Donald Trump’s exasperated declaration this past February—that “nobody knew health care could be so complicated”—perfectly encapsulated the complementarity between his boundless ignorance and his gargantuan ego. For a man who only a year earlier had assured us that “nobody knows health care better than Donald Trump,” this obvious fact was a revelation offered free of charge to those of us unblessed with his prodigious IQ. And it came only a few months after he had declared that repealing the Affordable Care Act and replacing it with “such great health care, at a tiny fraction of the cost” was going to be “so easy.”
It’s difficult to contemplate a President acting like this, but it’s easier if you remember that Trump seems to get most of his information from Fox News—which explains why he, maybe alone among politicians of any consequence, was gullible enough to believe for seven years that the GOP really, truly had a replacement plan, to be announced any day now. Now, after multiple failed attempts to repeal and replace the ACA, Trump is stuck with implementing it—and the first open enrollment period of his presidency is this week. What happens when the Fox News President is stuck in charge of what one of his party’s senators called the “greatest assault on freedom in our lifetime”?
I wrote, at the outset of this presidency, that Trump’s incompetence might curtail the positive achievement of his worst ambitions. But of course, the destruction of a functioning health-care system doesn’t quite fit this model. Here, Trump can advance his goals by easier means, such as lax enforcement. Moreover, the Administration’s health-care policy was, until recently, being run by one of Trump’s most fanatical and experienced appointees: Health and Human Services Secretary Tom Price. Price had started to take aim at obscure-but-important ACA programs, like the Center for Medicare and Medicaid Innovation, before resigning a month ago amidst a chartered flight scandal.
It’s too soon to know whether Price’s absence will significantly hinder Trump’s plans, especially regarding the host of quieter measures that could hamper the ACA without the trouble of protracted legislative infighting among Republicans. His resignation feels like ancient history only because time is now measured in what Ed Kilgore calls “Trump years, in which every day, week, and month can be excruciatingly long.” And in the last nine months, the Administration has taken plenty of harmful steps. The result is that, although the ACA has survived Republicans’ most drastic repeal efforts, it is by no means unscathed. The full extent of the damage—measured by premium increases, the rate of the uninsured, and so on—won’t be clear for some time. But the unmistakable intention of Trump’s White House has been to make the law function worse wherever possible. In some parallel universe, where a Republican Party interested in responsible governance exists, there’s a set of conservative reforms that some Administration could adopt in order to refashion the ACA along more ideologically amenable lines, without upsetting its basic purposes.
But in the world we inhabit, there is only the Trump Administration’s distinctive pettiness. Trump’s HHS all but eliminated the advertising budget for Obamacare sign-up, claiming that the ads didn’t work—despite a recent HHS study showing the exact opposite. Not only that: As a report in the Times showed, the agency spent money (probably from the same advertising budget) to create propaganda videos denigrating the very law it is tasked with executing; stamped its logo on a series of misleading infographics sent from Secretary Price’s Twitter account; and removed informative consumer guides from the HHS website. That last act is the most telling of them all. The agency’s anti-Obamacare propaganda, however noxious, was at least developed for the ostensible policy goal of replacing the ACA with a program that conservatives claim to believe would work better. But removing useful information does little more than make Americans’ lives more difficult.
This contempt for consumers wasn’t limited to HHS’s scrubbing of its own website. The agency also announced deep cuts in funding for “navigators”—who offer enrollment assistance to people who (for example) don’t speak English, or lack Internet access, or simply have complicated situations and need assistance. It instructed its regional directors not to participate in open enrollment events and explained its decision in an official statement that invoked conservative fantasies about Obamacare’s “collapse,” while expressing fake concern for “the American people who continue to be harmed by Obamacare’s failures.” This is especially rich, since the predictable effect of these efforts will be to leave Americans uninformed, misinformed, or simply confused, leading to a greater number of uninsured people. And this will lead, in turn, to preventable health problems, preventable financial problems, and preventable personal crises for thousands, maybe millions, of Americans—all abetted by their government in the service of a policy goal that, as the GOP’s dashed-off “replacement” plans revealed, exists only in the conservative imagination. Under our actually existing health-care system, Trump’s actions will probably depress this year’s enrollment numbers by at least one million, and perhaps more.
If these actions lack any constructive policy logic, they nonetheless exhibit a political one: Trump has frequently expressed his belief that when Obamacare collapses, Democrats will be forced to come to the bargaining table and join him in crafting a replacement. In this formulation, it’s implied that the law will collapse on its own—something that is an article of faith on the right, despite consistent evidence to the contrary. But, as Trump has shown, he’s more than willing to help usher that result.
The question is whether Trump’s political instincts are serving him well in this case. It’s worth stating clearly something that Trump’s persistently low approval numbers are making clear: His shocking election victory has resulted in widespread overestimation of his political sagacity. No doubt this President has an instinctive knack for lowest-common-denominator right-wing demagoguery, but that’s a very different skill than being able to game out the dynamics of legislative bargaining. But that’s precisely what Trump is trying to do in cutting off federal subsidies for cost-sharing reductions (CSRs)—which help insurance companies bear the cost of offering certain low-cost plans that the ACA requires. If insurance companies don’t receive this expected subsidy, a number of them might pull out of the exchanges. (What’s more, the CBO has estimated that eliminating CSRs would actually increase the federal deficit by $194 billion through 2026.) As Greg Sargent notes, while creating chaos in the insurance markets is evidently part of Trump’s grand plan, this latest example of brinksmanship is actually making congressional Republicans nervous, since the halting of these payments could harm many of their constituents. Bipartisan efforts to appropriate the money have so far been unsuccessful, and it’s not clear that Trump would even agree to a deal if one were reached.
Trump’s other recent step, announced in an executive order, expands the kind of cheap, barebones plans that proliferated in the years before Obamacare was passed, and which effectively made insurance unaffordable for millions of poor and sick Americans. Perhaps more than anything else Trump has done, this action could return large sectors of the American health-care system to the status quo ante, where healthy people can buy insurance policies that are cheap (in both senses of the word), at least until they actually need to use those policies—and where sick people face increased costs that will block many of them from getting the care they need.
Of course, this is still a far cry from the chaos that would result from full ACA repeal. Most importantly, Medicaid expansion remains in place. And even if junk plans proliferate under Trump’s new EO, the insurance policies sold on Obamacare’s exchanges would still be subject to minimum coverage requirements and other pro-consumer regulations. But these plans could grow rapidly in cost, particularly if healthy people decide to opt for the unregulated temporary plans that Trump wants to expand. Trump’s promotion of those plans exhibits his distinctive knack for simple, if stupid, messaging: “the way to make health insurance available to everyone is to lower the cost of health insurance.” But these plans aren’t like Trump’s steaks, neckties, or cologne—they actually exhibit some connection between price and quality. What they do have in common is the grinning huckster standing behind them, assuring you that nothing is more amazing, more tremendous. He’s beginning to realize that this health care thing is too complicated for him, but he’s not shy about taking huge steps anyways.