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Obamacare is now officially part of America’s social safety net

Obama smile

House Republicans introduced the American Health Care Act on March 6.

On March 24 — just 18 days later — it was dead. This was a very short debate over a very big policy proposal, one that would have gutted Obamacare’s insurance expansion and left a projected 24 million Americans uninsured.

I missed one-third of that debate when I got married last weekend and took a week-long honeymoon. It was worth it! But now that I’m back — and with the advantage of a few days’ hindsight — I’ve identified two big lessons we can draw from the AHCA’s quick demise.

Lesson 1: Republican legislators don’t have a serious, coherent replacement plan

Republicans had seven years of promising to repeal and replace the Affordable Care Act. This was a centerpiece item in two presidential elections (2012 and 2016) as well as two congressional cycles (2010 and 2014).

Republican legislators talked about how Obamacare had too-high deductibles and did not offer enrollees nearly enough choice. They promised to pass a plan addressing these problems.

Except they didn’t. The Republicans offered a plan that would leave millions without coverage and increase the deductibles on the marketplace.

“The Republicans’ defeat didn’t stem mostly from tactical errors,” David Leonhardt writes today at the New York Times. “It stemmed from the substance of the party’s position on health care. The Republican Party can’t pass a health care bill because it has no coherent health care agenda. Tactics can’t overcome that problem.”

This is markedly different from the legislative process behind the Affordable Care Act. When Democrats began working on health reform, there were plenty of policy tussles and fights. But the goal was always clear and shared among the caucus: The whole point of health reform was to expand coverage to more Americans.

With the AHCA, it was never clear what exactly the goal was. It wasn’t expanding coverage — we learned that from the Congressional Budget Office report. It wasn’t reducing deductibles, as legislators had promised. And it wasn’t deregulating the insurance market; that wasn’t a goal Republicans could achieve through the reconciliation process they planned to use to pass the AHCA.

Republican legislators seemed to understand this too. Many conservative groups refused to support the bill, arguing that it wouldn’t create the health care system they desired. And while Speaker Paul Ryan introduced and promoted the bill, once it failed, he and other Republican legislators seemed just fine with moving on to the next priority and putting health care on a shelf for the time being.

Lesson 2: Obamacare is more resilient than I ever expected

On November 9, in the wake of Donald Trump’s surprise election, it seemed really clear to me that Republicans would repeal the Affordable Care Act. After all, they had spent seven years campaigning on that promise. They knew the consequences: that millions of Americans would likely lose insurance coverage.

I had expected they would move forward anyway. While Obamacare enrollees number in the millions, they are still a very small share of the population. Republicans seemed ready to weather the bad politics of cutting the insurance rolls in order to deliver on a years-old political promise.

It now looks like I was wrong, and Obamacare has become more entrenched as part of America’s social safety net than I had ever expected.

Republican governors rallied to save the Medicaid expansion. "That is a very, very bad idea, because we cannot turn our back on the most vulnerable," Ohio Gov. John Kasich said of the idea of repealing the public health program that expanded to cover millions more low-income Americans under Obamacare.

Meanwhile, Republican legislators such as Reps. Barbara Comstock (R-VA) and Ileana Ros-Lehtinen (R-FL) refused to support the AHCA because it would have left too many of their constituents without coverage.

People who weren’t even signed up for Obamacare turned out at raucous town hall meetings, suddenly ready to defend a law that has never been very popular.

Repealing social safety net programs is incredibly difficult, as the work of political scientist Paul Pierson has documented. He has found that politicians who run on promises of scaling back the welfare state can rarely deliver. Welfare programs, once implemented, quickly develop a constituency among those covered.

For a while, Obamacare seemed to be the exception to this rule. Because it was passed on a party-line vote, Republicans initially seemed to be okay with rolling back the health law’s coverage line. They were free to criticize a law that none of their fellow party members had supported.

Even Pierson, when we spoke in January, said the zeal behind Obamacare repeal had him questioning some of his assumptions about safety net programs.

This was right before the inauguration, when Republicans seemed to be moving full steam ahead on their repeal plans. “A lot of the arguments about the welfare state say that you’ll get huge pushback from voters who are really sensitive to things being taken away from them,” Pierson says. “Republican voters seem less sensitive to this than they might have been in the past, partly because policymakers seem to care less about what they think.”

But Pierson’s original theories — that the welfare state is sticky and hard to turn back — ultimately proved to be true. Republican legislators became quite sensitive to the idea of taking away benefits from their constituents as they saw them turn up in droves to town hall meetings. Seven years after Obamacare’s passage, the law’s coverage programs are simply what Americans expect from the welfare state.

My colleague Dylan Matthews caught up with Pierson a few weeks ago, and he’d had a change of heart. His original theories had been proven quite right. Here is how he described it:

There is an important dynamic where for years and years and years, Republicans could vote against the Affordable Care Act and loudly declare they were voting against the Affordable Care Act, knowing that this was all theater, that it wasn’t a real vote.

It was an easy win for them given the districts they represented and the way in which the Affordable Care Act had been portrayed to their most important political audiences.

Now the day after the election, you’ve got to think about actually doing it. The more time that goes by, Obama’s not there anymore, the more this other kind of logic — which is, yes, you’re taking away valuable benefits from very large numbers of people, including large numbers of people in your district. So that’s the first factor that I think has made things more difficult.

It was never clear that Obamacare was part of the social safety net up until the point Republicans threatened to take it away. Public support has always been lukewarm, with voters evenly split between those who say they support Obamacare and those who don’t. About two dozen states have refused to expand Medicaid under the Affordable Care Act, restricting the law’s reach.

But once the ACA was actually threatened, things changed. Obamacare’s popularity went up. More states began fighting to expand Medicaid at the exact moment Republicans wanted to end that program. Obamacare supporters showed up to town halls. They proved that delivering on Obamacare repeal would not be nearly as easy as politicians had expected. It has become a program that millions of Americans rely on — and that makes it awfully difficult to roll back.