Donald Trump’s ideological nihilism — his complete lack of a moral core — has actually given some people hope. He’s thin-skinned and fickle, sure, but that makes him easy to manipulate, or so the thinking goes. Obama himself tested the limits of flattery as a political tool in the immediate aftermath of the election, including using his one-on-one with Trump to soft-pedal keeping the “good parts” of the Affordable Care Act. I can’t be the only one who imagined a scene with Obama whispering conspiratorially, “I get that you need to please your base, but don’t scrap the whole thing. Just make a few cosmetic changes and, hell, call it Trumpcare if you want.”
For optimistic ACA advocates, this seems pretty plausible! After all, making cosmetic changes and slapping his name on things is basically Trump’s entire business model. What’s more, Trump has explicitly advocated for universal, government-sponsored health care before! And as his party grapples with the complicated reality of his “repeal and replace” Obamacare promise, it seems likely that more is up for negotiation than many on the left have feared. Maine Republican senator Susan Collins is lukewarm on privatizing Medicare, for instance. The “replace” plan crafted by Trump’s pick for Secretary of Health and Human Services, Representative Tom Price, even includes a kinda-sorta provision against discriminating against preexisting conditions.
So maybe Obama defanged Trump’s seething resentment; maybe Trump’s serious about making sure that “Nobody is going to be dying in the streets if I'm president.”
This “anti–people dying in the streets” stance would certainly be a departure from the GOP platform of the last three decades — something Trump himself has pointed out. During the primaries, he seemed genuinely mystified that withholding health care from poor people was a clear Republican policy. “We’re not going to let people die in squalor because we are Republicans. OK?” he said in an early debate. “That’s part of the problem with the Republicans. Somehow they got fed into this horrible position.”
Of course, that was before Trump realized that his supporters weren’t just amenable to people dying in the streets, but actually unfazed by threats that Trump might do the killing himself — with a gun, on Fifth Avenue.
And make no mistake, turning a blind eye to human suffering isn’t a “problem” with the Republicans’ position on health care — it’s the defining feature. Perhaps the biggest lie the GOP is telling voters, for instance, is that they are going to “replace” the ACA, as if their proposals were simply a different approach to the same problem. But comparing the ACA to any of the GOP alternatives isn’t like comparing apples and oranges, it’s more like an apple vs. a hand grenade. I mean, both keep the doctor away, I guess?
The ACA is the deeply flawed product of a practical desired outcome — in other words, it’s politics as politics has been practiced for centuries. The problem: Given political and economic realities, how do we make health care available to the widest possible set of Americans? Twin values guided the project from its inception. First, that it’s a good idea to use government policy to increase the general health of the population — not to just take care of people when they’re sick, but to keep them from getting sick in the first place. Second, and just as important: If someone does get sick, the government has a responsibility to find a way to care for that person.
Everything in the ACA can be explained by that set of goals and values. But “replace” schemes ignore the ideals underlying the project. Even the most generous among them don’t claim to pursue access to affordable health care — they aim to increase access to health insurance, mainly using market mechanisms to make it cheaper. Sure, you can make insurance cheaper by making everyone buy it and forcing insurance companies to spread the risk, but Price’s Empowering Patients First Act goes the opposite route, making insurance cheaper by lifting pricing restrictions and the individual mandate. Under his plan, insurance companies can sell cheap insurance to healthy people and really expensive insurance to sick people — who will be “empowered” to not buy it if they can't afford it.
The idea that access to insurance should be the goal of health care policy is why you often hear conservatives making the argument that health insurance markets should be more like those for car or homeowner’s insurance. But the clear problem with that comparison is the gulf between how we feel about an abandoned car and how we feel about an abandoned child. This is not exactly to say that the Republicans behind “replace” plans lack compassion themselves, but it's incontrovertible that they don't build compassion into their policies.
Yet some Democrats and pundits are betting that the GOP will realize that throwing 20 million people off their health plans might be political suicide, which could act as a kind of emotional backstop to the campaign to repeal. Surely, reasonable people say, Republicans will run away from the prospect of the media hanging a thousand sob stories around their necks! (As Washington’s Democratic senator Patty Murray said of current negotiations over a “repeal and delay” bill: “You break it, you buy it.”) But I wouldn’t count on Republican distaste for bad optics, certainly not with this president in the White House. For Trump, “optics” are just another form of publicity — what would it even mean for them to be “bad”? The only person who's gone bankrupt underestimating Trump’s appetite for cruelty is the man himself.
The first rule of an autocracy, Russian journalist Masha Gessen wrote in the immediate aftermath of the election, is to believe the autocrat. This isn’t important because Trump has a specific policy agenda; it’s important because he doesn’t have one. He’s got no particular goal he’s moving toward, just an image to keep up. His public waffling on his own signature campaign promises should not comfort us, it should alarm us all the more. It doesn’t reveal a lack of will, it betrays a lack of interest. He doesn't have a short attention span, he has a total lack of empathy. His apparent ambivalence about policy exists only as long as it applies to other people. He doesn’t care about them, and not caring is the only thing the Republican establishment asks of him.