Trump's Unconventional Campaign Puts Policy Focus on Congress

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By Nathaniel Weixel

June 8 — Donald Trump has run his presidential campaign on a platform of very little policy experience, which could open the door for Congress to set the policy agenda when it comes to replacing the Affordable Care Act.

Policy experts and former Republican officials told Bloomberg BNA that the long-awaited ACA replacement plan that House Speaker Paul Ryan (R-Wis.) is set to unveil in the coming weeks could have a major impact—if Trump, the presumptive Republican nominee, chooses to endorse it. Ryan has recently endorsed the celebrity businessman, but that doesn't guarantee the candidate will agree with Ryan's principles.

In addition, health care hasn't played much of a role in the presidential campaign so far, and there are no signs that a detailed policy proposal from the campaign will be forthcoming.

Trump has put forward a health-care plan on his website, but the substance largely falls within the basic Republican ideals and doesn't match his sweeping campaign rhetoric.

“Trump is interested in branding. He's not interested in getting into the details,” so he'll likely look to the House or his staff, Bloomberg Intelligence analyst Brian Rye said, which is also why it will become imperative to find out who will make up the Trump Cabinet.

“If he can label [Ryan's plan] Trumpcare, he would support it without worrying about the details. That's why you see Paul Ryan try to drill his point home, and be the first one in Trump's ear,” Rye said in an interview.

Michael Leavitt, the former secretary of health and human services under George W. Bush, said Trump's unconventional approach and ever-shifting principles have put more scrutiny on what the House will produce.

“In a traditional campaign, a candidate would not be able to get through campaign without being able to lay out principles and specifics on what they would replace ACA with, if they would repeal it,” Leavitt told Bloomberg BNA. But because that doesn't seem to be happening, “look to Speaker Ryan, and what he’s introducing, and that will be the center of policy gravity.” Leavitt also ran the transition team for Mitt Romney's presidential campaign in 2012.

Republican Ideals

Details about the plan from Ryan's health-care task force have been slowly emerging over the past few weeks, but no date has been announced for its official rollout.

It's expected to include traditional Republican proposals, such as making Medicare a more voucher-based, premium support system. It also is expected to include tax credits to help make coverage more affordable and high-risk pools for people with pre-existing conditions.

Ryan has billed his agenda, called “A Better Way,” as highlighting what House Republicans are for, rather than what they are against. The agenda “looks past this president to what we can achieve in 2017 and beyond,” according to the agenda's website.

Importantly, the Ryan ACA plan would be a “white paper,” not a bill, making it harder for Democrats to criticize, but also harder to assess the impacts on coverage and spending. House Republicans have said on multiple occasions they don't see an immediate need to publish a bill, because it would get vetoed, just like the ACA-repealing budget reconciliation legislation (06 HCDR, 1/11/16).

Independent Agenda

The House is “trying to put forward a set of Republican health proposals that represent a forward-looking policy agenda, irrespective of Donald Trump. They also believe Republicans need to have clear policy alternatives to Democrats, and the ACA. That’s what they're trying to accomplish,” Drew Altman, president and chief executive officer of the Kaiser Family Foundation, told Bloomberg BNA.

“Regardless of the nominee, [control of] the Senate hangs in the balance,” Bloomberg Intelligence's Rye said, and candidates will need a health-care foundation to run on. So Ryan is attempting to “plant the flag and gain as much popular support as he can. He can't sit there doing nothing, he's trying to move the House in the direction he wants.”

However, it's a presidential election year, and the political reality is that any Republican plan will need to be backed by the party's nominee.

“It’s possible the Trump campaign may just say ‘well, that’s interesting. We’ll look at it later, we have our own ideas,'” which would not be a good look for Republicans, James Capretta, a health-care expert at the conservative American Enterprise Institute, said.

Julius Hobson Jr., a senior policy adviser for Polsinelli PC in Washington, said congressional Republicans and Trump have to come to an agreement for the Ryan plan to matter.

Being on the same page is “the only thing that makes it work,” Hobson said. “If Trump says he’s for it, then it works, but if he says no, or equivocates, then it becomes a problem. They can agree and campaign on general concepts [only] and still be in good shape.”

Experience Wins Out

Republican policy analysts said Ryan's expertise in health care would seem to immediately elevate whatever plan comes from the House, even if it's merely an outline of future legislation. Ryan is former chairman of the House Ways and Means Committee, which has jurisdiction over health-care programs, including Medicare.

Regardless of how tepid Ryan's support for Trump may be, any policy he puts out should be worth noticing, Thomas Scully, former administrator of the Centers for Medicare & Medicaid Services, told Bloomberg BNA. Even as a placeholder or policy outline, Ryan's experience would make the plan a strong starting point for whatever comes next in a Republican presidency, Scully said.

Capretta, another former George W. Bush administration official, said the Ryan plan should present a “clear and coherent, practical legislative direction.”

“Trump and his team are going to be at a huge disadvantage—it's clear they don’t have the capacity at this moment to put together a workable [ACA] alternative on their own,” Capretta told Bloomberg BNA in an interview. “It's inevitable what they’re doing in the House will be much more consequential.”

Capretta is a former associate director at the White House Office of Management and Budget. He said policy experts wouldn't necessarily dismiss a specific plan from Trump, but there are political liabilities associated with putting forward concrete ideas.

“People involved in policy would certainly be open to something coming from the Trump campaign, but health care is pretty complicated. The campaign would realize anything they say would have problems associated with it politically. In some sense, they're probably better off deferring to the House,” Capretta said.

Capretta said Trump's unconventional campaign has been viewed by his advisers mainly as an asset, not a liability.

“If you had a traditional candidate that won the primaries, by this time or soon after, there would have been a series of documents and papers that would have given a sense of direction, would have made the effort in the House less important than it is,” Capretta said.

Another Plan

The upcoming plan from the Ryan task force won't be the only Republican replacement for the ACA.

Sen. Bill Cassidy (R-La.) and Rep. Pete Sessions (R-Texas) have already unveiled legislation intended to be an alternative to the ACA if Republicans have control of Congress and the White House in 2017 (100 HCDR, 5/24/16).

Their bill (H.R. 5284, S. 2985) wouldn't fully repeal the ACA, which is a different approach from other Republican-backed efforts. However, it still would remove the law's mandates over employer and individual insurance coverage.

During a press conference after announcing the plan, Cassidy said he thought the plan would appeal to Trump. He even gave it a nickname that the Republican nominee could easily adopt: The World's Greatest Healthcare Plan.

“[Trump's] principles of giving the consumer, in this case giving the patient the power, he totally gets,” Cassidy said. But he wasn't so unequivocal when asked if the Trump campaign would readily adopt such detailed a proposal.

“I don’t know that his voters care about solid detailed proposals. They seem more inclined to say that he wants to take power away from Washington and away from Wall Street and give it back to us, the people. This bill takes power away from vested interests and gives it back to the patients, so his instincts will be to like this bill,” Cassidy said.

As to whether the plan would help Trump, Cassidy wouldn't speculate. “I can’t answer that, but he’s gone pretty far without being too specific,” Cassidy said.

To contact the reporter on this story: Nathaniel Weixel in Washington at nweixel@bna.com

To contact the editor responsible for this story: Brian Broderick at bbroderick@bna.com