The numbers are in. To no one's surprise, Paul Ryan's Republican plan to replace Obamacare with Trumpcare will do the opposite of what Obamacare accomplished. Where Obamacare increased the number of previously uninsured Americans who now had access to health care, whether through insurance or through an expansion of Medicaid, Trumpcare will result in some 14 million Americans losing insurance in the short run and as many as 24 million in the long run. Of course, it will also save the government money that it would have spent on Medicaid and it will provide a tax cut for the rich - a not surprising outcome given that the Republican party's primary priority always seems to be to add to the accumulated wealth of those who are already too rich.
As part of his "populist" rhetoric, candidate Trump promised better coverage for all - the opposite of what his party has proposed. If the Republican plan passes, will President Trump honor his campaign promises and veto it? Or will we once again see the success of the standard Republican strategy of gaining power by appealing to the anxieties of a downscale constituency and then using that power to further the interests of a much more upscale constituency? One way of reading Trump's takeover of the Republican party in last year's primaries was to interpret it as a successful rebellion on the part of the Republicans' downscale constituency against that business as usual. (That is one of the major themes, for example, of Matt Taibbi's entertaining account of the 2016 election, Insane Clown Car President: Dispatches from the 2016 Circus).
President Trump has two fundamental problems when it comes to fixing health care. The first is this obvious problem of his political party's distinctly non-populist agenda, which contradicts what candidate Trump promised his voters mere months ago. The second is that, within the limitations of an insurance-based paradigm, there is perhaps no better alternative to Obamacare. Of course, Obamacare could be improved upon by scrapping the private insurance paradigm and going with a government-run, single-payer system (e.g., Medicare for all). But, if that obviously superior alternative was off the table eight years ago, it obviously has no chance today. So Obamacare probably remains the comparatively best possible approach within the limitations created by dependence upon some system of private insurance. President Trump might have done better to exploit his popularity and political capital and to oppose his party on this by taking the initiative with an alternative that made some modest modifications in how Obamacare operates, which he could then successfully relabel as a totally improved Trumpcare. As it is, the Trumpace that his downscale voters will probably get will likely leave them worse off, with no one but themselves to blame. But, since in America we never blame ourselves, the President risks being the one blamed!