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Trump and his allies are desperate. With desperation comes cruelty.

General James Mattis Sworn In As U.S. Defense Secretary Olivier Douliery-Pool/Getty Images
Dylan Matthews is a senior correspondent and head writer for Vox's Future Perfect section and has worked at Vox since 2014. He is particularly interested in global health and pandemic prevention, anti-poverty efforts, economic policy and theory, and conflicts about the right way to do philanthropy.

Senate Republicans plan to write their latest health care reform bill — which according to the Congressional Budget Office could lead to 16 million fewer people having insurance and could drive up premiums by 20 percent — over lunch.

No, literally: Reuters correspondent Yasmeen Abutaleb reports that Senate Republicans plan to write the "skinny repeal" bill, which reportedly will involve repealing requirements that individuals and employers buy health insurance, over their policy lunch on Thursday. We know in broad strokes what the bill will say — or, at least, we’ve known since the whole idea of a skinny repeal bill was first broached a couple of days ago. But the details will apparently be hammered out in a single lunch.

This bill, to be perfectly clear, could become law. The plan is to have the Senate pass it, go into conference committee with the House’s health care bill, arrive at a compromise that repeals more of Obamacare than the Senate bill but less than the House bill, and then pass it between both chambers. But if the past few months are any indication, getting the Senate to agree to anything more than the skinniest possible repeal bill is tremendously difficult. And if the compromise agreed to with the House fails in the Senate, then the House might wind up doing what it did back in 2010 to pass Obamacare in the first place: passing the Senate version, without alteration.

With President Trump’s signature, skinny repeal would become the law of the land. A law, negatively affecting millions of people, written in a lunch meeting.

The policymaking of the Trump administration and its allies in Congress, in recent days but also since the inauguration, has been not merely cruel but desperate. At times, it’s been cruel because it’s desperate. Lawmakers and the president are in such a great rush to do something, anything, that might be perceived as fulfilling their campaign pledges that they are willing to inflict untold collateral damage in the process.

The Trump presidency is leaving human wreckage in its wake

Kristen Beck
Kristin Beck, a former Navy SEAL Team Six member and a transgender woman.
FBI/Public Domain

The process — “process” — behind the announcement of Trump’s ban on transgender military service is a surreal and infuriating case in point. According to the tick-tock of Politico's Rachael Bade and Josh Dawsey, the decision had basically nothing to do with Trump's actual views on transgender troops. House Republicans were weighing a spending bill that would include funding for a number of Trump priorities, notably for building fences and walls on the Mexican border.

But the bill was being held back because some House Republicans wanted to include a rider banning the Defense Department from funding gender affirmation surgery for trans troops. Trump decided to break the impasse via executive action: He'd not only ban such funding but ban trans service members altogether. That wasn't something anyone, even the House members trying to ban surgical funding, wanted. As one Hill aide told Politico, "This is like someone told the White House to light a candle on the table and the WH set the whole table on fire."

The decision appears to have gone against the wishes of senior Pentagon leadership. Defense Secretary James Mattis had reportedly been taking it slow on the issue, urging Congress not to force any major policy changes. Trump announced the policy change via Twitter while Mattis was on vacation, and did not alert members of the military before tweeting.

The Pentagon was so out of the loop that the nine minutes between Trump’s first tweet announcing the change — “After consultation with my Generals and military experts, please be advised that the United States Government will not accept or allow...” — and the second “raised fears that the president was getting ready to announce strikes on North Korea or some other military action,” per BuzzFeed. And it’s still waiting; the military hasn’t gotten a formal memo from the president as of this writing and is holding off on making changes until it does.

All this due to an impulsive decision meant to help ease a spending bill forward.

Trump has shown at times that he’s able to act in a more or less rational fashion in service of well-defined ends. The border wall itself is a longstanding goal that Trump has been willing to go to great lengths (like banning all trans troops) to achieve. And he has been able to cause incredible harm in a calm, premeditated fashion. His travel ban and suspension of all refugee admissions is the clearest example: policies planned and refined over the course of years, for a specific, harmful end goal.

But just as often, Trump inflicts pain in passing, as an offhand gesture in the course of pursuing something else. That’s how the 1,300 to 15,000 trans troops currently serving the United States heard they’re getting kicked out via a few Twitter messages. It’s how the Pentagon tenses itself for a war with a nuclear power, because the president is bad at doing Twitter threads.

