Obamacare. Maybe you’ve heard of it. It used to be kind of a big deal.

In 2012, Republicans made it the central issue of their election effort.

In 2013, they shut down the government for 16 days in a failed attempt to force defunding of the law.

In January 2016, the House and Senate formally repealed the Affordable Care Act, despite the inevitability of a veto, hoping—as they said at the time—to create a ballot issue for the November election.

Less than 60 days out from the presidential vote, however, the issue of Obamacare has all but vanished from the Republican message. Byron York reported in the Washington Examiner on August 28:

Donald Trump remains virtually silent on Obamacare. Look at Trump's last 10 speeches—the number since Trump began delivering prepared-text teleprompter remarks. All came during a period of bad news about Obamacare. But, according to the texts released by the campaign, one Trump speech didn't mention Obamacare at all, while several others devoted just a few—really, a few—words to the subject.

On September 9, Trump had this to say at the Values Voters summit:

We’re also going to repeal and replace disastrous Obamacare which gives the government control over the lives of everyday citizens. And the numbers are horrendous. Your premiums are going up by 50, 60, 70 percent. The deductible is so high you never get to use it unless you are going to lead a very long and very complex bad period—very, very long. It is a disaster. It’s a disaster, and everybody knows it. And it’s going to die of its own weight anyway, but we’re going to get rid of it and we’re going to replace it with some great, great alternatives—much better health care at a much lower price.

Hillary Clinton wants to have completely government-run health care, which would be a disaster for the liberties and freedoms of all America. That’s what she wants. That’s what she’s aiming at. That’s what Obama wanted. He didn’t quite get there, but he got this, and you see how bad this has been.

And … that’s it.

Trump’s formal platform on healthcare is equally perfunctory. It’s a one-page cut-and-paste job of long-standing, lowest-common-denominator Republican ideas, with one populist deviation: importation of lower-cost drugs from other countries.

Trump’s ideas are often casually considered. But with health care there’s something more going on than the sloganeering of “take the oil” or “Mexico will pay for the wall.” Trump early grasped something that has eluded more conventional Republicans over the past seven years: As compared to the Obamacare status quo, mainstream Republican health-care proposals would shrink coverage—and raise out-of-pocket costs—for many millions of Americans. Trump did not initiate or adopt new ideas. Almost alone among Republicans, however, he intuited the political hazards of the old ones.

Obamacare is a flawed, unstable program. But it’s something. It attempts to meet real needs that have gone disregarded for a long, long time. It has extended coverage to many who lacked it. Not always good coverage. Often coverage through the unsustainable Medicaid program. But still: coverage. Withdrawing coverage from those who have it is politically dangerous. Trump perceived the danger, when more orthodox Republicans did not or would not.

Trump feels no obligation to ideological consistency or budgetary coherence. So he can deal with the danger with a sequence of gimmicks: denounce Obamacare, promise to replace it with something better and cheaper, offer no specifics at all about what that something is, worry not even a little that the promise to improve Obamacare conflicts with the scant details of the policy he supposedly offers, and then … avoid the whole subject of health care to the maximum extent possible.

That solution will not be available, however, to the Republicans who follow Donald Trump. Assuming he loses the presidency (which seems a safe assumption) Republicans will not regain an opportunity to reform health care their way until 2021. By that time, the Affordable Care Act will have been the law of the land for eight years. Its defects will be more visible than ever. The expectations generated by the act will be more entrenched than ever, too. Removing coverage from people under 26; reinserting the notorious “doughnut hole” into prescription drug prices; again allowing the more notorious practices of the insurance companies; withdrawing ACA subsidies from perhaps 10 million people—there will be scant constituency for these things. Medicaid removal will become even more difficult as more states sign up for the ACA Medicaid program between now and 2021, just as Pennsylvania, Indiana, and Alaska signed up in 2015 and Montana and Louisiana signed up in 2016.

The current Republican health approach of “repeal-and-mumble-mumble" will become that much less feasible. More and more Republicans will perceive the danger that Trump perceived. Unlike Trump, they’ll care that their response to the danger makes sense and can actually be implemented. The old health care debate cannot be continued. Trump ended it. The next health care debate will start as soon as he exits the arena.

Republicans have fought hard and long to stop the ACA. Arguably, the fight was lost once the law was signed by President Obama in 2010. It was more certainly lost when Obama was re-elected in 2012. Should Republicans lose again in 2016, who but the most fanciful can imagine that repeal can happen in 2021? Who’ll want to fight the 2020 election on yet another promise—or threat—to remove health-care benefits from so many who have gained them since 2013?

The old health-care debate has ended. Leading Republicans to accept that unwelcome fact may be one of Trump’s rare positive legacies for the party that nominated him for president.


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