Like every other Republican running for the White House last year, Donald Trump routinely disparaged President Barack Obama’s signature accomplishment, the Affordable Care Act, which extended health insurance to 20 million Americans. He called it “amazingly destructive” and “a catastrophe,” saying at his final campaign rally before the election, “Real change begins with immediately repealing and replacing the disaster known as Obamacare.” Trump hasn’t let up since becoming president, claiming the program is “broken” and in “a total death spiral.”
Yet, as the New Republic’s Alex Shephard noted on Thursday, candidate Trump also broke with GOP orthodoxy on health care, promising not to cut Medicare or Medicaid and making a series of very broad commitments in a September 2015 interview with CBS News. “Everybody’s got to be covered,” he said. “This is an un-Republican thing for me to say.... I am going to take care of everybody. I don’t care if it costs me votes or not. Everybody’s going to be taken care of much better than they’re taken care of now.”
Many reporters have noted these and other contradictions in Trump’s health care positions since he launched his campaign in 2015: He’s been for ACA’s individual mandate and against it, complimentary of single-payer systems around the world even as he says he doesn’t want one in America. But now that House Republicans have passed their hastily crafted health care plan and a divided Senate GOP is scrambling to finalize its own version—both of which would uninsure more than 20 million Americans and cut Medicaid by hundreds of billions of dollars—Trump may finally face a difficult choice: Keep his promise to repeal Obamacare, or keep his promise to cover “everybody.”
Trump will have to break a promise either way. That’s the consequence of telling people only what they want to hear, rather than having a coherent policy agenda. Rhetorical promiscuity has caused Trump many headaches, but the Republican health care plan is an especially sticky wicket because it would force him to resolve the warring impulses that fueled his campaign: destroy Barack Obama’s legacy, and help the “forgotten men and women” of America.
His decision will have serious ramifications for more than 20 million Americans, of course, but may also determine the course of his presidency and of the Republican agenda. If Trump were a smart and rational politician, and willing to trust his best instincts, he would make the obvious choice: come out against the GOP’s health care plan—the sooner, the better.
Trump has long been obsessed with Obama, famously waging a years-long “birther” campaign claiming the president wasn’t born in the United States. But as New York Times columnist Charles Blow wrote on Thursday, Trump is still obsessed with his predecessor. Trump, whose approval ratings are historically low, envies Obama’s enduring popularity and clearly resents him for it. “The problem with Obamacare isn’t that it hasn’t borne fruit, but rather that it bears Obama’s name,” Blow wrote. “For Trump, the mark of being a successful president is the degree to which he can expunge Obama’s presidency.”
At the same time, there’s evidence that Trump doesn’t share congressional Republicans’ zeal for shredding the social safety net. Whereas House Speaker Paul Ryan has dreamed of slashing Medicaid since he was “drinking at a keg,” Trump has advocated for universal health care as far back as his Reform Party bid for president in 2000. The Washington Post recently called single-payer “his forbidden fruit,” noting how Trump praised Australia’s national system as “better health care” while also praising the House repeal bill: “Trump’s past—and now current—rhetoric doesn’t lie: He’s pretty impressed with government-run health care in the places it works. It’s almost like he wishes he could do it here.”
Single-payer is anathema to Republican Party orthodoxy. “Conservatives in America have spent the better part of the past century arguing that the idea is socialistic, would lead to long waits for lifesaving treatment, and would give the government power over the life and death of its citizens,” Vox’s Dylan Matthews wrote in April. And yet, “Trumpism in its purest, alt-right variety cares more about white working-class identity politics than traditional conservatism,” which is why some of his most prominent alt-right supporters favor single-payer. Democrats are driving the growing nationwide support for single-payer, but would the Republican rank-and-file object to the policy if Trump framed it as helping the “forgotten men and women”? His core supporters appear willing to stick with him no matter what he does, so long as he holds firm on immigration restriction and other policies communicating white racial solidarity. The one issue that might be imperiling Trump’s standing with his base, in fact, is the current Republican health care plan.
“The data suggests, in particular, that the GOP’s initial attempt (and failure) in March to pass its unpopular health care bill may have cost Trump with his core supporters,” FiveThirtyEight statistician Nate Silver wrote last month. According to Silver, Trump’s “strong approval” ratings fell five points between the introduction of the House bill and when it was pulled before a vote; the ratings fell further after it was reintroduced and passed in May. Now, the Senate bill is proving incredibly unpopular, even within the GOP. A USA Today/Suffolk University poll this week found that just 12 percent of Americans back the legislation—including only one in four Republicans. “Polling suggests that Trump would be better off politically if this bill failed, and he might be better off in terms of policy too,” FiveThirtyEight’s Harry Enten and Perry Bacon Jr. wrote Thursday.
