But first he needs to stop sabotaging Obamacare and indulging hardcore conservatives.

The dealmaker-in-chief badly wants a deal on health care. President Trump has even been willing to hold his nose and support terms put forward by the hardcore conservative House Freedom Caucus that are hugely unpopular with his own backers, like allowing insurance companies to turn down people with pre-existing medical conditions. Piled on top of a Republican bill with only 17% public approval, the further he goes to the right, the more likely he will come up empty-handed.

Since repeal didn’t go the way Trump thought it would, now is a good time for him to step back and decide what he wants to accomplish. The political imperative to repeal and replace the Affordable Care Act has shifted decisively. After learning about the alternative proposed by Congress, a record high 55% of Americans favor the ACA. Three-quarters say the president should try to make the law work and 61%, including a majority of Trump supporters, say he and the GOP are responsible for any problems going forward.

A little history is in order. Republican sabotage of the ACA predates Trump’s presidency. Championed first by outside groups and lawyers, one of the GOP’s biggest victories was stripping funding to insurers that was designed to keep rates from rising too fast. When Congress removed the money after the fact, among the first victims were a dozen or so new health plans called co-ops, included in the ACA to add competition in low-competition areas.

The law’s opponents went beyond garden-variety political tactics. They filed numerous lawsuits to cripple the ACA by pulling out core pieces. Insurers reported being warned by Republican congressional leaders not to participate. And, most notably, Republican governors or legislatures in 19 states turned down funds to cover millions under Medicaid.

The results of this sabotage include higher premiums, higher costs to taxpayers, millions of people in Southern and rural states left without insurance, and only one or two competitors left in many markets as insurers withdrew or were forced out of business. All so Republicans could point to the ACA and say, “See, it doesn’t work.”

So far the Trump administration is continuing that sabotage from the Oval Office. Standard & Poor reported last week that the exchanges are stable and the biggest impediments to success are now the administration’s own delays and potential tampering.

For instance, insurers are within weeks of setting their initial premium levels for 2018 and the administration hasn’t indicated whether it will continue payments that insurance companies use to reduce deductibles for low-income consumers. I met with a dozen insurance CEOs last week, each of whom told me that if funding isn’t confirmed by April 30, premiums will increase significantly — by 19% in one recent analysis.

How does Trump shift to an agenda that can gain broad support? He can start by throwing off the most extreme aspects of the Republican plan to gut the Medicaid safety net. This was always House Speaker Paul Ryan’s idea, anyway. It was never Trump’s and it was never popular with his base, so it shouldn’t be hard for him to abandon. And he has the perfect rationale.

The opioid crisis, one of the centerpieces of Trump’s domestic commitments, provides the opportunity to shift the dialogue on Medicaid. On the campaign trail in August, he promised to help people addicted to opioids. “We’re going to work with them, we’re going to spend the money, we’re going to get that habit broken,” he said in Columbus, Ohio. Medicaid funds a full one-third of opioid treatments and directly serves Trump’s base. More than four in 10 non-elderly Medicaid recipients are white, and the share is higher than that in rural states. In West Virginia, for instance, it’s 89%.

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Forgoing Medicaid cuts not only serves Trump’s constituents, who pay much more and lose coverage under the current Republican plan, but allows him to forge the alliances needed to create a bipartisan deal. They include a broad congressional coalition, ranging from Democrats to conservative Republicans, as well as governors who have been leading the fight against opioid addiction — among them Republicans John Kasich of Ohio and Charlie Baker of Massachusetts and Democrats Roy Cooper of North Carolina and Tom Wolf of Pennsylvania.

Until Trump takes these steps, no Democrat or centrist Republican will come to the table. That leaves him struggling to assemble a coalition of only the most extreme and unpopular views, and not enough support to get a bill through both the House and Senate. The president’s reaction to events in Syria shows he’s not moored to ideological positions and can pivot when he wants to. Trump’s choice is between sabotaging the ACA and helping his voters. Fortunately for him, choosing his voters is also the path to a deal that can put a health care victory on the board.

Andy Slavitt, a senior adviser to the Bipartisan Policy Center and a member of USA TODAY’s Board of Contributors, is a former health care industry executive who was acting administrator for the Centers for Medicare and Medicaid Services from 2015 to 2017. Follow him on Twitter @ASlavitt 

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