The Washington PostDemocracy Dies in Darkness

Opinion Does Trump want to destroy our health-care system? He can’t seem to decide.

(Pablo Martinez Monsivais/Associated Press)

Everybody says they want bipartisan solutions to complex problems, but what happens when a bipartisan solution actually shows up? In Donald Trump’s Washington, the answer is that whether it actually comes to fruition depends on the shifting whims of a president who doesn’t understand the issue and can’t even figure out what he wants to do.

President Trump is facing a dilemma: Does he want to destroy the American health-care system or not? At this point, all evidence suggests that he genuinely can’t decide what the answer to that question is.

As you know, Sens. Patty Murray (D-Wash.) and Lamar Alexander (R-Tenn.) have announced that they reached an agreement on a short-term plan to stabilize the health-care exchanges. It would continue the cost-sharing reduction (CSR) payments in the Affordable Care Act that Trump recently announced he’d be halting; give states greater flexibility to receive waivers of certain requirements in the ACA; restore funding for outreach to encourage people to sign up for coverage, which the administration has slashed; and allow more people to get high-deductible “catastrophic” coverage.

In other words, the compromise offers something for Democrats and something for Republicans. By no means would it solve every issue the law has, but it’s meant to provide some short-term certainty, which should slow the dramatic premium increases insurers have requested since the Trump administration began its campaign of sabotage against the law.

When the Alexander-Murray agreement was announced yesterday, Trump at first seemed supportive. “It is a short-term solution, so that we don’t have this very dangerous little period — including dangerous periods for insurance companies,” he said at a press conference. “For a period of one year, two years, we will have a very good solution.” But then this morning, he tweeted, “I am supportive of Lamar as a person & also of the process, but I can never support bailing out ins co’s who have made a fortune w/ O’Care.”

What gives? When you try to interpret the president’s shifting positions — and figure out how this is all going to end — there are a few things you have to keep in mind. First, it’s wise to assume that he has no idea how any provision of this agreement or the ACA itself actually works, and that will not change. For instance, he seems to have convinced himself that cost-sharing reductions are like an extra bonus given to insurance companies that they’ll just use to pad their profits. “That money is going to insurance companies to lift up their stock price,” he has said, when in fact the money is basically passed through the insurers to provide lower co-payments and deductibles for people with low incomes. He hasn’t bothered to learn what the law does, and he certainly isn’t going to quickly get up to speed on new proposals to provide technical fixes.

Second, you have to remember that Trump has no ideological principles on health care that can provide us a guide to what he might do. At various times he has embraced viciously cruel Republican plans that would cut off coverage for tens of millions, and said he wants the government to provide “insurance for everybody.” He simply has no consistent beliefs on this subject (and, of course, on many others).

Third, he is pushed in different directions by competing impulses, any one of which may dominate at a particular moment. It has become clear that there may be no desire that governs his actions more than his need to destroy and discredit everything Barack Obama did. We can debate why this is; my view is that Trump, who is obviously a deeply insecure man, looks at Obama and sees someone who is his superior in almost every way — smarter, more competent, more admired and respected — and is enraged by the inevitable comparisons. But the fact that Trump is driven to undo anything with Obama’s name on it is undeniable.

That goes a long way toward explaining why Trump is so eager to destroy the individual insurance market, at the cost of enormous anxiety and suffering among the public, when his advisers have surely explained to him that he will be held responsible for whatever happens to American health care on his watch. No matter how much it costs him politically, he wants to be able to say that Obamacare is dead, he killed it, and it was a terrible thing in the first place.

However, at the same time Trump is desperate to show that he can make a deal. The failure of the GOP effort to repeal the ACA plainly weighs on him. Despite his belief that he is the greatest dealmaker in human history, you may have noticed that he has negotiated precisely zero deals of any magnitude since becoming president. The Republican Congress has passed no major legislation this year. Trump’s increasingly desperate and comical insistence that he is piling up an awe-inspiring record of accomplishment — “in nine months, we have done more, they say, than any president in history,” he said today — only highlights his eagerness to have something he can say he actually got done.

Which raises the question of what he would do if the Alexander-Murray agreement actually passed both houses of Congress and found its way to his desk. My guess is that if he were actually presented with the choice he’d sign it, if for no other reason than that issuing a veto would be taking a firm stand. But before we get there, he’s going to keep undermining it with his public comments. That will only add fuel to the belief of ultra-right Republicans in the House that any bill that doesn’t set Barack Obama’s legacy aflame is a compromise with their beliefs and therefore unacceptable.

All of which suggests that though the Alexander-Murray agreement sounds like a perfectly reasonable thing to do and something Democrats and Republicans ought to be able to agree on, it’s more likely than not that it will fail. That won’t be entirely Trump’s fault, but he certainly won’t be helping.