Conservatives are still trying to repeal the Affordable Care Act (ACA) — even after the Republican-majority Congress failed to overturn the law in 2017. A coalition of conservative groups intends to release a new plan this summer. The groups will reportedly propose ending the law’s expansion of Medicaid (the federal program that helps fund health care for low-income Americans) and convert Medicaid funding into block grants to the states. And just last week the Trump administration’s Justice Department argued in a legal filing that key provisions of the law — its protections for persons with preexisting conditions — are unconstitutional.
Why are Republicans still trying to undo the ACA? We argue in a forthcoming article that the law’s political vulnerabilities and Republican electoral dynamics drive conservative efforts to uproot it.
In the past, conservatives have thrown in the towel
As politicians and political scientists both know, the political sustainability of reforms can never be taken for granted. Even so, the duration and intensity of conservative resistance to the ACA is historically unusual. The ACA is a moderate law, modeled on ideas that Republicans once supported, such as insurance purchasing pools. What’s more, many red states refuse to accept the ACA’s funding to expand Medicaid to more of their citizens — such as Texas, which has a large number of uninsured residents — even though you would think they would want those federal benefits.
To be sure, conservatives (a group that decades ago included both Southern Democrats and many Republicans) often fought against new social programs. But once enacted, conservatives frequently accepted or resigned themselves to their existence. The GOP’s 1936 presidential nominee, Alf Landon, did call for Social Security’s repeal. Yet by the early 1950s, strong bipartisan majorities supported increasing Social Security benefits.
The response was similar after Congress’s 1965 passage of Medicare, the federal health-care program for senior citizens – to which persons with permanent disabilities were added in 1972. Before Medicare passed, congressional debate was ideologically charged; its opponents alleged that the program would lead to “socialized medicine.” But once the law took effect in 1966, conservative resistance collapsed. There were no serious efforts to repeal Medicare or challenge its constitutionality. Similarly, Medicaid, which also passed in 1965, encountered little conservative resistance. By 1970, all but two states (Alaska and Arizona) participated in Medicaid.
So why is the ACA still politically vulnerable?
The answer lies partly in the way the program was designed.
First, unlike Social Security and Medicare, Obamacare does not have a well-defined population of beneficiaries. The ACA is not a single program but, rather, a series of programs, subsidies and regulations. It treats people differently depending upon where they live, where they work, how they get insurance and how much they earn. That complicates efforts to mobilize public support.
So does the ACA’s partial reliance on private insurance to deliver benefits. As Suzanne Mettler argues in her book “The Submerged State,” social programs that channel public authority through private markets may fail to build strong political constituencies.
Second, ACA benefits are not consistently generous enough to build the strong and cohesive national constituency enjoyed by programs such as Social Security. Many families still face rising health-care bills, which hits especially hard for working-class families in the 17 states that have not embraced Medicaid expansion. Other adults may not be able to afford insurance because they earn too much to qualify for substantial (or any) federal support.
Third, conservatives dislike how the law distributes benefits. When used with the traditional Medicaid program, the ACA insures low-income adults. It’s true that nearly eight in 10 Medicaid adults live in working families, and 60 percent work themselves. But millions of working-age people on Medicaid are not currently employed, often because of disability, illness or care-giving responsibilities. Some conservatives want more Medicaid recipients to work. And so they want to make it harder for people to qualify for benefits.
Fourth, conservatives object that ACA benefits are funded largely by taxes on the wealthy. That’s different from programs such as Social Security and Medicare, which rely on “contributory” financing: Workers and their employers pay a percentage of their payroll taxes to help fund the programs. This allows enrollees to claim they earned their benefits.
Republican electoral dynamics fuel conservative opposition
Beyond program design, the radicalization of the Republican Party has made Obamacare vulnerable. As Jacob Hacker and Paul Pierson argue, this is not your grandfather’s Republican Party. Today, activist groups and major donors in the Republican Party encourage conservatives to fight on against social welfare programs, even if success seems unlikely.
What’s more, Republicans have regularly held power in Congress in recent years. Throughout most of the postwar era, astute political observers assumed that Democrats had a permanent congressional majority. Minority status encouraged congressional Republicans to accept half a loaf and move on. Now, as Frances Lee notes, majority control is up for grabs in almost every election. That competitiveness encourages the parties to heighten their messaging and discourages conservatives from giving up on ACA repeal.
The war over the ACA is likely to continue until one side or the other wins a decisive electoral victory. That doesn’t seem to be on the horizon.
Is repeal likely?
Last year, Congress succeeded in eliminating the law’s penalty for individuals who do not obtain insurance. The Trump administration has also used its executive powers to try to unravel the law — for example, by proposing to allow insurers to sell skimpy plans that lack Obamacare’s consumer protections.
And yet conservatives are unlikely to uproot the law in 2018. With Democrat Doug Jones’s victory in Alabama’s special Senate election last year, the Republicans’ Senate majority is only 51 to 49. Majority Leader Mitch McConnell (R-Ky.) has little room to maneuver, since Democrats are unified against repeal.
For now, the ACA remains intact — but expect the skirmishing over its future to continue.
Eric Patashnik is director of the master of public affairs program and Julis-Rabinowitz Professor of Public Policy and Political Science at Brown University.
Jonathan Oberlander is professor and chair of social medicine and professor of health policy and management at the University of North Carolina at Chapel Hill.