Trump does this because he’s desperate — because rather than trying to sit down and consider whether the damage caused by his actions justifies the goal they’re in service of, he just charges ahead, trying to bypass obstacles as soon as he meets them.

Congress’s health care saga shows how desperation can lead to cruel policy

Senate Holds Procedural Vote On GOP Health Care Bill Drew Angerer/Getty Images

That’s also how his Congress has operated. A lot of my fellow liberals will disagree with this, but I really do think it’s possible to design a genuinely conservative health care plan that’s not unacceptably cruel. Conservatives believe deeply that the problem with the health care system is that consumers are too insulated from the cost of care. They also worry that Medicaid offers beneficiaries too little access to doctors.

There are conservative policies that can meaningfully address these goals. Conservative policy analysts Kip Hagopian and Dana Goldman have proposed having the federal government pay for a catastrophic plan for everyone not on Medicaid or Medicare, where the deductible is a share of their income above the eligibility line for Medicaid. They propose setting the deductible at 10 percent of excess income per person, and a maximum of 20 percent of excess income per family.

"Suppose, for example, that the Medicaid threshold for a family of three in a certain state is $30,000," Ed Dolan, a libertarian policy writer, explains. "If their household income is $35,000, they would be responsible for the first $500 of each family member’s health care costs, or $1,000, at most, for the family. If household income was $85,000, the deductible would be $5,000 per individual. If household income were $1 million, the deductible would be $96,500."

But conservatives would like to replace Medicaid with private insurance. No problem. “The Hagopian-Goldman variant of universal catastrophic coverage [UCC] could be implemented in a way that would render Medicaid unnecessary,” Dolan writes. “Suppose, as in our earlier example, the UCC deductible is set at 10 percent of the amount by which household income exceeds $40,000, roughly the Medicaid threshold for a family of four. The deductible for families below the threshold would therefore fall to zero. These families would get ‘first dollar’ coverage from their UCC policy, so there would be no need for Medicaid as a separate program.”

I don’t agree with all of this plan. I think Medicaid does a perfectly fine job as is and doesn’t need replacement; I think that everyone, not just those on very low incomes, should have access to health care more generous than a catastrophic plan. But a universal catastrophic plan would provide universal access to some kind of health coverage. It would not lead to a mass loss of coverage, with tens of thousands of annual deaths as a consequence. It would not be cruel.

But arriving at and passing a plan like that isn’t easy. It requires compromises by die-hard conservatives on their insistence that the government shouldn’t guarantee universal coverage at all. It requires thoughtfully designing reforms to Obamacare’s insurance subsidies, and thinking about how to implement an income-based deductible in practice. It requires serious buy-in to the idea of keeping many Obamacare taxes, or else doing something unpopular like ending the tax break for employer insurance to pay for the catastrophic plans.

None of that has happened. Instead, we’ve had a desperate process, where Republicans first wanted to repeal the Affordable Care Act without any replacement; then wanted to replace it with plainly inadequate tax credits and pair it with gargantuan cuts to Medicaid; and now apparently just want to remove its mandates, defund Planned Parenthood, and call it a day.

The triumph of “skinny repeal” is remarkable, since it indicates that conservatives in Congress really are, at the end of the day, willing to accept minimal legislation that repeals little of Obamacare. Universal catastrophic coverage would likely cost enough less than Obamacare to enable repealing more taxes than skinny repeal eliminates. Hagopian and Goldman envision pairing it with an end to not only the individual and employer mandates but other regulations too.

Why are conservatives like Mike Lee and Rand Paul accepting such a weak repeal bill? Desperation. Because Mitch McConnell has rigged together a chaotic process where the goal is to pass something, anything, the potential for better policies that make every faction of the Republican Party happier and aren’t nearly as disastrous for the country is foreclosed. Those policies take careful work. Skinny repeal isn’t careful at all. It was written on a lunch break. It’s desperate. And desperation lets people do things they’d never do otherwise.

Republicans could save more money than skinny repeal saves, repeal more taxes than it repeals, and do more to further their stated goals on health care, without leading 16 million people to lose coverage and millions more to pay greater premiums. But they haven’t, out of sheer panic, desperation, and need to do something, anything. And that frantic rush has, once again, led to policies with a great human cost.