Photo: Fabrice Coffrini/AFP/Getty Images
Amid the chaos of the endless ICE raids in Minneapolis, the capture of Nicolás Maduro, and the threats to seize Greenland, it was easy to miss that Donald Trump introduced a new healthcare plan last week. For a president increasingly obsessed with sowing discord abroad, this was a bid to bring the focus back to domestic priorities. None should matter more than healthcare, with America’s byzantine system growing ever more unaffordable, thanks in part to the expiration of Obamacare subsidies that the Republican-run Congress has failed to renew.
Trump’s thinly sketched proposal, amounting to a few paragraphs on a website, calls for redirecting insurance subsidies into individual health savings accounts, which could be used to purchase healthcare services directly. Republicans have been debating similar proposals, with the details varying over how much money should be used. Trump’s plan would require insurance companies to provide more transparency on the prices they pay medical providers and their profit margins, and force insurance companies to prominently post the frequency with which they deny care. The Trump plan also proposes more regulation of pharmacy benefit managers, the behemoth middlemen companies like Express Scripts and CVS Caremark that manage prescription drug benefits.
Some of these proposals, in isolation, have merit. The pharmacy middlemen need to be regulated; drug costs are too high. Price transparency is fine. The trouble is that Trump doesn’t care very much about fixing healthcare.. It’s not just that the details are largely missing here — it’s that, when it comes to helping the working-class and poor afford care, he has already made his priorities known , through his Big Beautiful Bill, which enacted severe cuts to Medicaid. And the healthcare savings accounts he proposes won’t do anything to actually drive down the cost of care. All the same problems will remain.
But even analyzing the Trump proposal to any serious degree lends it a bit too much credence. There is almost no chance the Republican Congress turns these ideas — whatever they might be — into law. Since Trump takes little interest in legislating, the chances that he forces Republican lawmakers to make any significant changes to the healthcare system are close to nil, unless he’s able to force through further cuts through a reconciliation package. House Speaker Mike Johnson’s margins in the House are razor-thin, and tackling thorny policy will be close to impossible. And Republicans don’t want to go near healthcare if they can help it. They’re staring down the barrel of a midterm that is probably going to make Hakeem Jeffries the next Speaker of the House.
The Republican dream of fully dismantling Obamacare seems to be dead. Republicans can weaken the exchanges and fail to renew the subsidies, but they’ve shown, despite repeated vows over the last decade and a half, that they can’t repeal and replace the system. In Trump’s first term, then-House Speaker Paul Ryan, attempted to fulfill the aims of the anti-Obama Tea Party and found the votes simply weren’t there. Obamacare is a flawed system, far too in hock to private insurance companies, but it is one that stands above whatever it is Republicans try to do.
Why, then, has Trump even bothered to offer up a vague healthcare proposal? It might be part of his half-hearted attempt to address his myriad domestic struggles, the sort that Americans actually care about. Trump’s approval rating has plummeted over the last year. Voters feel he hasn’t done enough to address inflation or any other cost-of-living challenges, and many have even found his immigration crackdowns alienating enough to endorse abolishing ICE. The Republican Party largely seems out of ideas, and remains beholden enough to Trump that none can really emerge. The GOP could, earnestly, care about fixing healthcare, but it’s easier for most lawmakers to subsume themselves to Trump and his rankest instincts. For the hawks in the party, foreign-policy distractions are welcoming. Lindsey Graham can fantasize about conquering Iran and Secretary of State Marco Rubio can try to scheme over whatever managing a post-Maduro Venezuela looks like.
Healthcare is harder for Trump and the Republican Party because they would probably have to admit — if, indeed, their goal is making healthcare cheaper — that the left wing of the Democratic Party has a few ideas they should accept. Other industrialized nations have far cheaper medical care and prescription drugs because the government plays a much larger role in the delivery of that care. It is hard to find any wealthy nation that patterns its healthcare after America’s; in Canada, Europe, and Asia, single-payer or heavily-subsidized government plans are the norm, and the idea of going into medical debt is entirely alien.
If not single-payer, would Republicans support an expansion of Medicare or Medicaid to cover every American who wants to buy into the plan? Would they back a public option for Obamacare to drive down the cost of private insurance? The answer is no. Democrats haven’t pursued any great structural reforms in recent years either; such changes would be impossible without eliminating the filibuster. So we’re left with a status quo that isn’t working, with nothing on the horizon — certainly not Trump and his party — to change that.
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