Donald Trump suffers from several pre-existing conditions – but none is as fatal as his chronic lack of self-awareness.

This is a challenge for a president determined to roll back healthcare coverage for Americans in the name of scoring points against his predecessor. Stuck on political life support, in the mid-30s of approval ratings, Trump is gambling what’s left of his polling on an ambitious plan to deny blue-collar voters their healthcare.

No wonder Republican Senate leaders took so long to release their super-double-secret healthcare legislation, and are so determined to get the deed done before they head back to see their constituents through the summer.

Healthcare is the white whale of American politics, and it has come close to shipwrecking Trump’s last three predecessors. Clinton sacrificed his congressional Democrats on the altar of universal coverage. Bush irreparably compromised his conservative credentials by expanding prescription drug coverage. Obama depleted almost all his political capital with a Republican plan for reform that left nobody happy.

Senate Republicans release healthcare bill that will affect coverage for millions Read more

For some reason best explained by psychiatry, the Republican party has now hoisted the mainsail on their president’s Ahab-like obsession to undo Obama’s version of a Mitt Romney plan.

The result is legislation that of course pleases nobody. It is too moderate for conservative Republicans like Rand Paul, and it is too conservative for anybody who wants to get re-elected by low-income and middle-class voters. Hacking back Medicaid, and handing a big tax cut to the wealthy, is no way to reward the rust belt voters of Trump country.

“I’m still hoping we reach impasse, and we actually go back to the idea we originally started with, which is repealing Obamacare,” Rand Paul said on Wednesday. “I’m not for replacing Obamacare with Obamacare lite.”

The prognosis is not good. Mitch McConnell can only lose two Republican votes in the Senate; three would mean defeat. As he knows full well from the Democrats’ experience with Obamacare, this means he will pay a high price behind closed doors to secure each and every vote.

Those secrets sweeteners – remember the Cornhusker Kickback and the Louisiana Purchase? – did more to damage Obamacare than any other part of the legislation’s passage, including the lack of any Republican support. And that was when the leaders had the pleasure of working with Democrats who could be bought.

Imagine the challenge of negotiating with ideologues like Rand Paul and Ted Cruz, who care little for home state pork. Imagine trying to negotiate away the anti-abortion measures in the House bill because they don’t meet Senate rules that would avoid a filibuster.

Then there’s the industry opposition to Medicaid cuts that hurt their bottom line. Insurers successfully blocked the Clintons in the 1990s and almost collapsed Obama’s first term in 2009. If McConnell wants to get these votes taken quickly, he needs to pay off the insurers, too.

Of course, there’s no paying off the 23 million Americans who will lose coverage if the House version of the bill is passed. We don’t yet know how the Congressional Budget Office will score the Senate bill. But we do know that most Americans won’t understand the details. They will, however, understand the secrecy of this bill’s writing, and the severe nature of the cuts.

Even the most skillful, detail-driven chief executive would struggle in these circumstances. Instead, we have Donald Trump, who held a victory ceremony for the House vote on Trumpcare, before condemning the same vote as “mean”.

Trump has already shown no appetite for the complex details of healthcare: a lack of interest that helped scupper the first House vote on Trumpcare. What he does care about are the polls, and the numbers do not look good for his first big congressional campaign.

His single-minded pursuit of the destruction of all things Obama has given the much-maligned Obamacare its best poll numbers ever. This is the peculiar affliction of Donald Trump: the more he tries to do something popular for his base, the less popular he becomes. Trump’s version of populism is weird that way.

Passing Trumpcare will no doubt be as much a relief as any older man could expect when passing any painful blockage. But this is a highly risky procedure for a president who has as little regard for his political health as his exercise regime.

Even if the patient survives, his party’s majorities in Congress will not. And with their demise begins the inevitable secondary infection known as impeachment.

Trump would be wise to learn from his predecessors’ pain and focus on his own survival. But wisdom isn’t covered by Trumpcare, and the patient seems oblivious to his own fate.