One of the reasons why Donald Trump captured the Republican presidential nomination in 2016 was his obvious willingness to burn the party establishment to the ground if he didn’t. In myriad ways, explicit and implicit, Trump made it known that if he lost the nomination there were multiple ways for him to scuttle the chances of whoever did, whether it was through a third-party candidacy or a relentless barrage of claims that the primary had been “rigged” against him.
Whether it was because they believed his threats or were simply unable to accept the possibility that Trump might actually win the nomination, much less the presidency, nobody in a position of power in the GOP tried to call his bluff. Whatever opposition there was to allowing a former reality television star to become the face of the party coalesced too late in the process, and many of its members later recanted in an effort to make peace with the new boss.
In the end, Trump never had to follow through on his threat to abandon the party and leave it a smoking ruin in his rear view mirror. Now the question of his was an empty threat must be weighing heavily on the party’s leaders because it’s what he’s threatening to do to the health insurance system set up under the Affordable Care Act.
Only this time, a small number of Republicans coming together to resist Trump at the last minute was enough to derail his plans.
In some ways, Trump’s approach to the long-running GOP effort to repeal former President Obama’s signature domestic achievement has been similar to his campaign for the Republican nomination: Promises of extraordinary success (“You’re gonna have such great health care at a tiny fraction of the cost, and it’s going to be so easy!”) if he gets his way, and threats of destruction if he doesn’t (“We’ll just let Obamacare fail.”)
While the tactic worked in the Republican primary, it appears to have failed pretty thoroughly in the effort to repeal and replace Obamacare. Now the question is whether or not Trump has the gumption to follow through on his threat.
There is no question that he has the means to do it if he wants to. Trump has already identified the levers he would have to push the ACA’s health insurance exchanges into free-fall.
One of the pillars that holds up the entire system is the existence of coverage mandates. Individuals who do not get coverage through their employers or through a government program have to purchase health insurance, even if federal subsidies are used to pay for them. If they fail to do so, they face a tax penalty. Trump can direct the Internal Revenue Administration to direct its enforcement activity away from monitoring compliance with the ACA’s coverage requirement.
Doing so would deprive health insurance companies of a stream of relatively healthy customers whose premium payments help subsidize the coverage of the sicker patients that the law requires them to accept.
Trump has also suggested that he may stop making risk-sharing payments to insurers, another element of the ACA put in place to strike a balance between the profit-motive of insurance companies and the law’s goal of making insurance both broadly available and affordable.
Those two steps alone could be enough to cause a major crisis in the health insurance industry, which Trump seems to believe would force lawmakers to accept whatever solution is placed before them. He doesn’t appear to have given much thought to the impact on the millions of Americans who would be left in coverage limbo in the time it took to resolve the problem.
But there is also reason to believe that Trump may not be able to bring himself to pull the trigger.
Remember how Trump was going to brand China a currency manipulator and begin punishing Beijing with trade sanctions on Day One of this presidency? Remember how Trump was going to deport millions of undocumented immigrants so quickly after his inauguration that it would make your head spin?
Remember how Trump was going to demand an investigation of Hillary Clinton for unspecified illegal activity as soon as he took office?
Those threats all have at least one thing in common: They turned out to be empty.
Trump is a frequent bluffer, and it’s a strategy that has often worked out for him. But, at least on the political stage, he has shown a reluctance to follow through on his most high-profile threats. Now that the effort to repeal and replace the ACA has gone down in flames, the millions of people who still benefit from the program must be hoping that he stays true to form.