They must recognize that past Republican threats to health-care coverage helped power Democrats’ wave election in 2018. And they likely foresaw that attacking the ACA would unify the left — which had become divided over single-payer — even as it divided the right on what the heck to replace the repealed law with.
Nonetheless, Trump boldly proclaimed the GOP the “party of health care” and subsequently instructed Republican lawmakers to come up with “a plan that is far better than Obamacare.” Or to use his earlier coinage, “something terrific,” though Republicans have had nearly a decade to produce that something and failed to deliver.
In fairness, it’s a near-impossible task, assuming terrific-ness requires (a) adhering to Republican principles; (b) fulfilling Trump’s promises to protect those with preexisting conditions and guarantee “everybody” gets covered; and (c) not producing a near-facsimile of Obamacare.
Despite the constant accusations of socialism, after all, the basic framework of the ACA uses market-based mechanisms to expand coverage and keep cost growth down. It preserves the private insurance industry, which is still the largest provider of insurance, and relies on private hospitals and providers. It was based on a plan first implemented by a Republican governor who went on to become the 2012 Republican presidential nominee: Mitt Romney .
Trump and his co-partisans have now explicitly committed to protecting another of those “legs” — preventing insurers from denying coverage or raising premiums for those with preexisting conditions — at least in rhetoric, though not in practice.
To be sure, there are parts of the law that Republican officials are less keen on, including subsidies to make insurance more affordable (that third “leg”) and the Medicaid expansion. But these are now quite popular, too, even among Republican voters, according to polling from the Kaiser Family Foundation. So good luck killing them.
The ACA is by no means a perfect law. It did a lot to expand insurance coverage but not enough to reduce costs. As written, it was too vulnerable to sabotage from those with political motive to do so (though arguably that might reflect more meaningfully upon the saboteurs than the law itself). Republicans could have spent the past decade working with Democrats to make the law stronger; instead, when not conducting show-votes to repeal it in full, they worked to destabilize markets by abruptly changing the rules on insurers, encouraging adverse selection through the expansion of junk insurance plans, and cutting funding for implementation of the law.
Besides subtracting elements of the ACA, Republican officials have also made some additions to the U.S. health-care system that have not exactly proved successful.
In fact, Trump’s administrative efforts to add work requirements to Medicaid were blocked by a federal judge Wednesday — specifically because, the judge determined, the programs in question (in Kentucky and Arkansas) did not advance Medicaid’s basic purpose of providing health coverage. The Big Government bureaucracy necessary to correctly ferret out the tiny population of supposedly “undeserving” Medicaid beneficiaries targeted by such programs is also arguably not terribly conservative; if promoting work was the objective, there are much more effective ways to do so than ripping away access to health care, which often enables people to work.
In any case, Republicans have demagogued themselves into a corner, and they know it. The late Republican senator John McCain arguably saved the party from itself by killing the last legislative attempt at “repeal and replace”; now that Trump has foolishly revived this losing battle, Republicans will be forced to return to shouting “Free markets!” into the wind, as though that will somehow produce a real policy.