With John McCain’s dramatic “no” vote, the Health Care Freedom Act (HFCA) died early last Friday morning and with it any hope of repealing the Affordable Care Act (ACA) for the foreseeable future. While conservatives might prefer to blame incompetent vote-whipping in the Senate, the ACA could prove resilient for the same reason Medicare and Social Security have: most voters prefer not to wonder if they will be able to eat when hungry or see a doctor when sick. Any program that gives more economic security to a broad, politically powerful group will be dangerous to meddle with, even in these polarized times.
Conservative activists and pundits who don’t want to contend with that reality may point to the president they were dealt: Donald Trump knew essentially nothingabout health care and he alternated between disengagement and crude bullying of wavering senators ahead of the vote.
Blaming Senate Majority Leader Mitch McConnell is less convincing. McConnell is a masterful legislative strategist and it took his maneuvering to bring a bill supported by less than 30 percent of the public to within one vote of passing. Indeed, McConnell may only have come even that close because he skipped the normal committee hearing process, protecting the proposal from more public and media scrutiny.
The real lesson here is that once major social programs are in place, it’s simply very hard to eliminate them.
In his 1994 book “Dismantling the Welfare State?” the political scientist Paul Pierson showed that major social welfare programs were very resilient, and conservative attempts to repeal them generally failed. This was true even in parliamentary systems with fewer choke points to stop repeal than the American system.
In the United States, the clearest example is Social Security. Before becoming president, Ronald Reagan had a desire to make it a voluntary program, but he quickly abandoned any thoughts of radically restructuring the program after taking office. Instead he oversaw a bipartisan plan to protect the program’s solvency through a combination of regressive tax increases and benefit cuts. When the Republican controlled-Senate narrowly passed a one-year freeze to seniors’ annual cost-of-living adjustment freeze during Reagan’s second term, the president abandoned the unpopular proposal, letting it die in the House of Representatives.
George W. Bush, after winning re-election in 2004, made Social Security privatization his signature domestic issue. Bush travelled the country, making the case for a system of voluntary private accounts to partially replace Social Security for young workers. But the idea was politically toxic, actually becoming less popularthe more Bush discussed it. Congressional Democrats, who had collaborated with Republicans on major domestic legislation during Bush’s first term, came out against the proposal en masse. Republicans controlled both houses of Congress but they refused to take responsibility for highly unpopular changes to a cherished program. No Social Security privatization bill came close to a vote. Republicans have not actively pursued the goal since.
Nor have Republicans had any success at attacking the Great Society’s cornerstone health policy, Medicare. Sometimes they actively go in the opposite direction. In George W. Bush’s first term, Bush worked with Republicans to pass a corporate-friendly expansion of Medicare to partially cover payments for prescription drugs. Tea Party activists consider this one of the Bush era’s major betrayals of small government conservatism. But even arch-conservatives like Rick Santorum voted for the law. The politics were irrefutable: senior citizens vote, mostly Republican, and they fill a lot of prescriptions.
In 2011, now-Speaker of the House Paul Ryan proposed a plan to convert Medicare into a system in which seniors received vouchers (whose value would decrease over time) to purchase health insurance on private markets. The proposal was extremely unpopular and created a major backlash. Ryan has never officially abandoned some form of vouchers as a goal, but he has not put any Medicare restructuring on his legislative agenda since taking the Speaker’s gavel. The Ryan budget’s threat to Medicare, however, proves a reliably spooky specter for Democrats to invoke when sending fundraising emails or appealing to older swing voters.
Social programs are often not fully appreciated by their beneficiaries until someone proposes getting rid of them. Facing an existential threat made the Affordable Care Act much more popular – as then-Speaker of the House Nancy Pelosi predicted, support for it increased once people found out what was in it. The Republican proposals to replace the ACA, conversely, are staggeringly unpopular. As recently as last year, more Americans disapproved of the ACA than supported it, but its approval ratings are now over 50 percent, while the repeal bills started out unpopular and became more so.
The majority support for the ACA wasn’t soft, either. Supporters of the ACA were far more motivated than its opponents during the repeal struggle, putting their time and sometimes their bodies on the line, such as when disabled people were ejected from the offices of members of Congress. This helps to explain why moderate Republican Senators Susan Collins of Maine and Lisa Murkowski of Alaska (not to mention Democratic senators representing states that Trump won in landslides such as West Virginia and Montana) were unwavering in their opposition. The weekend after the HCFA was voted down, Murkowsi was repeatedly greeted by supporters, some in tears, thanking her for her no vote, while Nevada Senator Dean Heller was rewarded for his “yes” vote by seeing his approval rating plummet to 22 percent.
This doesn’t mean that supporters of the ACA should be complacent. Even when Republicans have failed to eliminate major social programs, they have been able to make them less generous in ways that caused real harm, Reagan’s Social Security adjustment included. Trump is signaling that he will damage the ACA administratively, and 19 states are still refusing the ACA’s generous Medicaid expansion.
Moreover, the failure to eliminate major welfare programs is a tendency, not an iron law. In 1996, President Bill Clinton signed a welfare “reform” bill that led to more than 6 million mothers with children losing welfare benefits.
That was possible partly because welfare, unlike Obamacare, only benefits the poor, who are politically disempowered.
Still, Republicans just came closer to passing a partial repeal of the ACA than many would have thought possible.
The battle over healthcare is far from over, but the repeated failures of the GOP efforts to repeal it prove the political durability of the social safety net.