Trump just moved the GOP’s health care consensus permanently to the left

It’s a post-Obamacare world, and Republicans are learning to live in it.

Obamacare has permanently shifted America’s health care debate, and Donald Trump’s address to Congress proved it.

In the speech, Trump laid out five principles any Obamacare replacement must meet.

First, “we should ensure that Americans with preexisting conditions have access to coverage, and that we have a stable transition for Americans currently enrolled in the health care exchanges.”

Second, “we should help Americans purchase their own coverage, through the use of tax credits and expanded health savings accounts, but it must be the plan they want, not the plan forced on them by the government.”

Third, “we should give our great state governors the resources and flexibility they need with Medicaid to make sure no one is left out.”

Trump went on to propose, as his fourth and fifth principles, “legal reforms that protect patients and doctors from unnecessary costs,” as well as permitting insurers to sell plans across state lines. (See Sarah Kliff for much more detail on how Trump’s proposed policies work.)

It’s the first three that show how Obamacare has reshaped America’s health care debate. In those principles, Trump admits that any replacement will have to preserve most of the law’s gains — it will have to cover people with preexisting conditions, provide tax credits to boost affordability, and allow governors to keep the Medicaid expansion’s gains.

As always, the devil is in the details, and the paucity of details in Trump’s plan leaves much room for devilry. Trump’s rhetoric is plausibly consistent with the draft bill House Republicans have circulated — and a McKinsey analysis of a similar GOP plan suggested it could cut insurance in the individual market by 30 to 50 percent. But Trump promised tonight to “make health insurance available to everyone,” and his team knows that clip will be devastating if they have to send out cancellation notices to millions.

Consistent with that, Trump’s speech weighed in on the most consequential debate among House Republicans: whether their replacement plan should have tax credits and a continued Medicaid expansion at all. House conservatives believe otherwise, and are already denouncing the GOP plans with those features as “a new health insurance entitlement with a Republican stamp on it.” Tonight, Trump dismissed their concerns, and moved the GOP’s health care consensus permanently to the left.

With Obamacare and Trump’s speech, the debate on health care has moved from whether it should be the government’s responsibility to insure young, able-bodied people to how the government should insure young, able-bodied people, and how comprehensive the insurance should be.

Democrats are arguing for more generous, income-based subsidies, and Republicans are arguing for less generous, but more universal, age-based subsidies. Both sides, to my surprise, appear to now agree on a vastly expanded role for Medicaid, as even many GOP governors now defend the program’s increased presence in their states. The differences are real, but the question has narrowed.

“In some ways I can't believe how much they have moved,” says Nancy-Ann DeParle, who served as President Obama’s top health aide during the Affordable Care Act’s passage. “They have moved to adopt our goals of getting everyone covered, reforming the worst abuses of underwriting such as preexisting condition exclusions, allowing children to stay on their parents' plans until they are 26, etc.”

As consequential as the GOP’s movement on the policy is, the bigger change is that Republicans are now prioritizing health reform. It is unimaginable, absent Obamacare, that a newly elected Republican president would make passing refundable tax credits to increase insurance coverage his top priority. The GOP is, and remains, deeply divided on health care, and much more committed to tax cuts. “Republicans never ever agree on health care,” former Speaker John Boehner said last week.

It’s the GOP’s loathing of Obamacare that has forced them to at least try to come up with something they like better. The result is Obama’s successor is spending the beginning of his administration trying to figure out how to cover more people with better, cheaper insurance than the ACA provided, rather than focusing on the priorities that have traditionally obsessed Republican presidents. And it’s all due to Obamacare.

“Republicans have generally not been proactive in health care debates, but have rather played defense,” says Larry Levitt, vice president at the Kaiser Family Foundation. “In some ways, Republicans are now forced into being proactive because of their desire to repeal the ACA.”

None of this means the Republican plan — if they ever converge on a plan — will pass. For now, its odds are poor. It’s not clear there’s any bill that could fulfill Trump’s principles and secure enough support from conservatives to clear the House. Any bill that did make it through the House would probably be too conservative for a critical number of Senate Republicans. And any bill that somehow satisfied Republicans in both chambers would still require eight Senate Democrats to become law, as the insurance regulations can’t be passed through budget reconciliation, and so the GOP will need to break a Democratic filibuster. All of that is unlikely. And if Republicans fail, they are left managing Obamacare.

“Disrupting the status quo in health care is always hard, and the ACA is now the status quo,” says Levitt.