The Trump administration appears to be split on healthcare reform. A chasm is forming between the president’s own ideas and the current ones being tabled by Republicans like Paul Ryan.

The ‘repeal and replace’ mantra is now stuck in limbo between Paul Ryan freedom caucus version and the Donald Trump ‘I just want to, um, not deal with this’ version. Trump campaigned on populism – one side of the populism was nativism, anti-immigrant sentiment, and travel ban. The other side was him trying to be a different kind of Republican in that he promised to not cut Medicare, social security, Medicaid, bringing jobs back, anti-trade.

But, his Vice President is Mike Pence – a traditional, free market conservative, Paul Ryan, the speaker of the house is the same – so Trump’s different populist economic agenda is going to run head first into Pence, Ryan and all the other Republicans on the hill. If Donald Trump campaigned on cutting healthcare so he could give millionaires tax cuts, he wouldn’t have won.

Nobody knew healthcare could be so complicated

Trump and shadow president Steve Bannon are thinking long and hard about what the electoral consequences would be of wholesale repeal – how removing the healthcare coverage of millions of their voters might not be well received. The problem is, they have no idea what to do instead.

Trump, reportedly “exasperated” by the complexity of the matter had this to say: “Now, I have to tell you, it’s an unbelievably complex subject,” he added. “Nobody knew health care could be so complicated.”

Of course when the President says “nobody”, he means “I” as if there is one thing that everyone in congress can come to a bi-partisan agreement on, its that healthcare is extremely complicated.

Reportedly most of the detail work is being left to White House lawmakers, and top aides are wondering how to digest the issue at hand, that Trump has only spent a small amount of time trying to understand the complex minefield, but in the meanwhile has repeatedly asserted that his sweeping new plan is nearly complete.


The unclear path that the Republican Party finds itself on has led to several powerful people being quite happy to take advantage of the uncertainty.

This is Paul Ryan’s scary ‘steal from the poor and give to the elderly’ scheme: where the ACA expanded Medicaid to provide coverage for more lower-income Americans, and created a tax credit based on income to make insurance more affordable for middle-income Americans. RyanCare absolutely guts these provisions, slashing Medicaid funding for “able-bodied adults” and introducing a tax credit based on age that recipients can use to pay for insurance.

The president recently met with Scott Walker, Rick Scott, and John Kasich – the unholy trinity of Republican governors who will never be president – to hear their probably disastrous reform proposals.

Trump’s reaction to Kasich’s pitch threw a spanner in the works as the governor made his pitch while the president eagerly called in several top aides and then got Health and Human Services Secretary Tom Price on the phone. At one point, senior adviser Jared Kushner reminded his father-in-law that House Republicans are sketching out a different approach to providing access to coverage. “Well, I like this better,” Trump replied, according to a Kasich adviser.

CEO’s of some of the largest insurance companies in America gathered to meet with Trump to discuss the repeal and replace efforts. A great idea – who could be better positioned to help build a ground-breaking reform bill than those who are incentivised to make medical care as profitable as possible for their shareholders?

Leadership vacuum

This lack of leadership could prove increasingly toxic for the Trump administration as their public indecisiveness is opening the door for opportunists like Paul Ryan and private insurance companies to hijack the process.

All Ryan has to do is get the proposal in front of Trump and hope that in all likelihood Trump will just nod and go along with it for lack of anything better and because he wishes to appear decisive more than anything else – given he has no idea what he actually wants.

These shenanigans do not happen to a presidency that is consistent with its ideology, has actual policy ideas and adheres to a set of basic principles. One could argue that Trump’s presidency does not do any of that.

If this wild no-plan plan is executed, and the results are not popular – not least if they leave millions of American citizens uninsured, sick and angry – Trump will have to face the music.