The Plot Against Health Care

By Paul Krugman

Opinion Columnist

• May 31, 2018
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A demonstrator last year in Berryville, Va.CreditTom Williams/CQ Roll Call, via Associated Press

On Wednesday, Virginia’s legislature voted to expand Medicaid, accepting a key piece of the Affordable Care Act. Around 400,000 people will gain coverage.

The politics of the move aren’t hard to understand. Virginians overwhelmingly support Medicaid expansion; last fall, Democrat Ralph Northam won the governorship by a landslide after a campaign largely focused on health care. But wait: Don’t we keep hearing that Democrats are running on nothing except opposition to Trump? Hey, influential commentators say it, so it must be true.

Anyway, the will of the people on health care is clear: Whatever qualms voters may have had about Obamacare, a strong majority want to keep and expand the gains in coverage that America has achieved since the law went into effect.

In other news, there are multiple reports that Republicans in Congress may make another attempt at repealing the A.C.A. this summer. Even if they don’t succeed, you can be sure that they will next year — if they manage to hold on to the House in the midterm elections.

On the surface, these stories may seem contradictory. Expanding health coverage is a winning issue for Democrats; trying to take it away is a losing issue for Republicans. Why would the G.O.P. want to keep charging into that buzz saw?

But the growing popularity of key parts of Obamacare is precisely the reason Republicans are highly likely to make a last-ditch effort to kill the A.C.A. For them, it’s now or never.

Here’s what history tells us: Expansions of the social safety net are relatively easy to demonize before they happen — before people get to see what they actually do. Opponents declare that they’ll destroy freedom, that they’ll be wildly expensive, that they’ll be a national disaster. American politics being what it is, opponents of a stronger safety net also tap into racial resentment, convincing white voters that new programs will benefit only Those People.

Once social programs have been in effect for a while, however, and it turns out that they neither turn America into a hellscape nor break the budget — and also that they end up helping people of all races — they become part of the fabric of American life, and very hard to reverse.

This has happened again and again. When F.D.R. famously spoke about his opponents and declared, “I welcome their hatred,” he was talking about Republican demonization of the just-passed Social Security Act. But eventually Social Security became effectively untouchable, as George W. Bush learned when he tried to privatize it in 2005.

Medicare went through the same cycle. Before it was enacted, Ronald Reagan warned that it would bring socialism and “invade every area of freedom as we have known it in this country.” Today, Medicare has overwhelming public support, so much so that Republicans attacked the A.C.A. with the (false) claim that it would steal money from Medicare.

And this gets at the heart of conservative opposition to social safety-net programs: It’s not about the belief that they will fail, but about fear that they will succeed, and in so doing become irreversible — which means that they must be stopped before they can start showing results.

So it has been with Obamacare. Before 2014, when the program went fully into effect, conservatives were quite successful at turning public opinion against it. It would lead to “death panels”; it would lead to “rate shock”; it would cause the budget deficit to balloon.

But public opinion has shown a steady turnaround since then. The share of voters believing that it’s the government’s responsibility to ensure that all Americans have health coverage has shot up since its 2014 nadir. Approval of the A.C.A., while still not overwhelming, has shown a more or less steady upward trend.

When Republicans held town halls over A.C.A. repeal last year, they were shocked by the intensity of public opposition. And elections, both state elections like Virginia’s and special elections for Congress, keep showing that trying to roll back coverage is a big political loser.

Again, you might think this would lead the G.O.P. to drop the whole issue. And if Republicans lose the House this November, they probably will, and America will become like every other advanced country: a society in which access to essential health care is considered a basic right.

But that hasn’t happened yet; conservatives still cling to the dream of denying health care to another 20 million or 30 million Americans.

Unable to repeal the A.C.A. outright, they’ve tried to sabotage it — using last year’s tax cut to get rid of the requirement that people buy insurance even if they’re currently healthy, using administrative gimmicks to try to undermine the requirement that insurers cover people with pre-existing conditions. But the A.C.A. is proving, from their point of view, annoyingly robust; and most indications are that voters are, rightly, blaming Republicans for rising premiums.

So it’s looking as if Republicans won’t manage to kill health care on the sly. And that means that we can expect one final push at outright repeal — a push that will succeed if Republicans hold the House.

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A version of this article appears in print on May 31, 2018, on Page A25 of the New York edition with the headline: The Plot Against Health Care. Order Reprints | Today’s Paper | Subscribe

 

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