Trump and the ACA

The drama can still be viewed on-line. The Senate stood deadlocked, one vote from repealing the landmark Affordable Care Act (ACA). Senator McCain, the tie breaker, strode to the center of the Senate floor, as all eyes focused on him. He extended his arm and flipped his thumb downward, defeating the repeal. With that gesture, McCain saved healthcare for millions. He prevented health insurance companies from once again denying coverage to cancer victims, diabetics and others with pre-existing conditions. He allowed those up to age 26 to maintain coverage under their parents’ insurance. 

Since the failure of the repeal, Republicans’ approach to the ACA largely mirrors the politics of Medicare. Though most Republican legislators opposed the 1964 measure for seniors, they supported it once their constituents gained the benefit of healthcare. Similarly, many Republicans now echo conservative Idaho Senator Mike Crapo, who considers the ACA “part of all of the existing health structure.” Yet candidate Trump remains hostile. He continues to call for repeal, promising “much better healthcare for the American people.” Like his 2017 repeal effort, a replacement proposal remains conspicuously absent. 

Without an alternative health insurance program or discussion of any specific pitfalls of the ACA, it can be fairly suspected that Trump’s motivation to end the ACA reflects personal animus toward President Obama, and a desire to trash his signature accomplishment. The fact that millions of innocent Americans could be caught in the middle does not seem to be part of the equation. As a physician caring for patients dependent on the ACA, I worry about a second Trump term. 

The political influence Trump would leverage to end the ACA starts with die-hard MAGA loyalists who account for only about a third of the GOP. Yet, in Republican primaries, that core of support proves decisive. As Liz Cheney’s fate shows, neither Republican nor conservative bona fides will protect any anti-Trump incumbent. Trump’s near absolute control of Republican legislators should underline concerns about democracy in a second term. Based on the number of vulnerable Democratic seats in the Senate, Republicans will likely regain control after the 2024 election. 

Like previous elections, the House appears to be a toss-up. If Trump were elected with control of both Houses, the subservience of the GOP legislators would confer absolute power even without extra-legal actions. Only the Senate filibuster rule would stand in his way. If Trump moved to end the filibuster, who among this cohort of Republican Senators would muster the courage to give a McCain like thumbs down? The last independent minded Republicans have already been “primaried,” retired or otherwise sidelined.

As the events of January 6th showed, the sine qua non of Trumpism is avoiding the loss of power.

As the events of January 6th showed, the sine qua non of Trumpism is avoiding the loss of power. The January 6th investigations uncovered Trump’s use of bogus slates of electors to try to flip the states he lost. Only Vice-President Pence’s refusal to cooperate frustrated the coup. Given that brazen power grab, what might we expect from a term-limited Trump trying to extend his power beyond a second term? The likely answer is as ancient as the Roman empire and as current as North Korea’s regime. He would likely choose a family member as a surrogate for a third Trump term. How many of the Republican sycophants could be counted on to oppose Donald Trump Jr.’s ascent to the Presidency? 

In addition to the risk for American healthcare security, a second Trump term would also threaten progress on global climate change, reproductive freedom and voting rights. But misguided policies can be revisited as long as the system’s key checks and balances remain intact. Trump’s threat to irreversibly destroy constitutional norms and our legacy of representative government poses a unique and profound risk far exceeding the danger to the ACA and other specific policies.   

The dangers once posed by President Nixon’s Watergate activities now seem almost quaint compared to the possible election of a President willing to stage a coup to remain in power. Yet, the lessons of Watergate still apply. The night that Nixon fired Archibald Cox, the special Watergate prosecutor, Cox warned that, “whether ours shall be a government of laws and not of men is now for Congress and the American people.”  A half century later, Cox’s warning appears even more ominous as we approach this year’s presidential election. 

Dr. Daniel Stone is Regional Medical Director of Cedars-Sinai Valley Network and a practicing internist and geriatrician with Cedars Sinai Medical Group. The views expressed in this column do not necessarily reflect those of Cedars-Sinai.