Trump is sabotaging your health care because of spite

Is Trumpcare finally dead? Even now, it’s hard to be sure, especially given Republican moderates’ long track record of caving in to extremists at crucial moments. But it does look as if the frontal assault on the Affordable Care Act has failed.

And let’s be clear: The reason this assault failed wasn’t that Donald Trump did a poor selling job, or that Mitch McConnell mishandled the legislative strategy. Obamacare survived because it has worked — because it brought about a dramatic reduction in the number of Americans without health insurance, and voters didn’t and don’t want to lose those gains.

Unfortunately, some of those gains probably will be lost all the same: The number of uninsured Americans is likely to tick up over the next few years. So it’s important to say clearly, in advance, why this is about to happen. It won’t be because the Affordable Care Act is failing; it will be the result of Trump administration sabotage.

Some background here: Even the ACA’s supporters have always acknowledged that it’s a bit of a Rube Goldberg device. The simplest way to ensure that people have access to essential health care is for the government to pay their bills directly, the way Medicare does for older Americans. But in 2010, when the ACA was enacted, Medicare for all was politically out of reach.

What we got instead was a system with a number of moving parts. It’s not as complex as all that — once you understand the basic concept of the “threelegged stool” of regulations, mandates and subsidies, you’ve got most of it. But it has more failure points than, say, Medicare or Social Security.

But now, when Trump threatens to “let Obamacare fail,” what he’s really threatening is to make it fail.

On Wednesday, the Times reported on three ways the Trump administration is, in effect, sabotaging the ACA (my term, not The Times’s). First, the administration is weakening enforcement of the requirement that healthy people buy coverage. Second, it’s letting states impose onerous rules like work requirements on people seeking Medi-caid. Third, it has backed off on advertising and outreach to let people know about options for coverage.

And there may be worse to come: Insurance companies, which are required by law to limit out-of-pocket expenses of low-income customers, already are raising premiums sharply because they’re worried about a possible cutoff of the crucial federal “cost-sharing reduction” subsidies that help them meet that requirement.

The truly amazing thing about these sabotage efforts is that they don’t serve any obvious purpose. They won’t save money — in fact, cutting off those subsidies, in particular, probably would end up costing taxpayers more money than keeping them. They’re unlikely to revive Trumpcare’s political prospects.

So, this isn’t about policy, or even politics in the normal sense. It’s basically about spite: Trump and his allies may have suffered a humiliating political defeat, but at least they can make millions of other people suffer.

Can anything be done to protect Americans from this temper tantrum? In some cases, I believe, state governments can insulate their citizens from malfeasance at HHS. But the most important thing, surely, is to place the blame where it belongs. No, Mr. Trump, Obamacare isn’t failing; you are.