Today the Commonwealth Fund released a new survey on the performance of the Affordable Care Act, and it adds yet more data to the tide of good news on the Affordable Care Act. As a number of people have noted, the law's evident success is making it increasingly hard for Republicans to sustain their argument that Obamacare is a disaster and must be immediately repealed. But it's actually a little more complicated than that, and the ways different Republicans are changing—or not changing—their rhetoric on health care is a microcosm of the GOP's fundamental dilemma.
But before we get to that, let's look at what the survey showed:
The uninsured rate for people ages 19 to 64 declined from 20 percent in the July-to-September 2013 period to 15 percent in the April-to-June 2014 period. An estimated 9.5 million fewer adults were uninsured. Young men and women drove a large part of the decline: the uninsured rate for 19-to-34-year-olds declined from 28 percent to 18 percent, with an estimated 5.7 million fewer young adults uninsured. By June, 60 percent of adults with new coverage through the marketplaces or Medicaid reported they had visited a doctor or hospital or filled a prescription; of these, 62 percent said they could not have accessed or afforded this care previously.
That's a whole heap of good news, and there are a number of interesting results buried in the details, one of which relates to how happy people are with the insurance they have. One of the arguments conservatives have made is that people who ended up changing plans will hate the new ones they had to get because of Obamacare. Well, it turns out that among people who previously had insurance but are on a new plan they got through the exchanges or Medicaid, 77 percent say they're satisfied with their new plan, compared to only 16 percent who aren't satisfied, and the results are almost exactly the same for those who were previously uninsured. Not only that, 74 percent of Republicans with new plans say they're satisfied.
As more and more good news comes in about the implementation of the ACA, one would expect Republicans to talk about it a lot less, particularly given all their prior predictions of doom. And that is happening, but it's not happening in the same way everywhere. If you're a candidate in a swing state, it makes less and less sense, particularly as you move from your primary to the general election, to spend your time and ad dollars talking about how awful Obamacare is and pledging to vote to repeal it another 50 or 100 times should the voters send you to Washington to do the nation's business.
But the calculation is very different if you're running in a more conservative state, and there are lots of close Senate races in those this year, including Kentucky, Arkansas, Louisiana, and Georgia. In many of those places, the GOP candidate knows he can almost win solely with Republican votes. And for base Republicans, the emotional power of Obamacare is immune to factual refutation. No matter how much data we get demonstrating that the law is working well, those voters will still get angry every time the word is spoken. So it's in the candidates' interest to keep on talking about it, in the same apocalyptic terms.
This is where we get to the parallel with the larger Republican dilemma. On issue after issue, the interests of the national GOP are at odds with the interests of the bulk of the party's officeholders, because the latter come from conservative districts or states where political calculations look very different. The national party would like to pass immigration reform to woo the growing Hispanic electorate; individual Republicans need to take a hard stance on immigration to satisfy nativist voters in their districts. The national party knows it should moderate its stance on marriage equality to keep up with evolving public opinion and appeal to young voters; individual Republicans dependent on older voters and evangelical Christians need to hold the line for "traditional" marriage. In the broadest terms, the national party knows it should modernize, but a Republican congressman who won his last general election by 40 points doesn't see much reason to change.
The context where this dynamic will play out most visibly is, of course, in the presidential race, where Republican candidates will face two dramatically different electorates; It's as though they'll be running in Mississippi in the primaries, then in Ohio in the general election.
It's possible that in the next two years things will change in health care, and the ACA will look much worse than it does today. But it seems more likely that current trends will continue, and it'll look even better. Even if that happens, Republican candidates will still need to tell primary voters the law is an abomination that must be cast back into the fiery pits of hell from whence it came. To most voters in the broader electorate, that won't make a lot of sense.