Why Trump is the perfect pitchman for the GOP's atrocious health-care plan

If President Trump and the congressional GOP don't get a health-care bill passed this week, it really may never happen. They're boxed in by the technicalities of Congress' procedural rules: By the end of May, they need to pass a new spending blueprint to get started on tax reform, which means their chance to use reconciliation to pass a filibuster-free health-care bill through the Senate would go away. So it's put-up-or-shut-up time.

But the GOP probably wouldn't even have this last shot at taking down ObamaCare if it weren't for President Trump. It's not just that they needed one of their own in the White House. It's that no one else — not even another Republican — could sell this thing.

What the vast majority of Americans want from health-care coverage — whether they vote Democratic or Republican — is not hard to tease out. They want insurance plans that are generous enough to really help with their medical expenses, and they don't want to get screwed just because they have a pre-existing condition. They want premiums that are affordable, deductibles and copays that are low to nonexistent, and networks that aren't impossibly narrow.

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Yet health care is crazy expensive in America. So the purpose of the health insurance industry — paying for the health care Americans get — is a costly proposition.

So tradeoffs are inevitable: Skimpy coverage plans, narrow networks, and denying sick people coverage are all ways insurers hold down their costs. Do away with them and premiums rise. Ditto for cost-sharing: The lower deductibles and copays are, the higher premiums must go to make up the difference. The kind of health coverage Americans want inevitably demands a very high price.

Then there's the reality of America's profound income inequality. The bulk of middle- and lower-class Americans have faced stagnating wages for decades, even as health-care prices kept rising. So most Americans simply cannot afford the kind of coverage they want.

Sure, you could quibble over whether the amount of health care Americans want is the same amount they need. But as a political matter, if you forthrightly tell American voters you don't think they don't need all that care and you're not going to pay for it, you're going to get clobbered at the polls.

The only other fix? Just have the government tax the wealthy, and transfer money to everyone else. Maybe you do that by subsidizing premiums. Maybe you do it by subsidizing out-of-pocket costs. Maybe you do it by subsidizing the insurance industry directly. (ObamaCare does a mishmash of all three.) Or maybe you go the full Bernie Sanders and just create a single-payer system.

But there is no way to escape the basic reality that, one way or another, you must move a ton of money from the rich to everyone else.

The Republican Party's bedrock existential dilemma is that it really, really, really doesn't want to do that.

What the GOP wants to do is deregulate coverage — allow insurers to discriminate against people with pre-existing conditions, offer skimpy benefit packages, charge higher deductibles, and so on. This will lower premiums for some people: namely the young and the healthy. And for anyone who isn't young or healthy, they can pay the higher premiums or the eye-watering out-of-pocket costs as long as they're well-off. But everyone who isn't young or healthy or part of the upper class gets screwed. Especially older and sicker voters from rural areas, who also happen to be Trump's staunchest supporters.

The GOP's solution to this problem has been to dissemble like mad.

Sometimes they talk in half truths, pointing out that their deregulatory project will lower premiums, and just leave out the "only for some people" part. This allows voters to fill in the blank and assume they'll be among the beneficiaries. The more policy literate conservatives will claim their plan offers subsidies for premiums and high-risk pools for people with pre-existing conditions. They simply fail to mention their premium subsidies are far below ObamaCare's already inadequate levels, and that history and politics make it inevitable the high-risk pools will be grossly underfunded.

But the most brazen Republicans just straight up lie — and none lie with more unrestrained enthusiasm than Trump himself. During the campaign, he pledged "everybody's going to be taken care of much better than they're taken care of now." After the election, he promised "insurance for everybody," "much lower deductibles," and more. "There was a philosophy in some circles that if you can't pay for it, you don't get it," he added. "That's not going to happen with us."

Part of Trump's motivation was that this is what Americans want to hear. So saying it made him a politically stronger candidate. But another perverse advantage Trump has is that he seems genuinely ignorant of even the basics of health-care policy. His Face the Nation interview this past weekend revealed a man who has no idea what the bill he's pushing would actually do, or what tradeoffs he faces. And he doesn't seem to care.

Trump insisted "the health-care bill is going to help my supporters." (It won't.) He said "pre-existing conditions are in the bill," presumably meaning people with those conditions are protected. (The bill allows states to waive the regulation that prevents insurers from charging people more for pre-existing conditions.) He claims "we're going to drive down deductibles." (The Congressional Budget office says they'll go up.) And he just keeps repeating that "ObamaCare is dead" anyway. (The CBO projected ObamaCare's markets will stabilize.)

In terms of his own moral compunctions, what Trump doesn't know apparently has zero impact on what Trump is willing to promise.

Obviously, all politicians are free-wheeling salesmen to some extent. But could Marco Rubio, Jeb Bush, or even Ted Cruz have pulled this off? I have my doubts. The weight of their actual policy knowledge and their consciences would have interfered. Their pitches for Republican health-care reform would've been more hesitant, circumspect, or mealy mouthed — inevitably making them politically weaker candidates than Trump himself.

In a way, the health-care debate is a microcosm, not just for why Trump was able to become the GOP's presidential nominee, but for why he had to be it. No one else had his unique blend of ignorance and salesmanship. If Trump can't get this toxic disaster of a bill through the legislature, no one can.