GOP leaders have reached the cusp of passing a health care bill paradoxically: by making it crueler. To set aside their reservations and line up behind the legislation, conservatives insisted that the American Health Care Act include a politically toxic provision that would allow states to charge people with pre-existing conditions unlimited sums of money for health care coverage. Their leaders obliged.

The GOP’s new theory of victory rests on this provision surviving, and persuading moderate Republicans—the most vulnerable, but most easily bullied, Republicans in the House—to vote for it despite the political danger.

Enter President Donald Trump, who, over the weekend, muddied the House position in a way that threatens to scramble the leadership whip count, then turned around and (you may have heard this story before) pushed Republicans to vote on the bill this week anyhow.

This kind of policy schizophrenia—marked by mixed messages, over-promises, bluffs, and self-defeating deadlines—has typified the first months of Trump’s presidency. It created obvious problems for Trump himself as his 100th day in office approached, but it should also have Republicans in Congress asking themselves whose interests they’re serving by returning to the health care trough over and over again. After all, they will be held responsible as much as Trump for the ensuing chaos when the work of legislating is over and the technically challenging job of implementation begins.

If Republicans in Congress send Trump a bill, they won’t simply be replacing Obamacare with Trumpcare. They will be entrusting the administration of a major federal program to a man who won’t understand the most basic facts about the legislation he is signing.


On Sunday, Trump told Face the Nation host John Dickerson that Republicans are “changing” the bill so that pre-existing condition protections are “permanent” rather than “optional” for the states. In the same interview, though, Trump boasted that Republicans will “create pools [that] are going to take care of the pre-existing”—which is the condition upon which states will be allowed to waive protections for pre-existing conditions.

Was Trump lying or confused? The answer appears to be yes.

But his confusion isn’t limited to health care. Trump’s legislative initiatives have stalled, and his administrative initiatives have been held up by courts, because Trump does not grasp the complexities of the presidency. Yet as badly as he’s bungled his agenda thus far, none of the tasks before him have been as complicated as administering Trumpcare will be.

The Congressional Budget Office has yet to issue a cost estimate of the updated Republican health care bill, but we know from an earlier estimate that implementing the AHCA will not be as straightforward as shrinking aspects of the Affordable Care Act that are already in effect. For instance, CBO warns that by decentralizing the Obamacare marketplaces but continuing to issue subsidies on behalf of enrollees to insurers, AHCA would create a major compliance issue.

“[P]rocedures would need to be in place to enable the Internal Revenue Service and the Department of Health and Human Services to verify that the credits were being paid to eligible insurers who were offering qualified insurance as defined under federal and state law on behalf of eligible enrollees,” the report notes. “[Our] estimates reflect an assumption that adequate resources would be made available through future appropriations to those executive branch agencies to ensure that such systems were put in place in a timely manner. To the extent that they were not, enrollment and compliance could be negatively affected.”

Likewise, by fracturing the marketplaces, the AHCA would make the user experience for enrollees more frustrating. “With more plans that are eligible for subsidies offered directly from insurers or directly through agents and brokers and not through the marketplaces’ central websites, shopping for and comparing plans could be harder, depending on insurers’ decisions about how to market their plans.”

These complications won’t just resolve themselves. They will require the kind of competent execution Trump has shown no aptitude for.

Consider for a moment how difficult the implementation of the Affordable Care Act was for President Barack Obama, who ran an unusually tight ship and was a model of competence and deliberation compared to Trump. When ACA enrollment opened for the first time, the website didn’t work. The political consequences of that horrifying failure were exacerbated by the fact that insurers canceled thousands of plans ahead of the Obamacare rollout, leaving their former beneficiaries uninsured and without a working portal through which to purchase new coverage. Amid a nasty backlash, the Obama administration rushed out an order grandfathering plans that hadn’t been canceled and he spent the rest of his presidency answering for how things had gone so badly awry.

Do Republicans in Congress want to be on the hook when Obamacare beneficiaries lose their plans and can’t find comparable ones on Healthcare.gov? Do they trust the Trump administration to come up with quick solutions when people find that their new, deregulated plans are crap? Do they think Trump will care, or have the capacity to respond, when the Government Accountability Office determines that the federal government is wasting billions of dollars subsidizing scam health insurance plans? Thinking past the imperative they feel to pass something, if only because this gridlock makes them look ridiculous, do Republicans believe Democrats will fix these problems in the future, rather than scrap Trumpcare for something like Medicare for all when they inherit the mess?

As a general rule, it is a bad idea to make laws that will create political crises, especially when the president lacks the capacity to address them.

I think Republicans should not pass the AHCA because it is a bad bill, but even if I thought it was a good bill, I would be rattled by the thought of handing responsibility for its success over to an administration that can’t run the White House dishwasher without destroying something.