<h3><strong>“What’s My Motivation?”</strong></h3>
<p>As a reality TV star playing himself, President Trump probably never had to rely <a href=on “method acting.” But as the White House and the House Republican leadership scramble to put their Humpty Dumpty health plan together again, one might reasonably inquire as to their motivation. After all, both the president and Speaker Ryan declared they were moving on after the debacle (for them) on the House floor last month. 

It is possible the president doesn’t want the notoriety he gained from his star turn on “The Apprentice” to be superseded by a new reputation as “the biggest loser.” But there is really no need to turn to armchair psycho-analysis to explain the hard pivot back to health care since the president has helpfully made his motivation clear. It is almost as if someone explained to him that the big tax cut for the wealthy he is trying to enact would not be possible unless he funded it by raiding the funding for health benefits for millions of children, seniors, people with disabilities and working families. We really don’t have to speculate on this point. The president’s public statements have made his Robin-Hood-in-reverse- intentions all but crystal clear. For example, just recently he said in the Wall Street Journal: “If the health plan is signed, ‘we get hundreds of millions of dollars in savings that goes into the taxes,’…”

And Speaking of Motivation

The president also apparently believes that he can motivate Congressional Democrats to aid him in this wealth transfer to the top by threatening to blow up the non-group insurance market if they don’t play along. The incendiary device he is threatening to detonate would be to drop the administration’s appeal in House vs. Price.

This is the lawsuit the House filed against the Obama administration alleging that, in the absence of an appropriation, it was improper for the administration to reimburse insurers for the cost-sharing reductions (CSRs) they are required to give to certain low- and moderate-income Marketplace enrollees. The insurers are required to provide the CSRs regardless of whether the federal government reimburses them. However, unless it is clear the reimbursement will continue, many carriers might decide to abandon the marketplaces and leave people without affordable insurance options. Even if they choose to stay, the loss of federal payments could force insurers to raise premiums by about 20 percent to make up for the loss. This in turn would make coverage less affordable for people who are not eligible for Premium Tax Credits, meaning fewer (and sicker) people would be insured.

Of course, the administration cannot carry out this threat on its own. It requires collusion from Congress. If the Republican leadership in the House and Senate decide to appropriate funds for the cost sharing subsidies, then the final outcome of the lawsuit will not affect insurance premiums.

We don’t know what Congress will do or whether the administration will make good on their threat. However, one thing we do know is that in addition to being cruel and irresponsible, the tactic is illogical and doomed to failure. It is more likely to blow up in the faces of the administration and congressional Republicans than it is to motivate the Democrats to capitulate.

To understand why, go back to the initial observation that the effort to resurrect the GOP healthcare bill is motivated by Republicans’ desire to redirect funds away from health benefits to pay for tax cuts for the rich. Starting from this premise means any resulting bill must necessarily inflict a lot of pain on many of people. In essence, Trump has said to the Democrats in Congress, “I’ve taken the people who have non-group insurance hostage, and I’ll undermine their health benefits unless you help me undermine the health benefits of a much larger number of people, especially those on Medicaid.”

This is obviously bad deal on its face. And far from rushing to rescue the Republicans from their own folly, Democrats are rushing to defense of the CSRs. Democrats are demanding tCongress approve the funding when it returns from recess to complete the 2017 appropriations process (funding for many government operations runs out April 28th and must be extended to avoid government shutdown).

A Motivated Public

In fact, there’s no evidence the Democrats are even slightly tempted to aid and abet in the effort to hijack people’s health benefits. But even if they were, the fact that their colleagues across the aisle are continuing to get pummeled back home for their attack on health care is a powerful disincentive.

The bottom line is Republicans have badly miscalculated. They have tried to bootstrap people’s dissatisfaction with specific shortcomings of the ACA into a more generalized attack on the health security of millions. But people aren’t buying it. The number of people who would be hurt if something like AHCA were to become law far exceeds the 24 million who would lose coverage. It includes their families, the health care workers who would lose jobs, and the health care providers who would face a drop in revenue and a spike in uncompensated care – especially those who live in rural areas. Not only is the Republican health care plan wildly unpopular, but, by a 2-1 margin, polls show voters will blame the Republicans for the damage they are trying to cause.

So what happens next? The Democrats have not (yet) actually gone as far as saying they would shut down the government if CSRs are not funded. Nor have they ever said they would not negotiate with the Republicans on health reform. But one thing is clear: Thanks to the popular uprising in defense of health care, the precondition of any negotiation must be for Republicans to abandon their effort to use health benefits as a piggybank to pay for tax cuts.

With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.