Will Trump learn from his past and end the healthcare war once and for all?
© Greg Nash

Concerned about ongoing conflict, Donald Trump in 2012 tweeted “there is no instance of a nation benefitting from prolonged warfare.”

 "There is no instance of a nation benefitting from prolonged warfare." -- Sun Tzu

No stranger to oft-cited quotes, President TrumpDonald John TrumpThorny part of obstruction of justice is proving intent, that's a job for Congress Obama condemns attacks in Sri Lanka as 'an attack on humanity' Schiff rips Conway's 'display of alternative facts' on Russian election interference MORE might now tweet “a house divided against itself cannot stand.” Sun Tzu and Abraham Lincoln both understood the danger of division and conflict. 

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The incomprehensible shooting at a congressional baseball practice is a warning that our country is fast approaching a tipping point from which it may soon become impossible to return. While the current healthcare struggle is but one skirmish among many, it is unique in its nature and at times does feel like a war.

The healthcare war is one that we have been fighting for way too long. The no holds barred round began with Harris Wofford when he won his Senate seat in 1991, led to the aborted healthcare reform attempt by President and Hillary ClintonHillary Diane Rodham ClintonThorny part of obstruction of justice is proving intent, that's a job for Congress Nadler: I don't understand why Mueller didn't charge Donald Trump Jr., others in Trump Tower meeting Kellyanne Conway: Mueller didn't need to use the word 'exoneration' in report MORE in 1994 and intensified after the enactment of the Affordable Health Care for America Act (ACA) in 2010. The American Health Care Act (AHCA) and the Better Care Reconciliation Act of 2017 (BCRA) are the latest but likely not the last rounds in this endless saga.

The ongoing and relentless struggle is not surprising. Democrats and Republicans speak a different language and measure success in metrics far apart from each other. The underlying ideological dogma is equally distant and not reconcilable. Health is to Democrats what border security and national defense are to Republicans. Existential!

An enthusiast of history, Trump is seemingly intrigued by the toughness of Andrew Jackson, the inspiration of JFK and the success of Ronald Reagan. One additional historical lesson to be learned by our President might yet be his most important. Studying how President Obama responded to the Republican decision to not work with him on healthcare may provide the clues needed for Trump to make the biggest deal of his life.

Assume that President Obama was absolutely correct and that under no circumstance would Republicans work with him, compromise with him or cast a vote for his legacy making healthcare bill. Let’s also assume that Obama had the gift of prophecy and knew in advance that his legacy making healthcare bill might eventually be repealed or replaced and result in a Senate, House and White House all controlled by Republicans. Knowing all of this what might he have done?

Imagine if he had decided on his own to include an expansion of health savings accounts, tort reform, the ability to purchase insurance across state lines or any other program important to Republicans. What if he had included them without expecting a single vote in return? What would have the Republicans run on in 2012, 2014 and 2016?

Instead, Obama and the Democrats knew that they had the votes and pushed the bill through to the finish line. With hindsight, we now know the outcome of this decision and the political consequences that followed. Seven years later Trump is now following an almost identical path to Obama. As Republicans did in 2009, Democrats will not work with him now. As Obama and the Democrats did in 2009, Trump and the Republicans may yet find the votes needed to push their bill through to the finish line. But should they?

If Obama understood this in 2010 and if Trump were to understand this now we would have a chance, perhaps a small chance, to end these healthcare wars once and for all. We need a Gandhi, Martin Luther King or Sadat Begin moment. We need one side in this war to make that overture to the other side that will put us on a path to peace. Could President Trump find a way to make an overture that would be just enough to end the war?

Previously I described a limited and conservative case for a single-payer option and a plan to modify essential health benefits (EHB) as a possible path to compromise that could satisfy the ideological necessity for both Democrats and Republicans alike. Imagine if Trump and the Republicans were to now include a limited public option.

Imagine if Trump and the Republicans were to include a provision that would allow any person with a pre-existing condition to enroll in Medicaid for a premium based on an income determined sliding scale? What if persons 55 and above would be allowed to buy into Medicare with the payment of an unsubsidized market based premiums? What if these were to be included within the AHCA or BCRA without ever expecting a single democratic vote in return?

Republicans champion choice and the market. Unilaterally, offering these or other similar provisions would provide real choice. Let the people decide if they want a public option or a private option. Let the market work. Fix the federal payment to states and let the states do whatever they want to make up the difference in cost for people that choose Medicaid.

Let the states use state defined EHBs, let the states set up risk pools, let the states charge what-ever premiums they want on what-ever sliding scales they choose and let the states use what-ever cost sharing they need to make their plans work.

Let Medicaid and private plans truly compete in the market place. Some states would likely end up privatizing or somewhat privatizing Medicaid. Let the states intermingle Medicaid and private plans. The governors are likely to be receptive to this bipartisan approach. What a grand experiment. Let the 50 states do what they do best. Improvise and implement.

With or without short term Democratic support, this plan could be the overture that would transcend the politics of the day and achieve long term broad based public support. Will Trump learn from the lessons of the past, make the biggest deal of his life and find a way to make this overture and will it be just enough to end the healthcare wars once and for all?

Richard Manski is Professor and Chair of the Department of Dental Public Health at University of Maryland School of Dentistry.


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