For all of these tactical missteps, the fundamental problem for the GOP was larger. Both the House and Senate legislation seemed hatched in a time warp. In their determination to slash taxes for top earners, torch regulations on insurers, and to roll back federal spending on expanded insurance coverage (either through the private exchanges or Medicaid), each bill reflected the common Ronald Reagan-era Republican belief that their coalition is bound together above all by a determination to shrink government.
But since then, Republicans have grown increasingly dependent on blue-collar, older, and non-urban white voters who do not always agree that “government is the problem,” as Reagan declared. While these voters, many of them economically strained, remain deeply skeptical of programs like food stamps that shift resources to those they consider undeserving, they have shown much more tolerance for federal spending that financially supports people like them.
The failure to understand that distinction crippled the repeal effort. From every angle, the GOP bills imposed heavy costs on their own voters. 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 employer-provided insurance is less common there. Counties on the front line of the opioid crisis warned the Medicaid cuts would devastate their response.
All of the groups and places on that list preponderantly backed Trump last fall. As a candidate, he recognized that reflexive hostility to government did not serve his voters’ needs: He even pledged to defend Social Security, Medicare, and Medicaid. Yet on health care, Trump fatally deferred to the libertarian-infused instincts of House Speaker Paul Ryan.
Like many congressional Republicans, Ryan enshrines retrenching government above all other goals. On health care, that crusade opened a breach with the GOP’s own voters: The proposals (particularly the Medicaid and insurance-regulation cutbacks) faced widespread resistance from blue-collar and older whites, even in polling conducted by prominent GOP firms like Public Opinion Strategies. In this week’s ABC/Washington Post national poll, Trump’s approval rating was 19 points lower than his vote last November among white women without a college degree, and 16 points lower among non-college-educated white men.
Those men are likely to stick with Republicans in the midterm elections. But veteran Democratic pollster Geoff Garin said the recoil on health care is so great that Democrats next year could eliminate the GOP advantage with blue-collar white women. Indeed, the ABC/Washington Post survey showed those working-class women—who backed both Trump and GOP House candidates by nearly 30 percentage points in November—now narrowly prefer that Democrats control Congress after 2018. Cutting Medicaid, especially while slashing taxes for the highest earners, puts “Republicans on the wrong side of the populist divide that Trump himself exploited,” Garin said.