This article first appeared on the Brookings Institution site.
When Republican senators get home for their July 4 break, they will run into a buzz saw.
The health care bill they are considering is wildly unpopular with their constituents, and its implementation would have disastrous effects.
They are likely to return to Washington even less enthusiastic about this legislation than when they left, leaving Republican leaders with no obvious path to the repeal and replacement for Obamacare they have promised for seven years.
Two hot-off-the-press public opinion surveys highlight the political challenge Republicans face.
The NPR/PBS/Marist poll released June 28 finds that only 17 percent of registered voters support the Senate health care plan, with 55 percent opposed. In the core of President Trump's electoral coalition—whites without a college degree—approval stands at only 21 percent. Among Independents, a group Mr. Trump carried by 4 points in the 2016 presidential election, the bill does even worse: only 13 percent support it.
Not surprisingly, only 20 percent of registered voters, and 22 percent of white working-class voters, approve of the way congressional Republicans are handling the health care issue.
Obamacare fares much better. 16 percent of voters want to leave it as it is, and 46 percent would like to change it so that it does more. Support for outright repeal stands at only 25 percent. 51 percent of white working class voters want to preserve or improve it, a figure that rises to 66 percent for Independents.
The Quinnipiac poll released the same day reaches near-identical results.
Only 16 percent favor the GOP plan, with 58 percent opposed. Support among white working-class voters is 20 percent; among Independents, 11 percent. Overall, "strong" approval of the bill stands at 6 percent, strong disapproval at 48 percent.
One explanation: 41 percent of voters think their health care costs would rise under the Republicans plan, compared to only 10 percent who think they would fall.
Another explanation: only 24 percent of voters favor cuts in Medicaid funding, a central feature of the Republican approach to health insurance reform. Support for Medicaid cuts stands at 27 percent among working-class whites and 22 percent among Independents. Even Republicans oppose these cuts by a margin of 53 to 39.
Fourteen states that expanded Medicaid under Obamacare have at least one Republican senator. An Urban Institute report released this week assesses how the Senate health care bill would affect their states. The overall results should be enough to attract their attention: 6.3 million of their constituents would lose insurance coverage. Kentucky, home to Senate Majority Leader Mitch McConnell, would suffer the largest percentage cut in federal spending.
State Republican Senators Increase Percent change in
in uninsured (thousands) federal spending
Alaska Don Sullivan, Lisa Murkowski 67 -41.7%
Arizona Jeff Flake, John McCain 395 -25.5%
Arkansas Tom Cotton, John Boozman 367 -33.3%
Colorado Cory Gardner 575 -53.2%
Indiana Todd Young 666 -36.7%
Iowa Joni Ernst, Chuck Grassley 232 -27.8%
Kentucky Rand Paul, Mitch McConnell 541 -58.5%
Louisiana John Kennedy, Bill Cassidy 410 -34.9%
Montana Steve Daines 113 -39.1%
Nevada Dean Heller 328 -48.2%
North Dakota John Hoeven 70 -51.8%
Ohio Rob Portman 1,122 -38.3%
Pennsylvania Pat Toomey 1,221 -37.0%
West Virginia Shelley Moore Capito 218 -48.9%
Source: Urban Institute
A more detailed analysis shows that of the total lost coverage in these 14 states, reduced participation in the individual health insurance exchanges would account for 14 percent of the lost coverage. Cuts to the Medicaid program would be a far larger share—84 percent.
Although the Obamacare exchanges have occasioned greater drama, Medicaid is the heart of the policy and political problems Republicans now face. The Medicaid cuts would strike hardest at Mr. Trump's base—working-class whites living in Greater Appalachia.
The president carried Arkansas by 27 percentage points, Kentucky by 30 points, and West Virginia by an astounding 42 points. Under the Senate bill, 421,000 Arkansans now enrolled in Medicaid would lose their coverage, 44 percent of the state's current enrollment. Another 264,000 (50 percent of current enrollees) would lose Medicaid coverage in West Virginia.
And of all 50 states, Mitch McConnell's Kentucky would lose the largest share of Medicaid enrollees—52 percent, fully 704,000 of his constituents. His authorship of this bill may be a backdoor announcement that he will not be running for reelection.
Like the House bill, the Senate bill does not just repeal Obamacare's Medicaid expansion; it goes farther, changing the structure and funding of the entire program.
This reflects, in part, House Speaker Paul Ryan's decades-long hunt, comparable to Captain Ahab's dogged pursuit of the white whale, to turn Medicaid into a block grant and give control of the program to the states.
Equally important, massive Medicaid cuts are needed to pay for the tax cuts the House and Senate bills award to corporations and wealthy individuals. But Medicaid may turn out to the shoals on which the effort to repeal and replace Obamacare is wrecked.
What happens if it does fail? Whom will the people blame?
According to the NPR/PBS/Marist poll, 37 percent of voters now say that congressional Republicans would bear the responsibility, while another 15 percent would blame President Trump.
Only 24 percent would point their finger at congressional Democrats. This helps explain one of the survey's most dramatic finds: if the midterm election were held today, 48 percent of the electorate would support Democratic candidates, compared to 38 percent for Republicans. Quinnipiac finds that while 17 percent of the electorate would be more likely to support a candidate who votes for the Republican health care proposal, 46 percent would be less likely.
There's a long way to go until November of 2018. But when it comes to health care, Republicans may well be damned if they do and damned if they don't. If I were a Republican running for office, I'd be worried.
William A. Galston holds the Ezra K. Zilkha Chair in the Brookings Institution's Governance Studies Program, where he serves as a senior fellow.
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