Could Trump Sabotage the ACA to Push GOP Healthcare?

If there is anything Donald Trump hates, it’s losing. His presidential campaign was based almost entirely on sheer confidence and bluster, an intentional crafting of an image of winning. In a shock to pundits everywhere, it worked. Despite having zero public sector experience, Donald Trump bested the most experienced wonks in the business. His appeal to voters was that he was a doer and a winner, not a smooth talker.

Less than three months into his first term in office, Trump is now struggling to maintain his “winning image.” One of his key campaign promises, to repeal Obamacare, is in serious jeopardy after the initial attempt failed miserably. Despite his party controlling both the House and Senate, Trump could not stop intra-party disagreements sinking the American Health Care Act. The House bill, supposed to go for a floor vote on March 24, was called off when it appeared that too many Republicans would not vote for it.

For such a momentous bill to fail has been damaging to Trump’s image and renews questions about the political rookie’s ability to govern. Trump has criticized the tabling of the AHCA bill and still insists that Obamacare is a doomed law. He, and many other conservatives, have warned that Obamacare is in a “death spiral” and should be replaced before it can “collapse” and hurt consumers. Indeed, major health insurance companies have started abandoning the Obamacare exchanges, claiming that they cannot stay in business under the law’s regulations.

If Obamacare collapses, would Trump be vindicated? Would Republican legislators return to his side and offer their loyalty? The bombastic billionaire could go from being seen as foolish to being seen as wise and savvy.

Alarmingly, it turns out that there is a way for Trump to sabotage Obamacare and potentially force it into the “death spiral” he insists is imminent. Under previous President Barack Obama, a lawsuit put in jeopardy some $7 billion in Obamacare reimbursement funds to health insurers.  The Democratic White House was fighting to keep the subsidy program, while House Republicans were trying to block funding. With the turnover in presidents, the appeal has been put on pause.

President Donald Trump could decide, at any moment, to drop the White House’s appeal and let the $7 billion in subsidies to insurers disappear. Additionally, Trump and his Health and Human Services Secretary, Tom Price, could end any and all federal advertising for Obamacare’s open enrollment period, hoping to reduce the number of people signing up for insurance under it.  HHS could also take a step back and avoid trying to help stabilize health insurance markets that operate under Obamacare, hoping that instability takes over.

If Trump and Price decide to end any executive branch assistance for Obamacare, its system could indeed implode. Would Trump take such a political risk? That’s a tough call. Right now, he is hurt and humiliated. He has insisted that Obamacare is doomed, but how much blame will he shoulder for the pain felt by citizens if he decides not to help the program? The president is between a rock and a hard place: If he removes executive assistance for the law and tries to put Obamacare into a “death spiral,” he will be reviled as a monster. However, if he stays the course and continues to try to stabilize the Obamacare health insurance markets, he is actively working against his own rhetoric.

He might try to end the subsidies by advertising a “tough love” approach, insisting that Obamacare must “sink or swim” on its own in order to avoid future Republican attempts to repeal it. Such hard-nosed tactics would be condemned by Democrats, and even some liberal Republicans, if and when consumers feel the pinch. If Obamacare collapses, as Trump predicts, he could say that he gave it a fair chance.

But if Obamacare does not collapse, Trump will have put the entire GOP in a huge bind: He will be expected to honor his word about leaving the law alone. If the Affordable Care Act limps on without the White House subsidies, Trump and his fellow party-mates in Congress will have to let it live. It will become the “law of the land,” and eventually even Republicans will be expected to support it. 

Facing those tough trade-offs, Trump might be tempted to sit back and let Republicans in Congress prepare a second legislative assault on Obamacare. However, this could erode his image as a hard-charging leader. Having faced his first major policy defeat, he knows that all eyes are on him to see how he will respond. Will he retreat from healthcare reform and pretend that it was not a key focus of his presidential candidacy, or will he keep at it?

Trump’s own allies will likely push for him to use his executive power to remove the Obamacare subsidies, urging him to act as decisively on healthcare reform as he did on immigration.  “You’ll look weak if you have a move to make and you don’t make it,” they will tell him. “You were bold on immigration, and your image will suffer if you don’t keep that up on healthcare.”  Unable to back down from a challenge, Trump might be willing to gamble on Obamacare’s sans-subsidy fate. 

The costs could be steep, and few people will applaud the president’s maneuver that could jeopardize the healthcare of America’s poorest citizens. But, if Trump’s prediction is correct and Obamacare does implode, he will no longer be the rube.

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