Political malpractice: Trump's new attack on the ACA

President Donald Trump, having defeated those striving to tar him with colluding with the Russian government to win the White House, was expected to devote all his energy to a long, needling victory lap. Instead, he quickly plunged back into an old battle, picking a fight with Democrats on an issue in which they’ve consistently outpolled him -- and he is doing so with no weapons, no plan, no clear goal and few allies.

Trump’s Justice Department now wants a federal appeals court to strike down the Affordable Care Act in its entirety. Until Monday, the Justice Department had defended much of what remained of the ACA after Congress repealed the fine imposed for refusing to buy insurance. While the administration always argued that the end of the fine should mean the end of the mandate for individuals to carry coverage and the key provision that insurers must cover pre-existing conditions, the federal government is now siding with Republican state governors to overturn the entire law.

The new stance startled and dismayed Trump’s closest allies in Congress, and was opposed by some of the strongest forces in his Cabinet.

Tuesday, Trump told reporters that, “The Republican Party will soon become the party of health care,” having tweeted out the same sentiment a few hours earlier. That’s a worthy goal, but there is not even a whisper of a plan to make it so. And losing the Affordable Care Act with no replacement plan would be disastrous for both the GOP and those people, many of them Republicans, who would lose coverage.

Repeal of the ACA could throw the nation’s health care system and the lives of tens of millions of people into a chaos many Republican members of Congress and Trump have repeatedly promised to avoid. That’s why every attempt to repeal the ACA legislatively failed. If the ACA disappears, approximately 23 million people could lose their health insurance, including 12 million now on Medicaid, 9 million who receive federal subsidies to buy coverage and 2 million young adults who get coverage through their parents’ plans. Close to 3 million New Yorkers could lose coverage.

Medically assisted treatment for opioid addicts would be slashed. Lifetime coverage caps could be reintroduced, meaning those who need care most would lose all coverage once their treatments became too expensive. Bankruptcies would again skyrocket. Many would lose access to free mammograms, cholesterol tests and birth control. And about 130 million Americans with pre-existing conditions might not be able to get health insurance, or might not be covered for their existing problems by the policies they can get, or might have to pay staggering rates.

Thus far, Trump and his acting chief of staff, Mick Mulvaney, are just about the only Republicans arguing for the ACA to fall, claiming they have a better plan. GOP senators and House members are united in saying they have no replacement plan and no idea how to appease their constituents if the ACA simply goes away.

Trump might have hoped that Democrats in the House of Representatives would respond by demanding a single-payer health plan. Instead, they’ve wisely fallen into line behind Speaker Nancy Pelosi and her small-ball idea to subtly improve the ACA while bigger shifts get a slower study.

The ACA was never perfect, and Republicans and Trump have weakened it badly. They’ve refused to promote the exchanges, depressing enrollment. Only 34 states accepted the Medicaid expansion, so millions of people who could have had coverage never got it. Taxes meant to fund subsidies to make coverage affordable never went into effect, and promised payments to insurance companies that lost money covering sicker and older patients at affordable rates were never made. But the ACA has helped tens of millions of people, and striking it down without a plan to replace it will do them real harm.

Many legal experts, including many conservative ones, think it unlikely that the whole law will be struck down because many other aspects of the ACA operate independent of the repealed fine for refusal to buy coverage. But the Justice Department’s refusal to defend federal law is a bold political act that bolsters the legal effort to kill the law.

Today, tens of millions of Americans, with and without coverage, face medical bills they can’t afford. Prices for prescription drugs many Americans depend on are outrageous. Many people who are eligible for free or subsidized coverage are not enrolled, often because they do not know they qualify. And millions of people in the 16 states that did not expand Medicaid lack free coverage they should have.

If Trump wants the GOP to be “the party of health care,” as he said March 26, there is ample opportunity for that to happen. But tearing down the aspects of the ACA that make coverage affordable and available for a large segment of the nation, when he ought to be improving health care, is a prescription for political defeat. Worse, it’s a direct attack on the lives and finances of the Americans he has promised to protect.