Repealing Obamacare, the Congressional Budget Office tells us, will leave millions of people without health insurance. What is surprising is that anyone is surprised. After all, the whole point of Obamacare was to reduce the number of Americans without health insurance, so it only stands to reason that the repeal of Obamacare would increase the number of Americans without health insurance.
The mantra of repeal and replace has been the central rallying cry of the Republican Party since the Affordable Care Act was signed into law in 2010. Perhaps it was the broken promise that people could keep their doctor. Perhaps it was the encroachment of government into the private health care economy. Perhaps it was the giving away of more free stuff. Or perhaps it was just the fact that it had Barack Obama’s name on it. But whatever the driving motivation, repealing Obamacare has been foundational to the Republican Party for the better part of the past decade.
Last year, Paul Ryan threw up his hands and declared that he was done with divided government: it was, he had come to believe, just too damn hard. He was salivating at the idea of Republican control of the nation’s capital. It was, he assured anyone who would listen, the only way they would get things done. Then Ryan got his wish, and ― lo and behold ― nothing has gotten easier. Unitary Republican rule has proved to be no cakewalk, and it appears the worst lies ahead.
It is, of course, all Donald Trump’s fault. It is not just that Trump is not really a Republican, or that he cares not one whit for Paul Ryan’s Better Way or the normal conservative principles that Ryan presumed would animate GOP policy and legislation in a single party state. Instead, it is that Trump won the Republican nomination by riling up white working class and middle class voters who, for the better part of the past half century, have been loyal to a Republican Party that used them for their votes while caring little for the struggles those families faced in their daily lives.
Somehow, the billionaire from Queens understood something that eluded the middle class kid from Janesville, Wisconsin. Paul Ryan failed to grasp that while those white working class voters that Republicans have celebrated as their base since the days of Richard Nixon and Ronald Reagan might be cultural conservatives, the reality of their daily lives has nothing at all in common with the plutocrats who have long ruled the GOP. Whether they are sitting around a kitchen table in eastern Kentucky or the upper peninsula of Michigan, those Americans live paycheck to paycheck, and when it comes to health care, conservative or libertarian social theory means little to families facing one real world question: if a member of their family is sick, can they take them to see a doctor without having to worry about the financial consequences. Those voters may say they hate government in the abstract, but they love that Medicare provides for their parents. And when they say they hate Obamacare, Republican Senators who are contemplating making good on their promise to tear it down are beginning to wonder whether their constituents are saying that they hate Obamacare because it does too much, or because it does too little.
Seven years ago, the Republican Party was in a different place. Barack Obama was the unifying villain, and under the guise of the Tea Party and the House Freedom Caucus, GOP rhetoric returned to core principles: small government, strong defense, and a conservative judiciary. Obamacare represented everything the base of the party opposed―or so they thought. Just four years after Mitt Romney carried the party banner and declared war on those Americans who looked to government to solve their problems―vilifying the takers and glorifying the makers―Donald Trump turned the party on its head. He tapped into the rage and resentment of the party base at the turmoil that has engulfed rural America in the wake of globalization and technological change. He pointed the finger of blame directly at GOP elites, and won the nomination in a cakewalk. Gone were the Republican mantras of personal responsibility and no free stuff. Instead, Trump promised the world to his followers―including better insurance coverage at a lower cost―and he has not taken his foot off the gas.
The CBO scoring―particularly the 22 million or so people that it projects will drop off the insured rolls over the next few years―should not scare Republicans as much as it has. Those 22 million after all, are largely Americans who the CBO expects will decline to purchase health insurance once the individual mandated is eliminated. Republicans who have been railing away against the mandate should have a simple response to that number: of course those people are dropping their insurance, they weren’t buying it voluntarily to begin with.
The real hit is not addressed fully in the CBO analysis, that is the 25 million people―a different cohort from the 22 million mentioned above―who loom to lose their health insurance after funding for Medicaid expansion funding is fully eliminated beginning in 2025. This impact is barely touched on by the CBO, since the 10 year scoring window ends just one year later in 2026. Presumably, that is why the legislation stretches the phase out of Medicaid expansion so far into the future.
When Donald Trump criticized the House legislation as “mean,” he showed his cards. Any repeal of Obamacare was destined to be mean; it was supposed to be mean. Mean is what it means to be a Republican. This is not a slight on Republicans, it is an observation that Republicans are the ones who believe in safety nets not entitlements. Medicaid is a safety net, the Medicaid expansion enacted under Obamacare created an entitlement. The whole concept of a free market economy that is central to the Republican world view is that the individual is the central actor, incentivized to provide for their families, and to succeed. That is not the role of government.
Donald Trump, on the other hand, views himself as the national father figure. He told those families in eastern Kentucky and the upper peninsula of Michigan “Don’t worry about going back to school or moving your family to get a better job, I will bring those jobs back. Don’t worry that health care costs too much, I am going to make it cheaper and better than ever.” The Republican message to Americans used to be, if you face challenges in your lives, government may be able to help at the margins, but primarily it is up to you. Trump turned Paul Ryan’s entire world view on its head when he told those Americans, quite literally, “only I can fix it.”
Republicans in Congress face a difficult choice, and are damned if they do and damned if they don’t. If they don’t repeal Obamacare, they will have violated the promise they have been making, year after year, to their base voters. They will have proven themselves feckless, and will be judged accordingly. On the other hand, if they do pass the legislation in front of them, things may well revert to the way they were before, with millions more Americans without access to health insurance. That was supposed to be the idea, of course. It was inherent in the meaning of the world repeal.
But things aren’t the way they were before, and there’s no turning back the clock. Trump woke people up. He talked openly about the pain their communities have suffered, and promised that he would fix it. And the Republican Party jumped on board. Now, Republicans in Congress are supposed to deliver, and either way they vote only promises to make their problems worse.
Follow David Paul on Twitter @dpaul.
Artwork by Jay Duret. Check out his political cartooning at www.jayduret.com. Follow him on Twitter @jayduret or Instagram at @joefaces.