The collapse of the Republican effort to repeal the Affordable Care Act is a monumental political defeat wrought by a party and a president that never took health-care policy or the need to bring coverage to millions of Americans seriously. But their bungling also demonstrates that the intense attention to Obamacare over the past six months has fundamentally altered our nation’s health-care debate.
Supporters of the 2010 law cannot rest easy as long as the current Congress remains in office and as long as Donald Trump occupies the White House. On Wednesday, the president demanded that the Senate keep at the work of repeal, and, in any event, Congress could undermine the act through sharp Medicaid cuts in the budget process and other measures. And Trump, placing his own self-esteem and political standing over the health and security of millions of Americans, has threatened to wreck the system.
“We’ll let Obamacare fail, and then the Democrats are going to come to us,” Trump said after it became obvious that the Senate could not pass a bill. But if Obamacare does implode, it will not be under its own weight but because Trump and his team are taking specific administrative and legal steps to prevent it from working.
“I’m not going to own it,” Trump insisted. But he will. And if Trump does go down the path of policy nihilism, it will be the task of journalists to show that it is the president doing everything in his power to choke off this lifeline for the sick and the needy.
As long as “repeal Obamacare” was simply a slogan, what the law actually did was largely obscured behind attitudes toward the former president. But the Affordable Care Act’s core provisions were always broadly popular, particularly its protections for Americans with preexisting conditions and the big increase in the number of insured it achieved. The prospect of losing these benefits moved many of the previously indifferent to resist its repeal. And the name doesn’t matter so much with Obama out of office.
To the surprise of some on both sides, the debate brought home the popularity of Medicaid, which for the first time received the sort of broad public defense usually reserved for Medicare and Social Security. The big cuts Republicans proposed to the program paradoxically highlighted how it assisted many parts of the population.
This creates an opening for a new push to expand Medicaid under the ACA in the 19 states that have resisted it, which would add 4 million to 5 million to the ranks of the insured.
Republicans also found, as they did during the budget battles of the 1990s, that when they tie their big tax cuts for the wealthy to substantial reductions in benefits for a much broader group of Americans, a large majority will turn on them and their tax proposals. For critics of the GOP’s tax-cutting obsession, said Jacob Leibenluft of the Center on Budget and Policy Priorities, this episode underscores “the importance of making clear the trade-offs of Republican fiscal policy.” To win on tax cuts, the GOP has to disguise their effects — or pump up the deficit.
One Democratic senator told me early on that Republicans would be hurt by their lack of accumulated expertise on health care, since they largely avoided sweating the details in the original Obamacare debate after deciding early to oppose it. This showed. They had seven years after the law was passed and could not come up with a more palatable blueprint.
The popular mobilization against repeal mattered, too. With Republican senators discovering opposition to their party’s ideas in surprising places, pro-ACA activists drove two wedges into the Republican coalition.
One was between ideologues and pragmatic conservatives (Republican governors as well as senators) who worried about the impact of Senate Majority Leader Mitch McConnell’s designs on their states.
The other divide was within Trump’s own constituency, a large share of which truly believed his pledge to make the system better. They were horrified to learn that they could be much worse off under the GOP proposal. A Post-ABC News poll this month found that 50 percent of Americans preferred Obamacare and only 24 percent picked the Republican bill. Trump’s approval ratings are dismal, but the GOP plan’s were even worse. Defectors in the Trump base may have been the silent killers of this flawed scheme.
And that is why a scorched-earth approach from the president would be both cruel and self-defeating. Americans now broadly support the basic principles of Obamacare. Republicans, including Trump, would do well to accommodate themselves to this reality.
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