Since the Affordable Care Act became law in 2010, congressional Republicans have made more than 60 attempts to repeal it. After Donald Trump took the oath of office on January 20th, 2017, Speaker Paul Ryan, Senate Majority Leader Mitch McConnell, and now-President Trump made it clear that repealing the supposedly “disastrous” law was one of their top priorities. In the intervening eight months, we’ve seen numerous attempts be rebuffed, only to rise again. Seemingly, each of these zombie iterations of Trumpcare is less popular than the last. Given the fierce outcry that they’ve faced from their constituents, why do congressional Republicans seem so determined to repeal and replace President Obama’s signature legislative accomplishment?
Many reliably red states have made major gains under the law. West Virginia (which went by over 40 percentage points for Trump) dropped its uninsured rate from 14% to 6%. Kentucky, home to both the Senate Majority Leader and Rand Paul (the Senate’s resident conservative firebrand), had one of the best examples of a state-run health care exchange website in Kynect, until its current governor shut it down (KY’s uninsured rate dropped from over 20% to 6%). Alaska, which has some of the highest healthcare costs in the nation, has received a great deal of federal funding and support and, in fact, has made strides to shore up its struggling ACA marketplaces this year. While some red states haven’t made major gains under the law, that’s largely due to their governors deciding not to expand Medicaid. Many of these congressmen, women, and senators have constituents who are benefiting through the ACA.
Even so, congressional Republicans seem determined to see this effort through to the bloody end. There are several factors that must be weighed when we consider the Republican doggedness to wipe out the ACA. First, since the Tea Party wave of 2010, “repeal and replace” has been their rallying cry. Second, the Republican donor class has strengthened its influence and deepened its pockets. Third, the only consistent policy aim of President Trump’s tenure has been to attempt to undo everything that President Obama achieved. Finally, the “outrage machine” of conservative media has hijacked the possibility of any attempt to fix the law as it currently stands. This perfect storm of political pressure means that Republicans can’t afford to fail on health care.
The election of 2010 was a tidal wave, dousing Democratic dreams of Obama’s tenure. Anger against the recent passage of the Affordable Care Act (and the bailout and stimulus package that were passed to lift the United States out of the worst recession since the Great Depression) delivered Republicans an additional six seats in the Senate, 63 seats in the House, and six governorships. Not only did the ideal of “repeal and replace” take hold in the popular Republican mind during this election, but the subsequent strategic redistricting effort, known as the REDMAP (the REDistricting MAjority Project) ensconced Republican districts, many of which hold to this day. An unintended side effect, first seen on the national stage with the primary loss of Eric Cantor, then the second-ranking Republican in the House, was that incumbent Republicans became more worried about primary challenges from the radical Right. The rise of the Tea Party changed the tenor of the Republican party. While bipartisanship has been on the decline since the ‘90s, the staying power of the Freedom Caucus and continued influence of the Tea Party has made compromise across the aisle a sign of failure; this sentiment was evinced by Leader McConnell’s threat to his caucus in June, “Either Republicans will agree and change the status quo; or… we’ll have to sit down with Sen. Schumer.”
The increasing strength of the Republican donor class has also impacted why Republicans are making attempt after attempt to kill the ACA. After the Supreme Court’s decision in the now infamous Citizen’s United case in 2010, dark money from major Republican donors began to broaden their influence. The Koch brothers offered to create a pool of funding strictly for those party members who toed the line and voted for ACA repeal. Through targeting by their data firm Cambridge Analytica and the funding of Breitbart, the Mercer family has insinuated itself into the highest ranks of the Republican policy apparatus.
Another example of the outsized power of donors occurred over this past summer, as casino magnates Sheldon Adelson and Steve Wynn threatened Nevada’s Dean Heller over public remarks critical of the effort to dismantle the current health care system. This donor power is quite insidious, as it happens behind closed doors and through party backchannels, rarely seeing the light of public scrutiny. As soon as the public pressure eases on Republican Senators and House members, the donor apparatus kicks into high gear to resuscitate whichever bill is currently under debate.
As the nominal leader of the party, one would expect President Trump to be leading the charge on health care. While he’s shown eagerness to repeal his predecessor’s signature legislative achievement, he has shown no desire to learn the nuts and bolts of health care policy in any form, leaving it to so-called party “wonks” like Speaker Ryan and Senator Bill Cassidy of Louisiana. That said, healthcare is hardly the only issue that has demonstrated President Trump’s zeal in trying to undo the Obama presidency. Whether it’s reversing environmental regulations, removing protections for undocumented Americans, or undermining the ACA, the President has made that goal readily apparent. Not only is he threatening his own party members with primary challenges and badmouthing Republican stalwarts like Senator John McCain of Arizona, but he’s destabilizing the ACA on a month-to-month basis by causing uncertainty about the future of the cost-sharing reductions which fund tax credits for Americans insured through ACA marketplaces and the Medicaid expansion. That decision could harm too many American to be entertained as sound policy, rather than, say, a petty personal choice.
The final piece of the puzzle in repeated Republican efforts is the rhetoric from the conservative media apparatus. Even before the Affordable Care Act became law, outlets such as Fox News were spreading misinformation about it, causing Politifact to inaugurate their Lie of the Year award in 2009, which went to “death panels.” Over the course of the 2016 election, sides retreated further into their respective corners as polarization increased. On the right, websites like Breitbart and InfoWars gained prominence. Nonpartisan entities like the Congressional Budget Office were discounted in ways that hadn’t been seen prior to the effort to repeal and replace the ACA. Stoking the Republican base’s anger over the ACA has been incredibly profitable; outrage fuels viewership, encouraging many of these media outlets to heighten their rhetoric and which the base into a frenzy.
These factors have forced the hand of congressional Republicans. The Affordable Care Act, or Obamacare, is more popular than ever; for the first time since it became law, a majority of Americans approve of it. Meanwhile, the most popular Republican repeal efforts have peaked at roughly 24% popularity (with many falling well below). In some cases, Republicans have not been able to muster majority support from their own party. They’ve adopted the same behavior that they accused Democrats of with the ACA’s passage, rushing the effort and trying to force repeal on a party line vote. They are also experiencing one of the truism of American politics in action – once an entitlement program is in place, it’s incredibly difficult to roll it back.
Should any one of their efforts pass, it would likely be a lead weight around the neck of any Republican up for election in 2018. Even so, to just write it off as Speaker Ryan seemed to after the House’s initial failure to pass its repeal and replace effort would be just as damning. As reported in the Des Moines Register, Senator Chuck Grassley said, “You know, I could maybe give you 10 reasons why this bill shouldn’t be considered. But Republicans campaigned on this so often that you have a responsibility to carry out what you said in the campaign. That’s pretty much as much of a reason as the substance of the bill.” By treating health care as purely political, congressional Republicans have resigned themselves to live or die by the politics of the issue, the consequences for themselves and their constituents be damned.