Donald Trump has claimed that his election gave him a mandate to dramatically change health care in this country. There’s little reason to believe this promise won’t bite him the way it did his predecessors.
President Obama, of course, made health care reform central to his 2008 presidential campaign, as had his Democratic rivals that year. And his election by a substantial margin certainly suggested that he had the public’s support on the matter. But public opinion quickly turned against his proposal. Thanks to strong Democratic majorities in Congress, a version of the plan still passed, but it remained unpopular well after its passage even while individual aspects of the plan remained popular.
These events were something of a rerun of Bill Clinton’s 1992 presidential campaign, which had also made health care reform a top priority. Clinton had quickly tried to convert his plan’s perceived endorsement by the electorate into concrete legislation, but found that his proposals were unpopular and easily demonized. Unlike Obama’s reform, Clinton’s died in Congress.
It would be a mistake to think that the electorates of 1992 and 2008 changed their minds on policy grounds over the course of a few months. Clinton and Obama ran on health care reform because it was a central component to the Democratic Party platform for decades. Those active within the party had made sure that pretty much no one could get nominated who didn’t have a plan for expanding access to health care.
A promise to fix the health care system no doubt tested well in general electorate polls in those years, but chances are most voters didn’t base their votes on that promise. Their votes were largely determined by the state of the economy and their own partisan leanings.
When Bill Clinton and Barack Obama took office, they were certainly obligated to pursue health care reform given their campaign pledges. But producing legislation is a lot more challenging than making a promise. Suddenly there are individual components that can be picked apart, ridiculed, and demonized.
Health care policy is important for the precise reasons that make it so politically troubling. It’s enormous, comprising some 18 percent of the economy. It affects nearly everyone to some extent, and often at their most vulnerable moments. A good experience with the system can mean your life was saved; a bad one can mean destitution or death. Most importantly, while people may agree on the general principle of universal insurance or avoiding government overreach, no one who has access to health care wants it messed with, and they will punish anyone who tries to do that.
And now Trump finds himself in a similar situation to both Clinton and Obama. It would be a stretch to say he had to take a “repeal and replace Obamacare" stance in the primaries — obviously it’s what Republican activists wanted to hear, but they didn’t exert a whole lot of constraint over him — but he took it anyway and made it one of his campaign centerpieces. Indeed, other than building a wall at our southern border, repealing Obamacare was one of Trump’s few policy promises. And now he has to deliver.
The uncertainty over what repeal and replace means is politically deadly. It is being easily demonized by Democrats, who have long known how to frighten voters when Republicans start making noises about changing Medicare or Social Security. Telling people their health insurance is going to be replaced by something better is not at all reassuring. Telling people they might lose something vital to their lives now but will get something better a few years later is terrifying.
If Republicans follow through with their health care plans, it could well prove politically disastrous, resulting in the sort of midterm election voter anger we witnessed in 1994 and 2010. If they decide not to make any policy changes at all, that would similarly create problems for them. It would massively disappoint their activist base, and incumbents will quickly get blamed for any future problems with the health care system anyway.
Republicans may well end up pursuing the sort of strategy Jonathan Bernstein outlined: Pass a toothless resolution and call it reform. No, it won’t really make anyone happy. But it might make the fewest people angry.