Health-care policy, Donald Trump has admitted, is more complex than he once assumed. “Nobody knew that health care could be so complicated,” he said in February as he struggled to cobble together a plan to repeal and replace Obamacare. Still, he was optimistic about his chances. “Costs will come down, and I think the health care will go up very, very substantially,” he told insurance company executives, explaining that the current system was a “disaster” that would only get worse. “I think people are gonna like it a lot. We’ve taken the best of everything we can take.” In an interview in May, shortly after the House passed a bill that would cause an estimated 23 million people to drop or lose their insurance coverage, Trump boasted that he had become an expert on the subject. “It was just something that wasn’t high on my list,” he told Time magazine. “But in a short period of time I understood everything there was to know about health care.”
Nearly everything Trump has said, however, suggests that his understanding of the $3 trillion U.S. health-care sector remains dangerously limited. In closed-door meetings with Republicans to negotiate the House bill, he reportedly urged them to focus on the “big picture” and to “forget about the little shit.” Weeks after he struck up a brass band in the Rose Garden to celebrate the passage of that bill, Trump told a group of senators that the American Health Care Act was actually “mean,” “coldhearted,” and a “son of a bitch.” Lawmakers who stuck their necks out to vote for the bill, which the White House promoted, were furious. He seemed to forget his earlier criticism this week when he endorsed Senator Mitch McConnell’s own legislative vision for repealing Obamacare, which would have nearly identical results.
When a Republican insurrection on Tuesday forced McConnell to delay the vote on his bill, the unfortunately titled Better Care Reconciliation Act, Trump once again took up the mantle of dealmaker. “I just finished a great meeting with the Republican Senators concerning HealthCare,” he tweeted Tuesday, after inviting the entire caucus to the White House for a cheerleading session. “They really want to get it right, unlike OCare!”
What the president thinks it means for the Senate to “get it right” is unclear. On the campaign trail, he repeatedly promised that everyone would be covered under his yet-undefined health-care proposal. As recently as March, the administration was claiming that “nobody will be worse off financially” under the G.O.P. plan, and that costs would come down. In fact, the B.C.R.A. would do the opposite, as it slashes subsidies for the poor and elderly, leads to higher premiums and deductibles, and reduces Medicaid coverage to finance a massive tax cut. But as The New York Times reports, the president may not understand how the bill works.
The president’s confusion explains, in part, why McConnell has sought to sideline him throughout the legislative process. Instead of allowing the White House to lead negotiations, as it did during the messy public debate over the House bill, McConnell turned to Vice President Mike Pence to help wrangle support. He worked with a small group of lawmakers, lobbyists, and aides to draft the legislation behind closed doors, with limited input from the West Wing. And while writing the bill in secret may ultimately have backfired, for now, Trump’s ham-fisted attempts to steer the legislative process have only confirmed that McConnell was right to be wary of working with the president.
As it became clear over the weekend that the Senate health-care bill didn’t have the votes to pass, Trump reached out to conservatives Mike Lee, Ted Cruz, and Rand Paul, pleading with them to vote for the Obamacare repeal—to no avail. “The Senate health-care vote shows that people feel that health care is a defining issue, and that it’d be pretty hard for any politician to push a senator into taking a vote that’s going to have consequences for the rest of their life,” Senator Lindsey Graham explained to The Washington Post. Which isn’t to say that Trump’s allies didn’t try: When Senator Dean Heller, who is viewed as the most vulnerable Republican senator up for re-election in 2018, said he could not vote for the B.C.R.A., as written, a Trump-aligned political action committee launched a $1 million media campaign targeting him for breaking his “promise” to repeal Obamacare. McConnell, who is fiercely protective of his caucus, was appalled, reportedly complaining to White House Chief of Staff Reince Priebus that the ads were “beyond stupid.” According to Politico, the Senate majority leader “privately fumed that it would make it harder to get Heller’s support for the legislation.”
McConnell’s impatience with the White House, and his efforts to cut the president out of health-care negotiations, also points to a larger problem: lawmakers simply don’t respect the president in a way that would allow him to be useful in shaping policy. “This president is the first president in our history who has neither political nor military experience, and thus it has been a challenge to him to learn how to interact with Congress and learn how to push his agenda better,” Senator Susan Collins, who was a critical opponent of the health-care bill, told the Post.
Trump, for his part, rejected the implication that he doesn’t understand health care, tweeting Wednesday morning, in the wake of the Times report, that he knows perfectly well what he is doing. “Some of the Fake News Media likes to say that I am not totally engaged in healthcare. Wrong, I know the subject well & want victory for U.S.”
All available evidence suggests that the opposite is true, and that the consequences of the president’s ignorance could be dire. Without reassurances or leadership from the White House, health insurance exchanges across the country are failing, and insurance providers are increasing premiums. An estimated 22 million people stand to lose their coverage entirely, placing an untold number at greater risk of bankruptcy or death. A much smaller number of high-income households would see a considerable tax cut, worth hundreds of billions of dollars over the coming decade, as a result of this massive transfer of wealth, which is the primary feature of the G.O.P. plan. Trump is either confused on this point, or else he doesn’t care. As he said himself on Twitter this week, the process is “not easy.” Perhaps, he added “just let OCare crash & burn!”
