Clock Ticking on Trump’s Obamacare Reform Plan

We're all having lots of fun with President Donald Trump discovering -- surprise! -- that health care is complicated. But, seriously, what does his declaration mean for Obamacare?

It could be Trump's way of admitting that his and the Congressional Republicans' plans to repeal and replace the Affordable Care Act will end up more like tinkering and less like the radical redo they've been promising for years.

That's not to say they lack political will or muscle, and it's not to say they're entirely wrong about the issue. Rather, health care reform is emerging as the one force that Trump can't conquer by plain-spoken rhetoric or by an executive order on his first day in office.

The reason: Health care access is not an issue like, say, immigration or gay rights or defense spending. Those are complicated and emotion-riven as well, but they can be walled off, placed in a box and discussed.

Health care, by contrast, is like sound, or light, or, more to the point, blood. At 18 percent of the U.S. economy, it flows everywhere, touching virtually every American life, every company, every institution, not once in a while but constantly, and with way more friction than, say, the retail food sector.

It's why House Speaker Paul Ryan can't muster all the votes he needs.

It's why a report presented to governors in Washington on Saturday, showing that the Republican plan would sharply reduce individual Obamacare coverage and Medicaid eligibility, is so explosive. The outrage over Americans losing benefits would make the protests against Trump's immigration ban look like a letter to the editor.

The $3.2 trillion-a-year U.S. health care system boggles the mind. Unlike many industrialized countries, we don't have government as the payer for most working people, and we don't have government leveling the field by setting private prices, as in Germany.

Nor do we have a private system. And we will not move much closer toward one, despite Trump's desire along with Tom Price, Trump's free-market-loving Health and Human Services secretary, who now oversees Medicare, Medicaid and the subsidized Obamacare exchanges.

What we have is a patchwork of for-profit and nonprofit medical providers that's more than 50 percent financed by four separate, giant government programs (don't forget Tricare for the military), tied to university research with federal grants, regulated to the hilt, guided by secret price negotiations with insurance companies, joined by a parallel drug industry and largely directed by states.

"Nobody knew that health care could be so complicated," Trump mused in a meeting with governors in the White House Monday.

Translation: Uncle.

Expanded Choice

Still, the president took a hard shot at it Tuesday night in his first speech to Congress. He insisted the reform would repeal Obamacare with expanded choice, increased access and lower cost -- falling back on the magical thinking of the campaign.

Trump said the states should have "the flexibility and the resources they need for Medicaid to make sure nobody is left out," again, with no mention of taxpayer cost.

Trump's campaign health plan never showed how people would remain covered, but he was right about one big point. The ACA did not create enough incentives to cut costs. Years into it, the great hope for savings -- accountable care organizations made up of health providers and insurers collaborating to keep populations healthy rather than fighting over fees for services -- are still just experiments and pilot programs.

Trouble is, unlike having your car fixed or a kidney removed, the government can't sideline the system for the time it would take to make that transition work -- years, not months, as we saw with Obamacare. And it can't throw, say, 3 million middle-class people now receiving Obamacare subsidies out into the street without coverage.

Speaking of insurers, Obama trashed the Aetnas and Cignas of the world from campaign podiums. But as president, he needed that industry as a medical gatekeeper and flow monitor.

Likewise, Trump needs a healthy insurance industry and the insurance industry needs those Obamacare subsidies and some way to make sure people buy coverage. It's no coincidence the president declared health care complicated on the morning he was preparing to meet with Aetna's Mark Bertolini, Cigna's David Cordani, UnitedHealth Group's Stephen Hemsley and other CEOs.

And so we are left with more tinkering, not radical change, though it's not in Trump's nature to admit that. One place to look might be the crushing, multi-layered system of payment approvals and privacy assurance requirements. That might unlock hundreds of billions of dollars, enough for Trump to unwind the 3-plus-percent income tax surcharge on wealthy residents, which he despises, without ending the subsidies.

But that will take years because our patchwork system, which saves lives along with all the waste, can't be undone by fiat. It's too complicated. Who knew?

It will take tinkering. Huge tinkering. The best tinkering.

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