On Thursday morning, President Donald Trump assembled an audience of non-health-care professionals in the Roosevelt Room of the White House to applaud him as he signed an executive order crafted primarily for the purpose of making him feel better about his failure to repeal the Affordable Care Act.

At a subconscious level, Trump seemed given over to the fact that he was participating in an empty charade. Upon concluding his mostly-scripted remarks, Trump turned away from the order and attempted a swift exit, having apparently lost track in his own mind of the very thing he’d convened the event to do. Everyone gets befuddled now and again, Trump more so than most, but in this case his confusion, or resignation created potent symbolism.

The traditional point of signing ceremonies, apart from self-congratulation, is to celebrate the meeting of shared goals, and reflect upon the immense power policymakers have to change people’s lives. (It’s no coincidence that Vice President Joe Biden branded himself with the words “big fucking deal” at the signing ceremony for the Affordable Care Act.)

In Trump’s White House, a signing ceremony is just another occasion for the president to mouth off, without any particular regard for, or awareness, of the impact whatever he’s doing will have on the public.

Successful presidents don’t have to be steeped in the nuances of all the bills and orders they sign, but this week has served as an acute reminder that, to the extent Trump is implementing an agenda at all, it is a directionless one. Almost no considered judgment has been brought to bear on any of it. It comprises measures he doesn’t understand, that he has been manipulated into signing, and that have been devised to quell his rage spasms, which grow more frequent and pronounced as his presidency falters. We’re about to learn whether the American political system in the Trump era is up to the task of accounting for and remedying the devastation a malicious president metes out blindly.

There is no shortage of resentment within the Republican Party over the continued existence of Obamacare, and bitterness over the Senate’s failure to pass repeal legislation is not unique to Trump. But it is somewhat novel for a president to order up policy principally to be caught signing something—and then leave the details to a welter of subordinates with ulterior motives.

The order he signed Thursday instructs relevant cabinet officers to find ways to steer potential ACA beneficiaries into bad health insurance plans. It is consistent with a wide range of actions the Trump administration has taken to destabilize small-group insurance markets, including Thursday night’s announcement that Trump will end billions of dollars in payments to insurers that cover low-income beneficiaries.

Sabotaging the health care system has always been morally obscene, but before the repeal process faltered, it was at least possible to construe the vandalism as an intended catalyst for some larger goal. Now, its only upshot is to turn innocent people into the collateral damage of a demented revenge fantasy.

Though Trump demonstrably does not care, it is still unclear whether he understands that his desire to win—whether winning in his mind means stomping on Barack Obama’s legacy, or just notching a signing ceremony—is being channeled into policies that will increase suffering.

“They will have so many options,” Trump said Thursday. “This will cost the United States government virtually nothing, and people will have great, great health care, and when I say ‘people’ I mean by the millions and millions.”

Nope and nope.

If implemented as envisioned, the order will siphon younger, healthier people, out of regulated plans sold on the ACA’s state-based exchanges, and into short-term coverage plans and other unsound policies. These people will be harmed if and when, under duress, they find their off-market plans leave them underinsured. Sicker people, who need stable, comprehensive insurance, will be harmed because their issuers will flee the markets, or their premiums will soar, or both. And taxpayers will be harmed, because the subsidies that help most eligible consumers buy insurance will, by law, rise with the cost of premiums.

Ending the cost-sharing payments on top of all this will exacerbates each of the predicted harms.

It is anyone’s guess whether the instructed agencies will follow through with the order in earnest. There is a precedent in this administration of political appointees slow walking or even shelving Trump’s most vindictive commands. There are also compelling reasons to believe that at least some of the order’s aspirations are unlawful. But if the government implements it aggressively, it is alarmingly plausible that Trump will be blindsided by the blowback. What was once a relatively sub rosa sabotage campaign, meant to dovetail with a legislative process, has been transformed into an ugly, Trump-stamped policy regime that will be identified correctly as the cause of decay within insurance markets.

It is theoretically possible that Trump weighed all of these concerns and determined that, on balance, he’d rather own the consequences than be caught “losing” the health care fight.

But the unprompted nature of his decisions is much more consistent with a broader pattern of Trump tasking others with giving form to his impulses.

Trump could still sign marquee legislation before the midterm elections if Republicans in Congress manage to pass a large, regressive tax cut. That effort was already foundering before Thursday, when Bloomberg reported that Trump “grew angry” upon learning that his plan called for ending the deductibility of state and local income tax payments. But that provision has been a fixture in tax negotiations for weeks and weeks. The revenue it would raise (largely from upper-middle class residents of high-tax states) is an essential part of the GOP’s broader goal of giving the ultra wealthy an enormous tax cut without deficit-financing the whole bill.

Whether White House and congressional negotiators were trying to pull one over on Trump, or whether they believed they had his blessing, it’s evident that he didn’t have the slightest clue what he was advocating. Now that he knows, he will either pull the rug out from under his delegates, or be force-fed an idea he opposes, further enraging him.

Likewise, the content of the health care order was plainly devised by people with knowledge Trump lacks. Trump may have been told by bloodless ideologues that he has the power to make Obamacare collapse, but he appears to have no idea that the steps he’s just taken could leave hundreds of thousands or millions of people uninsured, and that he will shoulder the blame for it. He has, in other words, basically no idea what he just set forth as the policy of his own government.

Trump seems similarly oblivious to the Pandora’s box he will open when he declines to certify the multilateral agreement governing Iran’s nuclear capabilities. Echoing the health care order, Trump is barreling ahead blind, because he thinks being a faithful executor of a deal Obama struck will make him look ridiculous. Like a loser. He trashed the deal on the campaign trail, which makes certifying it now a source of such deep narcissistic injury that he reportedly “threw a fit” last time the deadline rolled around.

For the last nine months, the lodestar of American government has been Trump’s volatile appetite, rather than the interests of citizens. His incompetence spared us from some of the worst consequences for a time, but that is changing rapidly. Failure has driven Trump into a state of destructive atavism, and when people start getting hurt as a result, it will be incumbent upon those of us bearing witness today to explain that the damage was done not to advance some larger vision but for one man’s psychic benefit.