Here are some data points that Republicans ought to bear in mind as they contemplate their health-care strategy.
Donald Trump is unpopular for many reasons, not least of which is the public perception that he has failed to bring down costs, as promised. Next month, more than 20 million Americans may see their health-insurance premiums spike, some by double or more, when expanded Affordable Care Act subsidies expire. Also, American support for the 2010 health-care law, otherwise known as Obamacare, has reached a new high of 57 percent, according to a recent Gallup poll.
Despite these facts, Republicans just voted to let ACA subsidies expire. How is the public likely to respond to this between now and the 2026 midterm elections? Probably not by warming up to Republicans.
Fifteen years after its passage, the ACA is a gigantic political pain point for the GOP. You would think Republicans would have made their peace with the law by now and turned their attention to other issues. But unlike pretty much every other conservative party in the industrialized world, where the legitimacy of universal health coverage is largely a given, the GOP seems resigned to bleed out on health care.
A largely unspoken article of faith for Republicans is that access to medical care is a matter of personal responsibility. They don’t generally advertise this belief, because it is not popular—a growing share of Americans believe that it is the government’s duty to ensure all citizens have health-care coverage, according to Gallup. So the party’s strategy instead was to fight proposals to expand coverage. Until the ACA, this proved effective.
The United States has two features that have made enacting universal health insurance especially difficult. One is its legislative system, which, unlike parliamentary forms of government, requires multiple concurrent majorities, including a Senate that gives conservatives disproportionate representation.
The second is the nature of America’s employer-based insurance, which sprung up during World War II and gave working-age Americans a stake in a privatized status quo. The fear that health-care reform might compromise this insurance complicated the politics, and ensured that Congress cared more about preserving insurance for those who had it (particularly as they tended to be educated and engaged voters) than extending benefits to those who didn’t.
The ACA broke through decades of gridlock by keeping the employer-based system intact and building up coverage options for people who couldn’t access it. Low-income workers, whose jobs mostly didn’t provide health care, would get Medicaid. People with higher incomes who didn’t have access to employer coverage would get subsidized coverage on individual exchanges, which would have to sell plans to customers regardless of health status.
Passing the law proved challenging. Republicans made all sorts of terrifying claims about its effects: The exchanges would collapse; health-care costs would skyrocket; insurers would employ “death panels” to decide which patients were worthy of care. None of those things happened. The death panels were imaginary, the health-care-cost curve bent downward, and the exchanges drew millions of willing customers and worked just fine.
Republicans never reckoned with the failure of their doomsaying prognostications to come true. Nor have they fully assimilated how the politics of health insurance have changed since the law’s passage. It was easy enough for Republicans to block health-care reform when a program to expand coverage didn’t exist. Taking insurance away from people who have it, or jacking up the price they pay to get it, is a completely different matter.
Some Republicans recognize that their impulses are unpopular, but they are not interested in accommodating public opinion. House Speaker Mike Johnson, who appears to represent the majority of Republicans on the issue, has called the ACA marketplace “a broken system,” as if the predictions of its collapse had come true, and treats its beneficiaries—who are now at a record high of 24 million people, or 7 percent of the U.S. population—as if their numbers are slight enough to be ignored.
“You’re going to see a package come together that will be on the floor next week,” he told reporters Wednesday, “that will actually reduce premiums for 100 percent of Americans who are on health insurance, not just the 7 percent.” Before the Affordable Care Act, the needs of uninsured people could be brushed aside. Johnson’s dismissive reference to “the 7 percent” seems nostalgic for that political world.
Trump has generally attempted to bluff his way through the problem. In his first term, he repeatedly promised to “repeal and replace” the ACA with a terrific system that would give everybody much better insurance for less money. This worked as a campaign promise but has proved impossible as policy.
In his second term, Trump’s approach to wishing away the trade-off between paying less and getting better care has been to claim that he can bypass the insurance market completely by giving people money directly, thereby allowing them to get more for less. “I want to give the people better health insurance for less money,” Trump told Politico’s Dasha Burns on Monday. “The people will get the money and they’re going to buy the health insurance that they want.”
Trump’s plan seems to invoke the hazy concept that people can buy their own medical services like items at a grocery store. That does not work with medical care, because people rely on doctors for advice on what services they need, and because medical costs frequently spike far beyond what anybody can reasonably afford, which is why almost everybody pays for it through insurance.
The president inadvertently confirmed this when he attempted to describe his concept to reporters on Tuesday. “I love the idea of money going directly to the people, not to the insurance companies, going directly to the people. It can be in the health savings account; it can be a number of different ways,” he said. “And the people go out and buy their own insurance, which can be really much better health insurance, health care.”
So Trump’s “plan” is to stop giving money to people to buy insurance, because that enriches insurance companies, and instead give it to people to go buy … insurance. This sort of nonsense talk may work well enough when Trump wants to just get through interviews without admitting a problem. But it isn’t a workable solution to soaring insurance-premium fees come January.
Perhaps the GOP will one day recognize that its aversion to widening access to health-care coverage is just too politically costly, too untenable, to so stubbornly maintain. Until then, Republicans act like they are operating in a world where the ACA hasn’t already given millions of Americans this essential benefit, and where these same Americans won’t be bothered when this benefit is taken away.
