Republicans in the House unveiled their long-awaited plan to repeal and replace the Affordable Care Act on Monday, and the reception it got was so overwhelmingly negative that it has to represent some kind of milestone in American politics. With a mere seven years to prepare for this moment, Paul Ryan and the rest of the GOP leadership came up with something that's both a policy nightmare and a political catastrophe. And now we can see how the repeal effort will die.
Not that its death is assured, mind you. Republicans still control both houses of Congress and the White House; if they can stay unified, they can pass almost anything they want. But the reaction to this bill shows that unity on this issue will be awfully hard to come by.
Republicans have always faced a dilemma when it comes to repealing the ACA. On one hand, they've long promised their base that they'd slay the terrible beast as soon as they were able; they held 60 or so votes to repeal it when they knew that Barack Obama would veto them. They convinced their base that the law was the most despicable affront to human freedom since Stalin's gulag, and once it was dead, a new day of liberty would dawn. That base then invested ObamaCare with tremendous symbolic importance and came to understand the party's failure to kill it as evidence of their feckless weakness, a spirit that helped lead to the rise of Donald Trump. Now that Republicans actually have the power, they can't fail to do what they promised.
But on the other hand, it turns out that the public likes most of what the ACA does. Not only that, those vaunted white working class voters the GOP so lionizes are particularly reliant on the law's expansion of Medicaid and insurance subsidies. Now throw in the fact that the things Republicans want to do on health care will inevitably result in more uninsured and higher out-of-pocket costs, and repealing it seems increasingly dangerous.
So just look what happened when Ryan released the plan. It was no surprise that Democrats and liberals would condemn it, and they did. Less expected were the attacks from the right. Americans for Prosperity, the Koch brothers' political vehicle, came out against it, as did the free-market Club for Growth and the enforcers of right-wing orthodoxy at Heritage Action. Members of the Freedom Caucus, the House's collection of ultra-right congressmen, were quick to declare it vile, in large part because it gives some tax credits for people to buy coverage (though much less generous than the subsidies of the ACA) and because it doesn't dismantle Medicaid quickly enough. If we presume that Democrats will be united in their opposition, losing a couple of dozen House members would be enough to kill the bill.
But over in the Senate, Republicans have an even more acute problem. A few Tea Party senators have taken the same position as the Freedom Caucus, that the bill doesn't go far enough, while other Republicans are concerned it's too harsh. In particular, those from states that accepted the ACA's expansion of Medicaid are worried about the political impact of throwing thousands of their constituents off their health coverage, which will make for a whole lot of negative news stories and angry voters. And if only three Senate Republicans defect, the bill is dead.
Hovering in the back of all their minds is the 2018 midterm elections. They have good reason to be nervous, because the party that controls the White House almost always loses seats in midterms, and that's particularly true when the president is unpopular, as Donald Trump is now and probably still will be in a year and a half. The other key thing to understand about midterms is that they're all about turnout; the question is which party's voters are more angry and motivated to get to the polls.
The trouble for Republicans with this piece of legislation is that no matter how it turns out, it hurts them in 2018. If it passes, the ensuing suffering and chaos in the health insurance market will make Democratic voters upset and drive them to higher turnout. And if it fails, Republican voters will be disappointed and disgusted with their leaders, and thus more likely to stay home.
There's one more piece of this puzzle to account for: President Trump. He may not understand any of the details of reform, but he knows political heat when he feels it. It wouldn't be at all surprising if, as this bill gets more and more criticized, he edges toward abandoning it. That heat will only increase when the Congressional Budget Office releases its "score" of the bill, showing how much it will cost, how premiums will be affected, and how many will lose coverage. Republicans want to rush the bill out of committee before they get a CBO score (a highly unusual move), which shows just how nervous they are.
It's possible that Paul Ryan has some impossibly clever, multi-stage plan that he has now begun to execute, wherein the first iteration of repeal and replace gets pilloried and then he withdraws it and unveils an even better plan all Republicans welcome with open arms. But if that's what Republicans are waiting for, they'll probably be disappointed.