Taking health care hostage

Three weeks have passed since the Trumpcare debacle. After eight years spent denouncing the Affordable Care Act, the GOP finally found itself in a position to do what it had promised, and deliver something better. But it couldn’t.

And Republicans, President Donald Trump very much included, had nobody but themselves to blame. Basically, the party has been lying all this time, and the lies finally caught up with the liars. Mr. Trump promised health care that would be “far less expensive and far better”; in the event, all he and his allies had to offer were surging premiums, higher out-ofpocket expenses and mass loss of coverage.

But Mr. Trump, as you may have noticed, isn’t big on accepting responsibility for his failures. He has decided to blame Democrats for not cooperating in the destruction of their proudest achievement in decades. And on Wednesday, in an interview with The Wall Street Journal, he openly threatened to sabotage health care for millions if the opposition party doesn’t give him what he wants. In that interview, the president of the United States sounded just like a mobster trying to extort protection payments from a shopkeeper.

“Obamacare is dead next month if it doesn’t get that money,” he declared, referring to cost-sharing subsidies that reduce out-ofpocket expenses for low-income families and are crucial even to higher-income families, because they help keep insurance companies in the system. “I don’t want people to get hurt.” (Nice shop you’ve got here, shame if something were to happen to it.) “What I think should happen and will happen is the Democrats will start calling me and negotiating.” (I’m making them an offer they can’t refuse.)

It’s a nasty political tactic. It’s also remarkably stupid.

The nastiness should be obvious, but let’s spell it out. Mr. Trump is trying to bully Democrats by threatening to hurt millions of innocent bystanders — ordinary American families who have gained coverage thanks to health reform. True, Democrats care about these families — but Republicans at least pretend to care about them, too.

Why does Mr. Trump even imagine that this threat might work? Implicitly, he’s saying that hurting innocent people doesn’t bother him as much as it bothers his opponents. Actually, this is probably true — remember, we’re talking about a man who once cut off health benefits to his nephew’s seriously ill 18month-old son to gain the upper hand in a family dispute. But it’s not the kind of thing one expects to hear from the occupant of the White House. What makes Mr. Trump’s tactic stupid as well as nasty is the reality that Democrats have no incentive whatsoever to give in.

For one thing, what is he offering by way of a deal? Obamacare increased coverage two ways, via Medicaid expansion and subsidized private insurance. Mr. Trump might be able to undermine the private markets, but Medicaid wouldn’t be affected. Why would Democrats ever agree to Republican plans, which would basically kill both?

Then there’s the political reality that by sabotaging Obamacare, the Trump administration would be handing Democrats a huge electoral gift. Bear in mind that the places that are already poorly served by private insurers, and would therefore be most hurt, are relatively poor, rural areas — places that overwhelmingly voted Trump last year.

Maybe Mr. Trump believes he could somehow shift the blame for the devastation he has threatened to wreak onto Democrats. “See, there’s the death spiral I predicted!” But that probably wouldn’t work even if he hadn’t effectively proclaimed his own guilt in advance. Voters tend to blame whoever holds the White House for bad things, and in this case they’d be right: If there is a death spiral, it will have Mr. Trump’s name on it, and deservedly so.

There’s a reason an open letter to Mr. Trump urging that the cost-sharing subsidies be maintained was signed by a wide array of lobbying organizations, including very conservative groups like the U.S. Chamber of Commerce. What they understand is that sabotaging Obamacare would be a disaster for their interests.

So the Trump health care threat is, as I said, stupid as well as nasty. And it’s hard to believe that it will be carried out. But here’s the thing: Even if Mr. Trump wimps out, as he is doing on so many other issues, he may already have done much of the threatened damage. Insurers are deciding now whether to participate in the 2018 Obamacare exchanges. Mr. Trump’s tough talk is creating a lot of uncertainty, which in itself may undermine coverage for many Americans.

There is, of course, a good chance that Mr. Trump doesn’t understand any of this. Unfortunately, when you’re in the White House, what you don’t know can hurt a lot of people.