From a dispatch from Florida in the New York Times yesterday:

Dalia Carmeli, who drives a trolley in downtown Miami, voted for Donald J. Trump on Election Day. A week later, she stopped in to see the enrollment counselor who will help her sign up for another year of health insurance under the Affordable Care Act.

“I hope it still stays the same,” said Ms. Carmeli, 64, who has Crohn’s disease and relies on her insurance to cover frequent doctor’s appointments and an array of medications. 

Donald Trump ran an unusual campaign in that he was both ignorant and indifferent to anything related to policy. His campaign had some policy planks, but Trump himself seemed unfamiliar with them. But he did make some promises, and one of them was crystal clear: He said that he would repeal Obamacare. What that means in practice is anyone’s guess, because Trump makes up different things at different times. So, it’s possible for someone like Dalia Carmeli, who depends on Obamacare for coverage she desperately needs, to think that maybe Trump is on her side and won’t act to snatch away her health insurance.


Unfortunately, whether or not this is what all of his supporters intended to vote for, the most likely scenario is that Trump will enact the right-wing economic agenda of his party, including the dismantling of the healthcare safety net that Republicans have promised for years. Trump’s rhetoric sometimes suggests otherwise, which has been an effective tool in running a con on voters like Carmeli (he used the same ploy on taxes, and fooled a good chunk of the media for a spell — he talked a big game about a populist approach that would soak the rich, even as his actual policy platform proposes the greatest tax cut for the rich in the nation’s history; see also Wall Street regulation). Here’s where it can be useful to take note of the actual policy proposals as opposed to the bluster. Americans dependent on the ACA for coverage have every reason to fear that Trump and the GOP will fulfill their campaign promises — in which case more than 20 million Americans would lose their health insurance.

While Trump will no doubt continue to make gestural or symbolic overtures aimed to please everybody, it’s worth remembering who actually passes laws. That would be Congress, in GOP control. The Republican Congress already used the reconciliation process to pass a bill last year that dismantled the ACA’s coverage provisions and replaced them with nothing. President Obama vetoed the bill, protecting the law; it’s hard to believe that Trump would do the same.


So what would the Republicans’ eventual replacement plan be? House Speaker Paul Ryan (recently unanimously chosen for another term by his Republican colleagues) has the outline of a plan in place, known as “Better Way.” If you’re wondering why Ryan was so willing to back Trump, despite Trump’s periodic efforts to humiliate him, “Better Way” is the reason. Ryan correctly ascertained that if Trump was elected president, he would have a good chance to enact his longstanding dream plan to slash taxes for the rich, slash spending on the poor, dismantle the social safety net and dismantle Wall Street regulation.

What would Better Way mean for Americans covered by Obamacare? It would eliminate funding for the Medicaid expansion altogether, ending coverage for 14 million low-income Americans. That includes more than 250,000 Arkansans currently covered by the private option. It’s worth keeping this in mind when you hear debates about what the Arkansas legislature might do next year about the private option, the state’s unique version of Medicaid expansion. The truth is that the actions of the legislature are irrelevant until we know what Congress and Trump do. Regardless of what state legislators might want, if Ryan’s Better Way plan passes and is signed into law (and assuming the GOP nukes the filibuster, there’s no reason to think it wouldn’t), the private option — or Arkansas Works, or whatever you want to call it — is dead. Better Way also block grants the old pre-expansion Medicaid program, which would in practice amount to a massive funding cut.


So, using Arkansas as our example: The funding that enabled a coverage expansion to 250,000 low-income adults would be gone entirely. The state’s remaining program, meanwhile — covering kids, the elderly, the disabled and other vulnerable groups — would likely be forced to slash benefits to deal with a major, ongoing funding shortage.

Better Way would also re-make the Obamacare exchanges, the regulated marketplaces where individuals who don’t get their insurance through a job or through a big public program like Medicare can shop for health insurance. Better Way is vague on the details, but the gist is that people who are wealthier and/or healthier would tend to pay less for individual insurance than they do under Obamacare and people who are poorer and/or sicker would tend to pay more (sometimes much, much more). In the case of a trolley driver with Crohn’s disease like Dalia Carmeli, insurance which is affordable under Obamacare would likely become prohibitively expensive under Better Way.

Trump was so outrageous that it was easy for the actual policy stakes to get lost in the shuffle of proto-fascist gibberish, casual racism, sexual-assault braggadocio, bellicose disregard for American institutions and dumbed-down nationalism. But now that he’s in office, Ryan and company are going to be sending bills to his desk, and the policy stakes are going to become real. Among many other things, that means millions of Americans could lose their health insurance.