Did the AHCA pave the way for universal healthcare?

Much has been made about the political and policy implications of the House’s vote last week to repeal and replace the Affordable Care Act with the American Health Care Act—which could cost millions their healthcare coverage and generate billions in tax cuts for the wealthy. But before jumping off a cliff on what it will mean, it’s important to put a few things in context.

For starters, the likelihood of the Affordable Care Act surviving Trump is higher than most people, including Republicans, would want to admit. That’s because, as scholars like Ruy Teixeira note, healthcare becomes “sticky” once it is viewed as an entitlement. Despite the ACA’s flaws, it fundamentally shifted expectations on what Americans should expect out of healthcare (more on this below). The key provisions that the House Republicans sought to gut also happen to be universally popular among voters, and have drawn fierce defense from GOP governors worried about what would happen to their constituents.

That’s likely to be mean the Senate will either rewrite the bill or quietly kill it (while publicly claiming areas of GOP consensus), leaving the ACA (badly hobbled and likely vandalized by GOP hijinx) in place for next year and the duration of Trump’s term. It’s also not even certain the bill can meet the Byrd rule, which requires crossing the 60-vote threshold in the Senate. Even if the Senate passes something, it’s highly unlikely it can survive a reconciliation in the House, given the pressure conservative groups will exert on House members not to cave in to an even slightly more moderate version and vice versa for moderate members who are already feeling besieged.

So why did the White House and GOP leadership exert a lot of political capital to pass something that is unlikely to repeal Obamacare? Political calculation.

For all the talk that liberals make about being galvanized against Trump, enthusiasm among the GOP base to repeal Obamacare and Obama’s legacy is still high. Trump and his GOP colleagues might have help regain some enthusiasm among GOP voters who might have stayed at home next year had the promises to at least try and repeal Obamacare not been kept. This was, in the words of Trump, a “promise kept,” and the Senate’s failure to pass a repeal would only strengthen his ability to attack Red State Democratic Senators. Already, Republicans are trying to use any possibility of failure in the Senate for any of Trump’s priorities as a weapon to try to add seats next year.

For Republicans, the ideal situation would be having the AHCA die over the summer, rail against Obamacare, and keep their vulnerable incumbents from having to defend votes over a bill that never became law. Still, the uncertainty over Obamacare is tantamount to a maiming by a thousand cuts—a fact that should be of primary concern to Democrats and anyone else who has benefited from the ACA.

In fairness, Democrats will also use the vote to mobilize their base, and the early reports suggest that the enthusiasm is unlikely to wane. Keeping healthcare on the forefront of the next two elections puts Republicans at a disadvantage because it’s not their forte, and it prevents the GOP from changing the conversation to subjects they’re more familiar with, like taxes and deregulation.

But there’s an emerging consensus from both liberal and conservative corners that though the House GOP bill might have been a victory from an optics sense (though the post-bill photo op was anything but), the Republicans might have already lost the war. This is where the policy implications are too important to ignore. Regardless of what happens to the AHCA, the idea of Obamacare has already won, something that conservative writers like Charles Krauthammer begrudgingly acknowledge. Once something becomes an entitlement, it becomes next to impossible to take away, which is why Republican (and Democrat) attempts to reform social security and Medicare have fallen flat. Given how many older (and Republican) voters rely on Medicaid, which would be undermined by the AHCA, the Republicans have already lost both the substantive and messaging battles with their own voters.

Some might point to how the Republicans successfully managed to undermine public assistance programs in the 1980s and 1990s, leading Democratic President Bill Clinton to triangulate and sign a massive welform reform bill 20 years ago. However, welfare was never viewed by the majority of Americans as a necessary entitlement. Even though the majority of welfare recipients are white (and disproportionately live in rural areas where job growth has become stagnant), those who receive federal benefits are often ashamed of their public assistance. A successful campaign in the 1980s to racialize and urbanize welfare, particularly President Ronald Reagan’s infamous “welfare queen” line, essentially cast those receiving welfare as moochers. As such, the GOP was able to convince many lower-income whites to vote against their own interests. More importantly, suburbanites and more affluent Democrats didn’t see a need to defend welfare. In fact, President Obama did very little to publicly change the discourse about welfare under Clinton, which is why federal programs like SNAP have been easy targets for the right.

But healthcare works differently. Before Obamacare, there was wide recognition by Americans on both sides of the political spectrum that the American healthcare system was broken. With its passage and implementation, the ACA moved the benchmarks to where most Americans view healthcare as a right—something that GOP senators like Bill Cassidy readily acknowledge. With the government’s role in healthcare now increasingly accepted, and its impact on people across the socioeconomic spectrum beyond dispute, attacking Medicaid and provisions protecting people from insurers becomes untenable. If the GOP has largely won on taxes and regulation, the Democrats have owned the debate on entitlements. This is likely why we are shifting to a universal healthcare paradigm.

While it might not happen as soon as Krauthammer predicts, the ACA—and the GOP’s attempts to dismantle it via the AHCA and negligence— is now the catalyst that moves the political discourse towards universal healthcare. Trump’s praise of Australia’s single-payer system could prove prophetic, sooner rather than later.

The views expressed by the author are his alone and do not reflect the official position of the Hindu American Foundation.

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