The election of Donald Trump was supposed to usher in a new era of conservative governance. Instead, all it has done is divide the GOP along ideological and class based fault lines that have only grown since the GOP tried to repeal Obamacare.
The GOP failure to repeal Obamacare can be placed at many feet. It can be placed at Trump’s for being an aloof participant. It can be laid at Mitch McConnell’s for refusing to give anything to moderate holdouts. Paul Ryan made the bill far too conservative for the Senate while the Freedom Caucus in the House drove it far to the right. Rand Paul’s almost nihilistic stance against anything but full repeal. Party leadership’s strategy to go it alone. The list goes on.
But, the fundamental problem for the party was larger. The GOP’s healthcare strategy seemed like it was conceived in 1980. The party’s determination to slash taxes, cut entitlement spending and curtail regulations on insurers reflected a belief by party elders the GOP coalition was bound together by a determination to shrink government. It’s not and Trump’s election should have shown that.
Since Reagan the GOP coalition has generally been shedding affluent, smaller government type voters and gaining non-urban, rural, blue-collar whites who care less about less about more government spending and more about where it is being spent. These kinds of voters are skeptical of government programs like food stamps but supportive of Medicaid and Medicare which supports people like them.
Failure to understand this crucial distinction doomed the repeal effort. The GOP bill cut deeply into Medicaid and Medicare. The Urban Institute found that among those who would lose coverage under the Senate bill, 80 percent lacked a college degree, about 70 percent were in a household where someone worked full-time, and nearly 60 percent were white. Older working adults confronted enormous premium increases. Rural areas faced disproportionate risk from the Medicaid cuts because of fewer exchange options.
There has always been an inherent friction in the GOP between libertarian leaning conservatives and pragmatists, between reformers and voters happy with Medicare and Medicaid. George Bush learned this in 2003 when he barely, barely was able to get Medicare Part D through Congress. Largely the only thing uniting Republicans on healthcare was support for the status quo (which meant opposition to Obamacare).
During the campaign Trump was smart enough to distance himself from a shrink government at all costs mentality. It is not what many GOP voters wanted despite witnessing the budget battles of the Obama years. Rather, GOP and culturally conservative voters cared more about urban vs. rural and cosmopolitan vs. Jacksonian values. They wanted their views represented about a rigged system, college elites telling them how to live and a government that was forgetting about the hard working little guy.
Campaigning on these ideas was easy. Turning them into a governing vision is something else entirely and Trump seems to have caved to Ryan’s libertarian style view of healthcare. Ironically, Trump voters don’t seem to care. They still support Trump but their support of Congressional Republicans has shrunk significantly.
Neither Paul Ryan nor Mitch McConnell had an easy route to repeal and replace. After Democrats spectacular flop in 93 and 94 it took the party a decade in a half to coalesce around a basic vision of reform, “Including a mix of guaranteed issue, community rating, heavy coverage mandates for insurers, a purchase mandate for consumers, and an expansion of the existing Medicaid system.” Obama lied about the ACA, its costs, and consequences but he had the majority of his party’s leadership side with him and that made the difference. Republicans had an idea of reform predicated on Ryan’s Better Way Agenda but Trump’s election showed few voters in general supported such a plan in its entirety.
The polling bears this out. The latest ABC/WashPo survey found Trump’s approval rating was 19 points lower than his vote share among white women without a college degree and 16 points among white, non-college educated men. The same survey found these women, who favored the GOP by 30 points in November now narrowly prefer Democrats control Congress. The GOP bill’s emphasis on cutting taxes at the top and capping Medicaid was not a good move in an age of populism.
Worse, Ryan and conservatives seem willing to fight the same fight on the budget. The GOP budget blueprint, designed to allow for major tax cuts for all Americans, reaffirms the massive cuts to Medicaid, many governmental assistance programs and proposes to transform the retirement program into a premium-support system that provides seniors money to purchase private insurance. When President Bush even suggested a similar idea for Social Security in 2005 it failed spectacularly. Worse, the Kaiser Family Foundation found in 2015 a majority of whites opposed voucherizing Medicare and Medicaid.
Lest Democrats be jumping up and down in joy at the GOP’s cognitive dissonance they suffer from their own problems. The cultural gap between Trump voters and the party is so massive many non-college educated white men and women might favor the GOP over their economic interests. Democrats tend to campaign on the issues that remind non-college educated whites why they vote Republican. The same poll also found Democrats are defined not by their ideas, good or bad, but their opposition to Trump by a majority of voters. Worse, Democrats seem hellbent on going further to the left and forever defining themselves as the party of elitist, college educated, media dominating, identity politics baiting candidates in a bid to acquire the loyalty of suburban voters.
Trump had a favorable initial reaction to the GOP house budget. But, the good news for him, and the party, is that their own base is likely to help nix the most onerous Medicaid and Medicare cuts. A voucher system is unlikely to even make it out of committee. The budget is likely to resemble past budgets cutting social service programs but leaving entitlements untouched.
Slowly, the GOP is learning the dilemma of old-school Southern Democrats who are now all but extinct. The slow cultural and economically leftward drift of the Democratic Party eroded the trust between long-time lawmakers and voters. Democrats leftward pushes on race, gender and other issues slowly crowded out the populist policies of these Democrats. Combined with demographic change, the 1994, 2010 and 2014 elections all but eliminated any moderate, populist Democrats in Congress.
Healthcare and the experience of Southern Democrats offer Republicans a choice. Do they bow to the cut government at all costs ethos of many of their House members or do they realize their base is older, whiter, and favors government programs that help them? Does the party realize a West Virginia is solidly red because of culture and not policy?
If the GOP is hell-bent on tax cuts, healthcare reform and reforming entitlements they might get it if leadership and Trump push hard enough. But, they might also hand Congress over to Democrats in the process.