Donald Trump, never one to throw in the towel, has begun the hardball phase of healthcare reform negotiations.  After Friday morning’s fiasco in the Senate, where three Republican senators, Collins, McCain, and Murkowski, decided to end the hopes for any compromise through reconciliation, a resolute Trump has thrown a hand grenade into the fracas.  These three senators could not agree to a skinny repeal of Obamacare; in this proposal only the mandates for individuals and employers and the medical device tax were removed as a way of gaining a congressional conference to iron out details for a final bill.  This dysfunction demonstrates the difficulty of swimming in the Washington swamp.

President Trump has tweeted a possible new inducement to gain real negotiations.  He threatened to cut off federal subsidies to insurance companies under Obamacare and, perhaps the more serious threat, subsidies for Congress to avoid the true costs of Obamacare.  Obama garnered congressional support though executive action in which he allowed Congress an exception to the rules of his mandated healthcare coverage. 

This privilege was a clear break with the Contract with America principles that helped launch the Republican House majority under speaker Newt Gingrich during the Clinton era. At the time, the change in control was seen as a rejection of Hillarycare, then opposed by the insurance lobby.  Under the Contract with America, Congress could no longer pass laws that they were not bound by themselves.  This was the least popular item of the ten for the representatives who had privileged lives in the swamp.  Perhaps Trump (maybe with input from Newt Gingrich) has realized this kind of public pressure might induce real legislative change in the healthcare funding system.

President Trump had allowed the traditional method of negotiation via pork compromises and sweeteners for hesitant members of Congress to work its way via Speaker Ryan and Majority Leader McConnell.  This has failed in the Senate due the petty wishes of individuals in congress.  But, healthcare reform is not dead.  Trump has seen the glee among Democrats who wish a further move toward single payer funding.  Senator Schumer now thinks he has real leverage for his concept of reform: more subsidies from taxpayers.  House Democratic leader Pelosi has slipped again by warning that all families may come to see the benefit of Medicaid expansion. 

Republican supporters of a federal role have deluded themselves into believing Medicare will be the ultimate single payer, but this is financially unsustainable.  The loss of private insurance reimbursements for hospitals and providers will result in less innovation, fewer equipment upgrades, and lower quality service.  But, then the Washington insiders live in a bubble of protection.  Now, Trump threatens to end this safety net.

The shakeup in the White House now allows Trump to pursue his version of swamp clean-up.  He is creative and does not like to lose.  He wants people who get things done.  General Kelly will likely reorient the effort; with a unified message under Scaramucci perhaps the Trump tweets will reinforce the White House policies.  After six months of an establishment approach to the swamp under Reince Priebus, a frustrated Trump has decided to put on the heavy breathing gear, go into the swamp and pull down “resistance” swimmers.  Trump supporters will see his effort favorably, but the establishment will renew its effort to take him down and maintain their privileged lives.

Caricature by Mike Harris.