Republicans' painful collision with reality

To hear Republicans tell it, they have no greater legislative priority, nothing they want more urgently to do with their newfound control of Washington, than repealing the Affordable Care Act. They will slay ObamaCare — crusher of freedom, destroyer of hope, enemy of all that is right and good about America — as the first step in their headlong dash toward the restoration of American greatness.

But now, before their new president has even taken office, the ObamaCare repeal effort is imploding.

They arrived at the point where ACA repeal is so vital not because they care deeply about health policy or because the ACA has turned out so badly. It's because Republicans turned the ACA into a symbol of their defiance of Barack Obama.

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ObamaCare was everything they hated about him and about government, an allegedly socialist scheme "rammed down our throats" by the diabolical means of having a year of debate and hearings culminating in votes of both houses and a presidential signature. They even insisted that the ACA was a cruel act of racial vengeance against white people: "This is a civil rights bill, this is reparations," said Rush Limbaugh. After voting to repeal it 60 times, and after a campaign where an angry conservative base rose up against what it perceived as a weak and ineffectual GOP establishment — with no clearer example of their impotence than the continued existence of the ACA — Republican congressmen know they had better come through.

But now they've got a serious problem on their hands. It's easy to blame every problem anyone has with health care on ObamaCare when you're out of power, but once you control the entire government, you become — get this — responsible for the changes you bring. And this painful collision with reality is making some Republicans terrified.

For instance, Democrats have cried out for years in anguish that while this vaguely understood thing called "ObamaCare" can't seem to crack 50 percent support among the public, almost everything the ACA does is hugely popular, with the exception of the individual mandate (which makes the whole thing work). In a recent Kaiser Family Foundation poll, for instance, many of the law's key provisions, including the expansion of Medicaid, the creation of insurance exchanges, and the elimination of cost-sharing for preventive services, garnered the support of over 80 percent of Americans. Even Republican voters love the things the ACA does.

That means that while it's easy to say "We'll free you from ObamaCare! Won't that be great?" it turns out to be a lot harder to say, "We made it so insurance companies can deny you coverage if you have a preexisting condition! Isn't that great?" This is what Republicans are now realizing.

There's a psychological principle working against them, known as "loss aversion." It states that we put a higher value on avoiding losses than achieving future gains, and it's the reason why it can be hard to get support for new government programs, yet even harder to eliminate a program once it's in place. And right now, Republicans are contemplating taking away a very big program and harming a lot of people. Tell the 20-30 million Americans who will lose their health coverage if the ACA is repealed that you'll give them "access" to a free-market alternative that might eventually work out better for them, and you'll be met with some very cold stares.

That reality is one of the reasons why, seven years after the ACA was passed, Republicans still haven't been able to agree on a replacement plan. And it's why their initial idea of how to deal with their problem — "repeal and delay" — has gone over like a lead balloon. Under "repeal and delay," they'd pass the repeal of the ACA now, with a ticking clock until it actually takes effect. In the meantime, they'd supposedly settle on their replacement plan.

Even many Republicans can't take that seriously, which is why at least nine Republican senators have come out publicly to say that if they're going to repeal the ACA, they shouldn't do it until they have a replacement plan ready. That's more than enough to defeat repeal in a vote in the Senate, where Republicans have only a 52-48 lead.

And it's no accident that many of those senators, though staunch conservatives, come from states that accepted the ACA's expansion of Medicaid. Rand Paul, for instance, may be a quasi-libertarian who hates government health insurance, but he knows that kicking 439,000 Kentuckians who have Medicaid because of the ACA off their insurance is a very bad idea — politically for him, even if he doesn't care about their actual welfare. The same goes for hard-right senator Tom Cotton of Arkansas, who has 324,000 constituents who stand to lose their Medicaid coverage.

There's another problem waiting for them when they finally unveil their replacement plan. The single biggest complaint Americans have about health insurance right now is rising out-of-pocket costs, which Republicans sometimes wield as a critique of the ACA, as in, "Sure lots of people have insurance, but deductibles are so high it doesn't matter!" The trouble is that all the replacement plans Republicans envision would increase out-of-pocket costs. Indeed, that's how they're designed: By giving people "skin in the game" — i.e. making them pay out of pocket — we're all supposed to become clever health care consumers and drive down costs.

Democrats will have no problem creating opposition to that, which means that while the "repeal" half of "repeal and replace" is already unpopular, the "replace" half isn't going to do much better.

There are still a couple of ways this whole thing could end. But at the moment, it's not looking good for Republicans. Which is good news for Americans' health.