On Monday, President Donald Trump warned Republican senators that voting against Mitch McConnell’s (still mysterious) health care bill would amount to a betrayal of the Republican Party. “Obamacare’s lies have caused families nothing but pain,” Trump said. “Any senator who votes against starting debate on health care [is saying] that you are fine with the Obamacare nightmare.”
Trump’s statements about health care over the past few months have been so bewilderingly contradictory that it’s hard to ascribe any of the bill’s policy details to him personally. Trump famously promised to protect Medicaid and guaranteed low-cost universal coverage to all Americans — promises this bill does not keep. Its core ideas (which are wildly unpopular) were conceived of years ago in conservative think tanks and bolstered by Speaker Paul Ryan’s “A Better Way,” which Trump theatrically ridiculed during the campaign. Trump has given no indication of understanding or caring about the details of the legislation he’s promised to sign.
The result of all these factors is a tendency to see the House and Senate health bills as operating on a parallel but separate track from the “real” Trump agenda emerging from the White House.
This tendency is mistaken.
At some point over the past seven months, Trump transformed from an ambivalent enabler of Ryan’s health care vision to its leading and perhaps most vocal advocate. Despite Trump’s unclear personals policy views, few if any officials would deserve more credit — or blame — if it passes.
Trump is desperate for a win on the health bill
Six days after the inauguration, Sen. Bill Cassidy (R-LA) found a clever way to explain Trump’s indecipherable desire for the Republican health care bill. “[Trump] gives an order to build a 110-story structure, and he doesn’t tell you how deep to make the foundation. But you know he wants a very tall building,” Cassidy told me at a Republican policy retreat in Philadelphia. “It’s the same thing with us here.”
Cassidy’s metaphor flattered Trump’s reputation as a private builder, and it hinted at the skeleton of a coherent plan for governing: Trump would dictate the overall goals for a Republican health care vision, and then he’d let his lieutenants hash out the specifics.
But Cassidy was presuming that Trump cared about how tall he wanted his building to be, rather than simply demanding a building be constructed. Trump’s leading contribution to the House health care debate wound up having nothing to do with setting these kinds of overall objectives — like protecting those with preexisting conditions — but in merely bullying the contractors to just get something done.
At every stage in the health care debate, successive rounds of reporting have emerged that make clear Trump’s overriding desire is to sign something that could be called “Obamacare repeal,” regardless of the vital and transformative policy specifics:
- "Forget about the little shit," Trump told roughly 30 House conservatives at a planning meeting this March when he tried bullying them into passing the health bill. Some of them were reportedly taken aback that Trump wanted to rewrite one-sixth of the American economy without more careful deliberation. "Let's focus on the big picture here."
- After the bill finally did pass the House in May, Politico reported: “In the end, House members came around to Trump’s way of thinking: They wanted a political win.”
- Politico’s Josh Dawsey again reported about Trump’s lobbying for the Senate health bill: “To Trump, the Obamacare fight has always been about scoring a win. He doesn’t care nearly as much about the specifics, people close to him say, and hasn’t understood why legislators won’t just make deals and bring something, anything, to his desk.”
Trump reportedly cursed at recalcitrant Republican House members and promised retaliation against those who defied him. He has tried to threaten, joke, cajole, lobby, tweet, and dine the bill to passage. Regardless of his “true” underlying motivation, all of those efforts have ultimately been in service of the underlying repeal-and-replace health care vision.
Trump is doing nothing to protect Republicans from an unpopular bill
At the outset of this congressional session, the president seemed reluctant to champion the legislation.
“Trump kept the GOP health care bill at arm's length for more than a week, offering a smattering of favorable remarks but failing to embrace it in convincing fashion,” Politico’s Tim Alberta reported this March. “Ryan's rivals on Capitol Hill got the message: The president was lukewarm about the legislation.”
But instead of pressing Congress to align the bill with his campaign pledges, Trump simply ... decided to support it instead.
The Senate debate gave Trump yet another opportunity to push the bill in a more moderate direction. He could have bolstered GOP senators like Lisa Murkowski (R-AK) or Rob Portman (R-OH) who worry about its Medicaid cuts, or argued that the bill should do more to address the opioid crisis, or intervened to stop Sen. Ted Cruz’s (R-TX) plan to remove some of Obamacare’s regulations.
Instead, he’s done just the opposite. Trump has threatened to primary Republicans, like Sens. Dean Heller (R-NV) and Jeff Flake (R-AZ), who have sounded ambivalent about the bill. On Monday, as if to eliminate any lingering uncertainty, Trump again went on television to try to cow Republicans into supporting the health care bill.
For months, it looked like Democrats would have to choose whether to concentrate their firepower on Trump or on the health care bill that primarily belonged to Paul Ryan and the congressional GOP. The choice is no longer one they’re forced to make.