Updated | Before President-elect Donald Trump this week told Congress to ditch Obamacare without delay, a few of the newly empowered Republicans in Congress were wavering on whether to do so without a Trumpcare plan on the drawing board. Even House Speaker Paul Ryan was starting to talk about replacing it with a GOP plan “concurrently.”
About 22 million Americans now rely on the Affordable Care Act, and polls show two-thirds of U.S. citizens think repealing it without a replacement is a bad idea. The Department of Health and Human Services says its surveys find four out of five ACA marketplace consumers are very or somewhat satisfied with their insurance plans, and that they are “just as satisfied with their coverage” as people with private, employer insurance plans. Despite complaints, last month’s poll found Americans are less worried about not being covered by insurance and about not being able to afford drugs. And they are much less worried about losing their insurance—down by 10 percent.
So what constituency do congressional Republicans think they would be serving by getting rid of Obamacare, pronto?
First, Trump voters: In Election Day exit polls, a majority of non-college-educated whites and 81 percent of Trump voters said they agreed with the statement that Obamacare “went too far.” But despite the roars of joy that Trump enjoyed at rallies when he promised to repeal it, the polls didn’t ask whether those same voters wanted to lose it altogether. And, similar to Trump winning the election with a minority of the popular vote, while some Republicans believe they have a mandate to kill Obamacare, polls make it clear they do not. The Kaiser Family Foundation regularly does surveys on health care issues and its last poll found that 28 percent of those who support repeal don't want it repealed without a replacement, while 47 percent don’t want it repealed at all.
Second: O-care haters. About 30 percent of Americans, meanwhile, really and truly dislike Obamacare—and they always have, since even before it was signed into law in 2010. Not surprisingly, this 30 percent isn’t worried about losing health insurance, or about not being able to afford health services, according to the Kaiser polls. They tend to be white, male, Republican (83 percent) and well off, with more of them making over $90,000 than in any other polled category. They are also more likely to be middle-aged, in the 50-to-64 age category—old enough to be chronically sick but still too young for Medicare.
Interestingly, they also happen to be the most likely of those polled to have someone in their home with a pre-existing condition (32 percent).
These purist Obamacare haters are a minority, but they are an insistent and provocative one. The mere whiff of socialized medicine has a strange effect on some Americans. Since 2009, when a New Hampshire man showed up outside an Obama town hall health care event with a weapon strapped to his leg, and then when dozens more armed men protested another Obama health care town hall in Phoenix, it has been clear that this particular policy issue makes people crazy.
The AR-15s and ankle-holstered Glocks outside the 2009 town halls signaled a visceral connection between opposition to gun control and to public health care, with its menacing government caches of personal information and patient data. At the time, Larry Pratt, director of Gun Owners of America, connected the dots: “If this becomes law, there’s no place to escape” if the government wanted to use federal medical records to deem citizens “medically unfit” to carry a gun, says Mr. Pratt. “No trial, no due process—just gone.”
Third: well-funded free market ideologues. At Freedom Partners, a Northern Virginia-based enterprise that funnels Koch money into politics and that has been called the Kochs’ “secret bank,” Senior Policy Adviser Nathan Nascimento said senators who are reluctant to repeal immediately “owe it to the American people to free them from this disastrous law, and that requires the full repeal of Obamacare, the elimination of harmful regulations, and targeted, patient-centered health care reforms. As long as Congress stays on that path—and avoids trying to create yet another health care monstrosity—Americans could finally see some relief.”
Fourth: the congressional Republicans themselves. In Washington, ideology isn’t driving the long effort to kill Obamacare; it is simple political math: If white, male, middle- and working-class Americans—the seemingly shrinking core of the GOP’s demography in a multicultural and many-gendered world—get used to the benefits of national health care, who knows what might happen to the Republican base. And in the Rust Belt, where this in fact has started to happen, it’s unlikely that a total Obamacare repeal with nothing to replace it will sit well for long, even if it’s cloaked in ideology.
The law went into effect in 2013, and despite a disastrous rollout and legal challenges that went to the Supreme Court, 22 million more Americans—and especially more Trump-voting Americans—are now insured. The law has clearly benefited the very poor: Almost 16 million more Americans are covered by Medicaid than before the ACA. But an Urban Institute study found that more non-college-educated whites are on Obamacare than minorities and college-educated whites together in the five key Rust Belt states that flipped for Trump—Michigan, Pennsylvania, Ohio, Iowa and Wisconsin. The numbers of uninsured dropped dramatically in those states, too, by 40 percent to 60 percent.
After it passed, Republicans resorted to dozens of doomed-to-fail show votes to repeal Obamacare, but now that they control Congress and the White House, they have their best real shot since 2010 to drive a stake into the ACA for good. Senate Majority Leader Mitch McConnell says he is willing to kill it immediately, without a replacement plan. Republican senators Mike Lee, Marco Rubio and Ted Cruz sent a letter to Senate Republican leaders calling for repealing Obamacare within the first weeks of Congress, by jamming it into the budget reconciliation bill. “Indeed, we should try to use the reconciliation process to repeal as many provisions of Obamacare as possible, especially the insurance mandates that are driving up health insurance costs for millions of Americans,” they wrote. McConnell appears to be ready to go along with this tactic, but five of his Senate Republicans are urging lawmakers to get a backup plan in place before they repeal it.
Republicans used to to count on deep-pocketed health care industry lobbyists as being in their repeal constituency. When the ACA was in the drafting stage, U.S. health insurers, through their lobbying group American Health Insurance Plans, spent more than $100 million in attempting to kill it using “grassroots” outreach and advertising featuring a “creepy Uncle Sam” getting in people’s private business, and stoking fears about losing “choice.” But that once-reliable business constituency isn’t stepping up to the plate now that repeal can actually be accomplished. One reason is profits: once the Affordable Care Act passed, insurers began to make millions of dollars on the new consumers the government brought in. In Washington, insurance, healthcare and Pharma lobbyists are laying low.
The repeal strategy now will rely on making the constituency look large, with the testimony of Americans who have experienced Obamacare and who are unhappy with its costs or other aspects of their plans. And the ideological constituents are scouring the hinterlands for them. “A certain group of people are opposed purely because it conflicts with their ideology,” concedes Levi Russell, spokesman for the Koch brothers PAC Americans for Prosperity, one of the leading foes of Obamacare. “They don't like a big-government solution and don't like being told they have to purchase a product or be fined by IRS. But opposition to Obamacare has peaked at over 50 percent over the years [“somewhat unfavorable” views of Obamacare are currently around 47 percent], and what that means is you get plenty of people who identify as independents or Democrats who say this is not working out for me. They are a large group of people who are not happy with it because of their personal experience or what they have heard about it.”
Correction: The Kaiser Family Foundation was incorrectly referred to as Kaiser Permanente in an earlier version of this article, and a reference to the 22 million people covered under the ACA was incorrectly said to be 20 million.