Graeme Sloan/Sipa USA via AP Images
Scene from a protest at the Supreme Court demanding the Court preserve the Affordable Care Act, November 10, 2020, in Washington
The most public legislative face-plant of the Trump presidency was surely his party’s failure to repeal Obamacare. It’s been half forgotten already, but a repeal bill passed the House, and only failed in the Senate by one vote when Sen. John McCain (R-AZ) decided against it at the last minute. That single vote prevented something like 23 million people from being kicked off their insurance, as well as untold damage to the insurance and provider systems that had been dramatically overhauled by Obamacare.
The failure was probably a good thing for the subsequent political fortunes of the Republican Party. Republicans still lost badly in 2018, but had they actually caused that much devastation and disorder they would have lost even worse, and likely not come close in 2020.
So it’s rather mysterious that the Republican Party has coalesced around an even more unhinged health care agenda; not only repealing Obamacare but also slashing Medicaid and Medicare to the bone. This should be electoral poison—if voters ever actually hear about it.
Ronald Brownstein outlines the details at The Atlantic. Both the House Republican Study Committee and Project 2025 (recently covered by the Prospect) would repeal the requirement for insurers to offer affordable coverage to people with pre-existing conditions, transform Medicare from insurance into a private voucher, and turn both Medicaid and the Children’s Health Insurance Program (CHIP) into a state block grant—that is, a fixed pot of money for states with certain rules about how it can be used, rather than a mandatory spending program that anyone can access if they’re eligible. For good measure, Republicans would also repeal the Inflation Reduction Act’s provision allowing the government to negotiate what Medicare pays for certain prescription drugs.
It’s hard to say with any precision what this would do to the health care system, especially because a lot will depend on how states react. But it’s not a stretch to say that it would be an utter catastrophe. At a minimum, tens of millions of people would lose their coverage in the private market, and tens of millions more will lose Medicaid coverage. The experience with welfare reform, in which a New Deal–era cash benefit for very poor mothers was turned into a block grant, suggests that Medicaid and CHIP will cease to exist entirely in many conservative states. These days, Republican states routinely spend their welfare money on “crisis pregnancy centers,” which spread disinformation about abortion, or in the case of Mississippi, just give it to Brett Favre.
All this would wreak untold havoc with providers. At a time when hospital consolidation, ruthless private equity asset-stripping, and lack of insurance coverage in certain regions are already driving many hospitals to cut their services (especially labor and delivery units), if not close up entirely, huge chunks of important provider revenue streams will vanish overnight. The phenomenon of “health care deserts” where people lack nearby access to basic medical services will skyrocket.
All told, as Brownstein writes, the plan “calls for cutting federal spending on health care by $4.5 trillion over the next decade. That’s four times as much as the GOP envisioned cutting in its 2017 bill to repeal the ACA.”
Republican plans are so extreme that voters commonly refuse to believe them, especially on health care.
This enormous threat has barely sunk in among the public. In a recent Kaiser Family Foundation poll, 43 percent of adults said they were not sure if Trump had a plan to replace Obamacare. Even more tellingly, 48 percent said that Trump had the better approach to the law (as compared to Biden’s 50 percent), but 92 percent said it was important that people not be denied coverage because of their medical history—that is, the exact protection Republicans want to get rid of. Clearly, the median voter has little or no idea that Trump wants to gore Obamacare, let alone block-grant Medicaid and fully privatize Medicare.
In fact, Joe Biden is busily fixing the bits of the health care system that Trump did manage to mangle. Last week, the administration released a new rule limiting off-exchange “junk insurance” plans that Trump had willed into being, which have lower premiums but do not provide baseline benefits like prescription drugs or maternity coverage, and simply do not cover patients with certain pre-existing conditions, leaving them with no insurance support when they most need it. Presumably, the only people who know that Trump created crappy insurance that only works if you never use it are those with the misfortune of signing up for the plans.
Trump himself seems to blearily realize this isn’t a great issue for him. In 2016, he won the Republican primary by boasting that he was the only candidate who would promise to protect Medicare, Medicaid, and Social Security. But in office, he nearly killed Obamacare, and he has since repeatedly called for it to be replaced, which makes his current walk-backs less than convincing (over and above the garbled syntax from his dissolving brain). “I’m not running to terminate the ACA,” he recently posted on Truth Social, “AS CROOKED JOE BUDEN DISINFORMATES AND MISINFORMATES ALL THE TIME.” The lady doth protest too much, methinks.
Still, getting this message out will be a challenge. Democrats do not have anything like the propaganda foghorn that conservatives do, and also face a long-standing problem that Republican plans are so extreme that voters commonly refuse to believe them, especially on health care. As Robert Draper wrote in The New York Times Magazine, when back in mid-2012 Obama campaign staffers convened focus groups to test messaging on Mitt Romney’s health care and tax plans, “respondents simply refused to believe any politician would do such a thing.” President Biden and the rest of his party better get cracking.
