On Tuesday, the Senate—with the late, dramatic arrival of Sen. John McCain, who cast a deciding vote—opened the floor to Obamacare repeal. A procedural vote, it was the remarkable capstone of an unprecedented effort to pass major legislation without hearings, independent testimony, or public input. What makes it potentially history-making, and not just noteworthy, is that it also marks a milestone for our country: the beginning of what is, thus far, one of the most aggressive attempts at revoking a broad guarantee of the American welfare state. A door that, once opened, may prove difficult to close.
Conventional wisdom says that, once passed, entitlements never go away. They may shrink and they may change, but they never quite end. That conventional wisdom is rooted in the history of the federal social policy. Since the creation of the American welfare state with Franklin Roosevelt’s New Deal, its broad story has been one of expansion. In the 1940s, lawmakers passed a sweeping expansion of federal support for private and public housing, to say nothing of the GI Bill, which helped create the (white) American middle class; in the 1950s, they expanded Social Security, covering millions more American workers; and in the 1960s, they guaranteed health care to both the poor and the elderly under the Great Society. It’s not that these weren’t hard-fought battles—Ronald Reagan made his first major splash in national politics as a staunch opponent of Medicare, slamming it as the harbinger of “statism” in America—but that, once in place, Americans saw these benefits as tantamount to rights, entitlements of American citizenship.
Major expansion ended in the 1970s and wouldn’t resurface for another 40 years. But fundamental retrenchment never came, despite the rise of the conservative movement and its vocal crusade against “big government.” Eight years after President Ronald Reagan called government the “problem” of American life, and four years after his successor took the reins of government, the core programs of the New Deal and the Great Society remained intact. Republicans would strike one blow against the safety net, working with President Bill Clinton to enact “welfare reform” in the 1990s. Still the structure of the welfare state would endure, surviving the larger turn from state guarantees that characterized Clinton’s presidency. Welfare was vulnerable to cuts, but the core entitlement programs—Social Security, Medicare, and Medicaid—were popular among all Americans, left and right. They were all but untouchable, a fact made clear when President George W. Bush pushed for Social Security privatization in 2005, an initiative that promptly collapsed in the face of broad opposition. Eventually, under Barack Obama, the Democratic Party would return to a program of expansion, reinvigorating the guarantees of the safety net with the Affordable Care Act, which expanded Medicaid and put the United States on the path toward universal health coverage.
If successful, the current Republican drive to repeal Obamacare would represent an almost revolutionary shift from the direction of American history. I say “almost” revolutionary because the repeal drive isn’t entirely anomalous. In some respects, it is similar to the push for welfare reform. Aid to Families With Dependent Children welfare reached about 12.6 million Americans in 1996, or just less than 5 percent of the total population, before it was refigured as Temporary Assistance for Needy Families, where help hinged on meeting work requirements and actual benefits were stingy. By 2012, after nearly 20 years of this reform, the number of beneficiaries was down to just 4.6 million people, or roughly 1 percent of all Americans. In percentage terms, the Republican Party’s proposed cuts to Medicaid are of a similar scale. According to the Congressional Budget Office, those cuts would remove 14 million people from the program. That’s 4 percent fewer Americans who would receive Medicaid services, an impact similar to welfare reform.
But a closer look reveals large, consequential differences that make the threat to Medicaid an order of magnitude different than the attack on welfare. To start, Medicaid services a much larger group of Americans than welfare ever did, in any form. The program, which funds nursing homes and treatment for the disabled as well as health insurance for the poor, reaches 70 million Americans—1 in 5. If welfare reform was a sucker punch to low-income families, then Republican Medicaid cuts—which also enable even deeper reductions from state governments—constitute a crippling blow.
It matters too that welfare was never popular, in part because of American attitudes toward “handouts” and in part because of a racist belief that those benefits were an unfair giveaway to black Americans. The picture is different for Medicaid. Three-fourths of the public have a favorable view of the program, according to a recent survey from the Kaiser Family Foundation. And substantial majorities—including 52 percent of Republicans—say it works for most low-income people. Critically, just 12 percent of Americans (including just 22 percent of Republicans) want to reduce Medicaid spending. Slashing a large, popular, and well-liked program is a far different project than doing the same to a smaller, unpopular one.
The United States isn’t the only Western democracy to have pulled back on cash payments to low-income citizens. In the United Kingdom, for example, Tory governments have allowed key benefits for children and the unemployed to erode, in addition to cutting other forms of assistance. But if Republicans repeal Obamacare and slash Medicaid to a shadow of its current self, the United States would emerge as the only Western democracy to establish and then fully revoke an entitlement to government assistance for health care. In turn, that could open the door to full retrenchment of the entire safety net, including Medicare and Social Security. It is not hard to imagine a future where large-scale retrenchment and a tightening of benefits breeds resentment between those who receive help and those who don’t, potentially fueling calls for fewer benefits to the allegedly “undeserving.” Indeed, we’ve seen versions of this on the state level, where conservative politicians like Scott Walker harnessed resentment toward public employees and their benefits to slash overall government spending.
Even if those programs escape the chopping block, it is significant that this push is happening with little public support. It’s not just opposition to Medicaid cuts; in a survey of Republican health care plans, just 12 percent of Americans supported the Senate proposal as Mitch McConnell was trying to shepherd it toward a July 4 vote. Indeed, Donald Trump won the White House promising the opposite of major health care cuts, and conservative rhetoric on the Affordable Care Act has never acknowledged the practical consequences of slashing subsidies and support for health insurance. Even now, Republican lawmakers deny that anyone would actually lose coverage under their health care plans, arguing instead that Americans will simply choose to forgo insurance. “People will buy what they value,” said Texas Sen. John Cornyn on Twitter earlier this month.
It would be one thing if voters were clamoring for a return to pre–Great Society, or even pre–New Deal, America. But that’s just not the case. In the abstract, at least, Americans want more assistance—more help from the federal government. Even for lawmakers on the right, that popular desire should influence their approach to public policy, as it suggests ordinary people want government to deliver (or facilitate) improvements to their daily lives.
But it doesn’t. And this disregard for public opinion—along with its corresponding indifference to independent analysis—augurs something ominous for the country. The Republican governing coalition in Washington—elected by a minority of Americans—is showing its willingness to transform American society with little deliberation or consensus. It has become so polarized that it will use whatever power it has to push a maximalist agenda through Congress, its representatives tearing through any norms or procedures that stand in their way to slash public assistance to the bone, and then some. The goal, should they reach it, will be a populace left to fend for itself.
Top image: Sen. Mitch McConnell, flanked by Majority Whip John Cornyn (right) and Sen. John Barrasso, after the Tuesday vote to open debate on Obamacare repeal (Getty Images).