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Ben Roback is Head of Trade and International Policy at Cicero Group and a member of the US Embassy’s Young Leader’s UK programme.

‘The Democrats are pushing for Universal HealthCare while thousands of people are marching in the UK because their U system is going broke and not working. Dems want to greatly raise taxes for really bad and non-personal medical care. No thanks!’

Under recent pressure over Embassy-gate, the Special Relationship was tested this week over questions about the NHS. Few would have expected President Trump to have sat up and taken notice of Saturday’s ‘Save the NHS’ march – which flew in the face of those who claimed that the #MainstreamMedia wouldn’t cover it – let alone cite it is as an example of the kind of healthcare system the US should avoid.

The rebuttal from the Government was fast. Jeremy Hunt became a rare voice of unity, defending the national healthcare system:

‘I may disagree with claims made on that march but not ONE of them wants to live in a system where 28m people have no cover. NHS may have challenges but I’m proud to be from the country that invented universal coverage – where all get care no matter the size of their bank balance’

The Prime Minister backed him up. Despite treading a narrow tightrope with an American president who invests so heavily in personal relationships and resists any kind of criticism, Downing Street insisted the Prime Minister is “proud of having an NHS that is free at the point of delivery”. Though it was hardly a stinging rebuke, it was important for May and Hunt to defend a record on which the Conservatives are rightly proud to campaign. The top of the Party had to set an example, and they did.

If at first you don’t succeed

So we know at least what President Trump doesn’t want the healthcare system to look like. The GOP has tried to reform healthcare, but without success so far. Similar to this Government’s Brexit position, Republicans seem like they have a loose idea of what they want but lack a detailed plan on how to get there.

Healthcare was the first legislative priority of this Trump White House and Republican Congress, but attempts at wholesale reform have failed. Since then, there have been various attempts to tweak the system around the edges. The Tax Cuts and Jobs Act repealed the Obamacare individual mandate that required all Americans under 65 to have health insurance or pay an annual penalty. In January, the administration issued guidance that will allow states to impose work requirements on Medicaid recipients for the first time in the safety net’s history. The letter to Medicaid directors creates a path to cutting off the provision unless recipients are employed, volunteering or in enrolled in education. Ten states are ready to press the start button with at least three more close to a decision.

It represents a clash of ideologies. Should the government provide some kind of healthcare provision to all, irrespective of income or circumstance? Or should recipients have to prove themselves in order to benefit from the generosity of the state? It is unclear where this president falls in that choice. It has left many wondering what this president really wants from a healthcare reform package; he has never truly settled on one position. The closest we got was the Murray-Alexander bill, a bipartisan piece of legislation that Trump was consulted on heavily during its creation. Despite that, within an hour of Senator Lamar Alexander (R) telling reporters he and the President had had a “great talk”, Trump tweeted he could never support bailing out insurance companies who have made money from Obamacare.

Insurance for everybody, or universal healthcare, will become a key pillar of progressive candidates running for president in 2020 – the likes of Kirsten Gilibrand, Elizabeth Warren and Cory Booker – but it was once favoured by Trump. As recently as January 2017, the President said “insurance for everybody” was the ultimate goal for a healthcare package that would repeal and replace Obamacare. While aspirational, it is hard to see that being navigated through a Congressional Republican caucus that wants less state-provide healthcare and to expel out of Washington anything that could be branded as ‘Obamacare-light’.

Taking away free healthcare is hardly a vote winner

Tweaking healthcare around the edges or wholesale reform of America’s healthcare system will be politically difficult to say the least. Taking away free healthcare is hardly a vote winner. Medicaid enrolls more than 68 million low-income Americans. Under the Affordable Care Act, Obama’s flagship healthcare legislation, Medicaid expanded in more than 30 states. Moderate Republicans are concerned about how Medicaid cuts and changes to Obamacare regulations will affect their constituents ahead of midterm elections in November. A further bump in the road ahead, like so many other of President Trump’s attempts to shock the country into change – although in many cases through Executive Order and not legislation – fundamental shifts in the US healthcare system are likely to run into legal challenges at the state and federal level.

Those midterms in November make major healthcare reforms unlikely this year. The Republicans have tax cuts as their major piece of legislation to campaign on, with little incentive to upset the balance with another attempt at healthcare reforms that were unpopular at their first attempt. The White House is instead far more likely to focus on infrastructure and immigration, where it can present a bipartisan approach on the former and traditional Republican values on the latter. So healthcare will be kicked into the long-grass, perhaps a sensible outcome for a White House that seems uncertain on what those reforms should ultimately look like.

24 comments for: Ben Roback: Trump knows what he thinks about the NHS, but does he know which healthcare policy he wants for his own country?

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