Notwithstanding cynical and/or stupid Republican campaign promises to the contrary, ACA repeal–in the absence of a good replacement plan–died on the vine in 2012. Here’s why.
First, ACA was cleverly constructed to co-opt numerous potential well-funded opponents. Democratic negotiators got the buy-in of the pharmaceutical industry by preserving Medicare’s inability to negotiate drug prices. They got the buy-in of insurance companies by creating a mandate for consumers to buy their product. Hospital lobbyists participated heavily in the negotiations as well. In doing so, the Obama administration created a set of well-funded stakeholders to oppose changes to the plan. Politically, it was a real accomplishment, and made repeal a challenging proposition–many Republican elected officials count those industries as substantial donors.
Second, people are generally loss averse, and once implementation began in earnest after the 2012 election, there were real beneficiaries with gains to protect. For example, most people who are now eligible for Medicaid assuredly appreciate their new health coverage. Individuals who want to strike out on their own can get health coverage through heavily-subsidized individual markets. We should expect them to protect their gains at the ballot box aggressively, in the absence of a replacement plan that protects their interests. Republicans who rescind those benefits without offering something comparable will face their electoral wrath.
More generally, loss aversion has contributed to the ACA’s growing popularity in 2017. As half-baked Republican repeal-and-replace plans make their way into the public consciousness, people are concerned about the impact those plans will have on their health coverage. The predictability of the status quo seems better and better in that context.
Third, the parts of the ACA most vulnerable to tinkering and conservative reform–the essential services and such–passed the Senate with 60 votes, not 51. To repeal those without a comparable majority would require an extremely favorable ruling from the Senate parliamentarian over reconciliation rules, or the destruction of the filibuster.
Fourth, the GOP squandered several very winnable Senate seats in 2010 and 2012, giving them a razor-thin margin vulnerable to the whims of heterodox conservatives like Susan Collins, Lisa Murkowski, and John McCain, and windmill-tilting libertarians like Rand Paul. Solid Republican nominees were defeated in primary contests in several states.
– Mike Castle, a surefire winner in Delaware, lost in a primary contest to Christine O’Donnell.
– Sharron Angle in Nevada lost a highly winnable seat to the extremely unpopular Harry Reid.
– Ken Buck lost Colorado by a razor-thin margin while inching past Jane Norton in the primary.
– Sarah Steelman, a strong candidate in Missouri, lost the nomination to Todd Akin, in part because Missouri Republican primary voters were influenced by an ad campaign mounted by Claire McCaskill.
– Richard Mourdock successfully primaried Senate institution Richard Lugar in Indiana, and lost the general election to Joe Donnelly.
Having Mike Castle, Dick Lugar, Sarah Steelman, Jane Norton, and Sue Lowden in the Senate would have made the reconciliation-based pieces of ACA repeal much more feasible. Oops!
Fifth, the Supreme Court upheld the ACA in 2012 as constitutional, while simultaneously granting relief to states that did not accept the Medicaid expansion, thus neutralizing one source of energy for repeal.
And finally, the GOP could not find a nominee for president in 2012 that was a good match for ACA repeal. Not only was the ACA essentially warmed-over Romneycare (which made sense in Massachusetts in the context of a dysfunctional federal health care system), but Mitt Romney himself was also extremely vulnerable in crucial states because of his wealth and patrician air. He simply did not play well in parts of the country that have proved critical to GOP majorities in the 2010s: specifically, the Rust Belt and Inland North. If the GOP had nominated a candidate in 2012 who was both philosophically opposed to Obamacare and more amenable to swing voters, the outcome may well have been different. And every day that the ACA was law was another day harder for it to be repealed root-and-branch.
In short, ACA repeal died the night that Obama won in 2012. If the GOP wants to replace the ACA, it must craft a plan that protects the gains of the beneficiaries of the ACA and gets Democratic votes to compensate for their thin majority. The sooner the GOP accepts that reality, the better.
Alternately, we can muddle through with an incompetent president and dysfunctional Republican majority until the voters, out of immense frustration, reinstate full Democratic control of the government and expand the role of the federal government in health care ever further. I know which I expect to happen.
Image by tedeytan