WASHINGTON – President Barack Obama took on the problems of a lack of access to health care and high cost, but he and Democrats paid a political price. President-elect Donald Trump has promised to undo much of what Obama put in place, and pledged to make the system better.
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Although Trump is lacking in specifics, he seems to want to make costs his priority. States, insurers, businesses, and individuals would get more leeway to sort out access.
Health care keenly reflects the country's deep political divide. A look at some lessons Trump might learn from Obama's rough ride:
THE PERILS OF PROMISES
Obama promised that "if you like your health care plan, you can keep it." But then several million people were threatened with the loss of policies that didn't conform to his overhaul. Obama said premiums would come down, too.
Trump hasn't made such specific promises, yet it may already be too late for him. In the campaign, Trump made it sound like replacing the law would be quick and easy, and people would be widely satisfied with the results.
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Consider his idea for allowing insurers to sell policies across state lines. "Get rid of the artificial lines and you will have yourself great plans," Trump said. That ignores practical issues such as whether an insurer in Houston can set up a viable network of doctors in New York.
"There are no easy solutions in health care," said Jim Capretta, a health policy expert with the business-oriented American Enterprise Institute. "Whatever is done will necessarily involve some trade-offs, and winners and losers. There are political risks associated with every kind of policy proposal."
MEDICARE AND MEDICAID
As a candidate in 2008, then-Sen. Obama proposed requiring parents to get health insurance for their children, one of several steps to move toward coverage for all. As president, he embraced a broader "individual mandate" requiring most people to be covered. Enforced with fines from the IRS, it's been unpopular from the start.
Separately, Obama and a Democratic-led Congress financed part of the coverage expansion in the Affordable Care Act with cuts in Medicare payments to service providers. That was an unwelcome surprise to older people. Even if Medicare cuts improved the program's balance sheet, older voters helped deliver the House to Republicans in 2010, a few months after Obama signed the overhaul.
Trump has promised not to cut Medicare, but Republican leaders in Congress want to revamp the program to provide future retirees with a fixed amount to purchase private insurance. Will Trump go along?
Trump initially also said he wouldn't cut Medicaid, the health care program for low-income people. During the campaign, though, his views shifted to backing a "block grant" that would limit federal money to states and could result in big cuts.
Medicare and Medicaid have been around for more than 50 years and are politically popular. Most people, including Republicans, don't equate the programs with the health law. So Trump could be left exposed.
GOING IT ALONE
Democrats passed the 2010 law over solid GOP opposition. Progressives blamed Republican obstinacy and said the overhaul contained many provisions with a centrist, even Republican, pedigree. But the lack of bipartisan support stoked years of opposition.
Trump's ability to win over some Democrats will determine whether his ideas are remembered as a fleeting lurch to the political right or a lasting course correction.
At the moment, it's hard to detect any glimmer of bipartisanship.
"If President Trump succeeds in getting the ACA repealed, he and the Republicans will 'own' America's health care system," said Ron Pollack of Families USA, a leading advocate for Obama's law. "As tens of millions of people lose coverage, the blame will go squarely onto the shoulders of those who engineered the repeal."
PEOPLE LIVE HERE
When Obama signed the measure into law, Democrats hailed it as the fulfillment of historic aspirations to close the last major hole in the nation's social safety net.
If Trump gets to sign "repeal and replace" legislation, the rhetoric will be about getting government off people's backs and giving consumers the options they really needed.
How will the reality measure up?
Obama's law has been a lifeline for many people who previously could not get coverage. For others it brought unwanted legal obligations and expenses that burdened household budgets. The law did not hold back the trend of rising out-of-pocket costs for those with employer coverage.
People worry about the overall affordability of their health care, said Larry Levitt of the nonpartisan Kaiser Family Foundation. Consumers have gotten savvy that out-of-pocket costs, which come on top of premiums, erode the value of their insurance card.
"Republicans may be tempted to push insurance premiums down by allowing insurers to offer skimpier coverage with fewer benefits and higher deductibles," he said. "That's not likely to satisfy consumers in the end."