There is a hitch in the above poll: Eight in ten Republicans said they support repealing Obamacare, and “close to a third say the law should be repealed even if a replacement health care plan isn’t ready yet.” But the poll also asked, “How important is it to you that lower-income people who became eligible for Medicaid through the Affordable Care Act continue to be covered by Medicaid?” Almost three in four Republicans said it was “very” or “somewhat” important to them. Here, we see that the warring impulses within Trump are mirrored by the party’s base: They hate everything Obama has done, but also believe poor people with health care shouldn’t have that health care ripped away from them.
This is the destructive power of negative partisanship. By defining themselves only in opposition to Democrats, rather than through a positive policy agenda, the Republicans have painted themselves into a corner. Obamacare repeal was their main campaign promise for the better part of a decade, and now that voters have handed them the power to gut the law, they feel obligated to do so—rather than, say, implementing a health care reform plan that uses conservative principles to expand insurance coverage.
But Trump has never felt obligated to keep his own promises, let alone his party’s. One of the few benefits of his rise to power—including his defeat of Senator Ted Cruz in the primary—was exposing the GOP base’s disregard for the small-government ideology embraced by the likes of Ryan and the party’s donor class. An analysis last year from the liberal think tank Demos found that non-donor Republicans opposed the party’s austerity agenda, including the Ryan budget and the Bush tax cuts. Trump is also, if nothing else, a salesman, and diehard Republicans almost always buy what he’s selling. In arguing for the GOP to drop Obamacare repeal, he could say he wants to work instead on creating jobs and tightening the nation’s borders. He could even claim that he was “saving” health care for more than 20 million Americans, against the wishes of the party establishment he hates. It’s hard to imagine the base siding with Ryan, who’s less popular than Trump among Republican voters.
Then there’s the question of whether Obamacare repeal would hurt the GOP in next year’s elections. Enten and Bacon wrote that “strong disapproval of the bill far outruns strong approval of it. In other words, enthusiasm—one driver of turnout in the 2018 midterms—will likely be running against the bill. Obama signed a somewhat unpopular health care bill into law in 2010, and then watched his party’s House majority get wiped out a few months later, in part because of that health care vote. And the GOP bill is more unpopular than Obamacare was at the time of its passage.” Why would Trump want to risk losing the House over an issue he’s not even that passionate about?
With health care behind him, Trump would be free to move on to priorities that are more central to his political identity. On Inauguration Day, NPR noted that Trump has been consistent on a few key issues for as long as he’s dabbled in politics: “Common themes include his view that trade wasn’t fair, that the world has long laughed at America and countries have taken advantage of U.S. generosity while refusing to pay their ‘fair share’ for all the U.S. does globally.” He’s similarly maintained what The New York Times in 1999 called a “firm” commitment to immigration restriction, and his racist law-and-order rhetoric dates back at least to 1989, when he placed a full-page ad in the New York Daily News calling for the death penalty for the Central Park Five. In other words, while the president has long held many reprehensible views, depriving millions of health insurance was never a priority. Why stake his legacy on it?
Throughout this legislative process, Trump has been rightly ridiculed by pundits, Democrats, and even members of his own party for lacking a basic understanding of health care. “When asked if the president understood or had a solid grasp on the important facets of the Senate or House incarnations of repeal-and-replace, one official—who works closely with the president on health-care policy, replied initially with a few moments of light chuckling—before answering ‘not to my knowledge,’” The Daily Beast reported on Wednesday. Yet there are moments when he seems to understand the issue better than any Republican in Washington. The president was right to call the House bill “mean,” and on Wednesday, in a meeting with dozens of Republican senators, he reportedly made “an off-note remark at the top of the meeting that it could be ‘OK’ if the GOP’s repeal effort failed.”
That remark, if true, is especially stunning given the president’s obsession with winning. “Maybe,” Senator Bob Corker hypothesized to Politico, “he’s making the statements in the way that he is to condition [people] in the event it doesn’t happen.” Or maybe Trump is beginning to realize that, in this case, true victory would come in the form of failure.