President Trump's health care nightmare

"Now I have to tell you, it's an unbelievably complex subject," President Trump said on Monday, speaking about the Republican effort to repeal the Affordable Care Act. "Nobody knew that health care could be so complicated." By which I suppose he meant, "Everybody except me knew that health care is really complicated, but they just explained it to me, and wow."

Hard though it may be to determine what lurks in the depths of the president's mind, he now appears to be realizing that his promise to repeal the ACA and replace it with "something terrific" may not be so easy to achieve. In his defense, it does seem that congressional Republicans are also only now grappling with the complexity of health care reform (they probably knew it was complicated, but preferred not to think about it until they were forced to). But the truth is that the problem isn't just that it's complicated. Overhauling a car's transmission is complicated, but if you know what you're doing you can accomplish it to everyone's satisfaction.

The trouble with health care reform is that it requires tradeoffs between competing goals, like low cost and comprehensive insurance, or universal coverage and individual flexibility. And once you have a system in place that reaches some kind of compromise between all those goals, undoing it will not only create tremendous upheaval, it will also create winners and losers. Which may be hard to accept, if you thought that once you took power there'd be so much winning we'd all get tired of winning.

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One explanation for why the president is suddenly realizing the complexity of this task may lie in some meetings he has had recently. As The Washington Post reported, last Friday he met with Ohio Gov. John Kasich (R), who accepted the ACA's expansion of Medicaid and as a result was able to see 691,000 more of his constituents get coverage, almost entirely at the expense of the federal government. Kasich tried to convince Trump that turning Medicaid into a block grant and then cutting it — what many Republican plans call for — would be a bad idea:

But the next day, Trump met with two Republican governors who had rejected the Medicaid expansion, Scott Walker of Wisconsin and Rick Scott of Florida, who told him something different. And on Monday he met with CEOs from insurance companies, who accepted the ACA's new regulations because they'd get a lot of new customers; they surely told him of their trepidation about the loss of the individual mandate. And governors meeting in Washington just got a grim report from Avalere Health and McKinsey and Company, showing that the Republican plans could lead to drastic declines in the number of people with health coverage.

It's all so confusing! Republican governors disagree about Medicaid repeal, and there are even differences within the White House: Vice President Mike Pence is gung-ho for repeal, while Trump advisers like Steven Miller and Stephen Bannon are reportedly more wary of a public backlash. So Trump can't even get the same answer from every Republican he talks to; forget about all those angry citizens pouring into town halls to demand that their representatives not repeal the law. The president's head is spinning with all this complexity. Why can't they just show him "something terrific" and then pass that so he can sign it?

Alas, with no such magical unicorn in the offing, here's where Trump and the Republicans are left. Insurers don't want the ACA repealed, nor do doctors, nor do hospitals, nor does the AARP (possibly the most powerful lobby in Washington), nor does the public as a whole. Republican members of Congress want to repeal it, but they're terrified of the backlash that will almost inevitably result. Legislative gambits like "repeal and delay" (pass repeal now but with a countdown clock, to force themselves to come up with a replacement) keep getting floated and then discarded.

So perhaps in the wee hours of the morning, as he settles in for a soothing hour or two spent with Fox & Friends, Trump may find himself haunted by a troubling thought: What if there's no good way out of this problem? Repeal the law outright and the base will be happy, but millions will suffer (and blame him for it). Don't repeal it and the base will be enraged. Pass a Republican replacement plan and the political blowback will be intense, as the fake media keeps showing tear-jerking stories of families left without care.

It's a conundrum, alright. And it is definitely not terrific.