As they struggle to figure out how to deliver on the most important (and repeated) promise they made to their constituents over the last eight years — repealing and replacing the Affordable Care Act — Republicans face two sets of problems, both of which are far thornier than they imagined.

The first are the policy problems, which arise from the fact that health care reform is incredibly complex (and yes, they’re just realizing that now). The second are the political problems, which may be even more challenging. And their political task is going to become much harder when they actually propose something and try to get it through Congress, for a reason few seem to have noticed: Republicans are totally alone. 

Health care reform, more than perhaps any other issue, implicates — and potentially threatens — the interests of a wide array of constituencies, groups, industries, and political actors. You’ve got citizens/patients/consumers, of course. Then there are the doctors, and the hospitals, and the insurers, and the various health care industries industries, and patient advocacy groups, and even larger groups like the AARP. After all, we’re talking about a sector that employs over 12 million Americans, makes up 18 percent of the entire American economy, and touches absolutely everyone’s life. If you get opposition from even some of those interests, the whole effort can begin to crumble.

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That’s why, when Democrats set out to construct the ACA in 2009, they spent an enormous amount of time and effort trying to co-opt as many of those groups as they could, often to the consternation of liberals. It was a tricky balancing act: some got on board wholeheartedly, some maintained opposition, and some, like the insurance industry, seemed to toggle between support and opposition on an almost daily basis. They had to be cajoled, convinced, threatened, and bought off.

But in the end, it worked. Democrats got the support of the American Medical Association, which had opposed just about every health reform effort in history, including the creation of Medicare. They convinced insurers that the new regulations they’d be subject to would be made up for by an infusion of new customers. In the end they held this tenuous coalition together just long enough to get the 60 votes they needed to pass the bill through the Senate, without a single vote to spare.

But who is with Republicans right now in their effort to repeal the ACA? Who has their back? The answer is: nobody. Hospitals are terrified that repeal will mean a flood of patients unable to pay their bills. The AMA is telling them not to do repeal without a replacement plan fully in place. Insurers are starting to panic, threatening to pull out of the individual market next year. The AARP, the most powerful lobby in America, is issuing warnings about GOP replacement plans that could increase costs for middle-aged consumers. Employers who may not have liked the law in the first place are nervous about the upheaval repeal will cause. Even the reliably pro-GOP U.S. Chamber of Commerce is telling them to slow down.

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While this is happening, much of the grassroots energy is on the Democratic side. There are crowds of angry constituents hounding their representatives not to repeal the law, but the pressure on the other side seems less visible.

And if they push ahead and repeal the law, all the bad effects will happen just in time for the 2018 midterm elections. Which is why Republicans are getting ready to cast off the very idea of repealing the ACA, the thing they voted 60 times in the House to do and have promised again and again. Here’s what the New York Times reports today:

Congress’s rush to dismantle the Affordable Care Act, once seemingly unstoppable, is flagging badly as Republicans struggle to come up with a replacement and a key senator has declared that the effort is more a repair job than a demolition.
“It is more accurate to say ‘repair Obamacare,’” Senator Lamar Alexander, Republican of Tennessee and chairman of the Senate health committee, said this week. “We can repair the individual market, and that is a good place to start.”

Orrin Hatch, who chairs the Senate Finance Committee (the other place the reform effort has to run through), told the Post that he is okay with either repealing or repairing the law. Hatch said: “I’m saying I’m open to anything. Anything that will improve the system, I’m for.”

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This is absolute blasphemy — but it’s spreading. The dramatic shift in language comes after their retreat in Philadelphia last week, in which they fretted about the political and policy difficulties in repealing the law, and were told by pollster Frank Luntz that they should use the word “repair” when talking about what they plan to do.

Which is why you’re suddenly hearing the word “repair” come out of Republicans’ mouths every time this subject comes up. “Repeal” is out, “repair” is in. Yes, there are still Tea Party members insisting that the whole law needs to be tossed as quickly as possible. But they’re being overtaken by the “repair” contingent, as Republicans realize not only that full-scale repeal would be catastrophic for the health care system, but that if they do it, there will be no one to help them with the political fallout. Despite the fact that pretty much all Republicans have promised for years to repeal the ACA, it’s possible that, if they brought up a repeal bill tomorrow, all those interest groups would quickly mobilize against them, frightened members would begin to peel away, and the measure would fail.

There may be one silver lining for Republicans in this extended debate. As there has been a public discussion of the consequences of repeal, the law has been getting more popular, with more Americans approving of it than disapproving of it. I wouldn’t be surprised if even some Republican voters who a few months ago would have said “Trash the whole thing!” are now perfectly amenable to a more careful approach. That may give Republicans some room to take things slow without paying too much of a price with their base.

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But they’ll still be responsible for the damage they cause to people’s coverage when it’s all done. Even if they manage to hold on to many of the ACA’s more popular provisions, the things they want to do are inevitably going to decrease Americans’ health security, raise their out-of-pocket costs, and increase the number of uninsured. They won’t escape the political consequences of all that, no matter who — if anyone — winds up on their side.

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