools” for those expensive to insure)—combined with immense pressure from the White House and the House leadership—managed to convince 217 Republicans (though zero Democrats) to approve the bill just after the end of the first hundred days. Many “yes” voters confessed to being in the dark regarding the impact of the measure, but wanted “a win” to show that the GOP majority could hold together on major legislation. Indeed, President Trump showcased the House action with a triumphant Rose Garden celebration on May 4 where he claimed that Obamacare was “dead, it’s essentially dead,” even though without Senate support it really was not dead at all.⁶² In fact, the Republican-controlled Senate indicated it would begin from scratch in drafting its own version of a law to repeal Obamacare, with no guarantee that it could bridge its own internal divides (see Section IV).

      Other measures moved even more slowly than health care reform. The White House hastily unveiled a one-page outline of tax reduction proposals on April 26 (Day 97) but without detailed legislative language. It did not reveal the full presidential budget for fiscal year 2018 (with specific spending targets for discretionary and entitlement programs, as well as revenue estimates) until May 23. Even Republicans were hesitant to embrace the White House budget proposal, which boosted defense spending but slashed $1.7 trillion in domestic programs and health entitlements over ten years.⁶³ When budget hearings finally began in the House and Senate, many of the cuts proposed by the president came under fire and seemed likely to be reversed. Legislators also questioned the optimistic economic forecasts embedded in the administration’s budget, which predicted a 3 percent growth in gross domestic product (GDP) each year for an entire decade. The administration projected that the growth would produce higher tax revenues, thereby shrinking future budget deficits, but economists pointed out that the 3 percent projection far exceeded consensus estimates of GDP growth. (The Congressional Budget Office, by contrast, estimated GDP would grow at a rate of 1.9 percent. That seemingly small gap added up to a $3.7 trillion larger deficit over ten years.)⁶⁴

      In the end, of the twenty-eight bills signed by Trump into law during the first hundred days, all originated in Congress rather than from the new administration. Nearly half of them were narrowly targeted (though sometimes substantively important) resolutions rolling back Obama-era departmental regulations. For example, one of the bills reversed a 2016 environmental protection rule that limited dumping mine waste into streams. In another hotly contested reversal of Obama policy, Congress gave states and local governments the power to withhold federal funds from Planned Parenthood and other health care providers that perform abortions.⁶⁵ A third lessened prohibitions against internet providers seeking to monetize user data. The regulations targeted by these laws could be repealed relatively quickly and smoothly, because the procedures established by the Congressional Review Act of 1996 prevented Democrats from filibustering. Thus, the repeals passed on largely party-line votes, with Vice President Pence casting tie-breaking votes in favor when necessary.

      For all the optimism and opportunity that comes with any new presidential administration, significant challenges confront them all. Given the size and complexity of government, it is difficult for any president to control even the executive branch itself. At the same time, the reality of polarized politics, which by 2017 was worse than any point since the Civil War, complicates the ability of modern-day presidents to achieve legislative success—even those, such as Trump, who enjoy unified government. To Trump’s dismay, there are simply too many “veto points” in the American government to assume smooth adoption of any new policy.

      New presidents also typically face unrealistically high expectations. This is partly a result of their own doing. As candidates, they promise change (for Trump, to “Make America Great Again”) that cannot easily be converted into concrete success. And, of course, unexpected events at home and abroad can thrust a bevy of unanticipated challenges on a president and potentially transform a nascent presidency. For example, the September 11, 2001, terrorist attacks on the United States made George W. Bush a wartime president literally overnight, even though he had entered office intent on focusing on domestic priorities.

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