The Three Dumbest Republican Self-Owns on Health Care

How the party hurts itself, its voters, and the country.

(Composite / Shutterstock)

REPUBLICANS SAY THEY DON’T HATE health care programs, but they’ve been fixated for years on ideas that pretty much scream ‘let’s abandon everyone and everything that we pretend to care about.’

It’s all on display in recent GOP health policy choices that will do harm to people, principles, and political groups that are, allegedly, party priorities. Here are three examples:

1. So much for small business.

Republicans talk a good game about entrepreneurs and small business, especially in May during National Small Business Week (and last weekend on “Small Business Saturday”). But there’s a huge gap between the innovation and creativity they claim to value so highly as a driver of the U.S. economy, and their widespread, irrational opposition to the 2010 Affordable Care Act (Obamacare)—from its cradle to what they never stop hoping will be its grave.

The latest sabotage attempt by the GOP, which has tried to kill or weaken the ACA more than seventy times in fifteen years, is to end the enhanced premium subsidies instituted and renewed by Democrats. They will expire at the end of the year, unless President Donald Trump and his party have second thoughts about the millions who will soon discover they can’t afford coverage anymore.

And guess who those people are? “We estimate that 48% of adults under age 65 enrolled in individual market (direct purchase) coverage are either employed by a small business with fewer than 25 workers, self-employed entrepreneurs, or small business owners,” the health research organization KFF said in September, citing its new report based on census data. “In other words, about half of adult enrollees in the individual health insurance market—the vast majority of which is purchased through the ACA Marketplaces—is affiliated with a small business.” For comparison purposes, only 16 percent of adults overall are in the U.S. small business sector nationwide.

Studies from pre-ACA days found that for all the bragging America does about its go-getters and self-starters, the U.S. small business sector was, well, small compared with other developed nations. They found more job-lock in America among people with employment-based insurance, more entrepreneurs among people married to spouses with health insurance, and more business start-ups among people about to turn 65 and qualify for Medicare.

It’s no wonder that the ACA’s fifteen-year anniversary this year moved the Small Business Majority advocacy group to proclaim, “Affordable Care Act Revolutionizes Entrepreneurship.” That Third Way, a centrist Democratic group, says entrepreneurs will be “crushed” if the premium subsidies are not restored. And that Protect Our Care, another advocacy group, released a “Trump-GOP Premium Disaster” report on the “GOP Health Care Affordability Crisis,” complete with state data and individual tales of woe—from a Georgia woman with a doula business to a Milwaukee chef with two restaurants and a pre-existing condition.

2. Big talk about small government.

Call it “skin in the game” or forcing people to prove their worthiness, but the conditions and requirements Republicans love to add to social programs are not conducive to shrinking government. We’ve seen real-time state demonstrations of this in ACA-authorized Medicaid expansions that cover those with incomes up to 138 percent of the federal poverty level.

Main takeaway: Another conservative tenet shot to hell. The administrative state grew larger—as well as more complicated, intrusive and labor-intensive—with the addition of cumbersome requirements ranging from work and proof of that work, to tiny monthly deposits into a health savings account.

Mike Pence as Indiana governor tried the latter approach. The result was a frustrating, time-consuming mess for program participants and administrators alike. Some people were locked out of coverage for months for missing a payment to their health savings account. For about half of enrollees, that payment was just $1 a month. Health care access and outcomes, meanwhile, were no better than expansions in other states.

Work requirements have also failed real-life tests, largely because nearly two-thirds of Medicaid participants already work, and almost all the rest are sick or disabled, in school, or caring for relatives. In his first term, Trump approved work requirements in thirteen states, the first in the history of the Medicaid program. Predictably, given the complexity and bureaucracy involved, a 2020 Harvard study found that 18,000 eligible people in a 2018 Arkansas program lost coverage and employment did not increase.

A week into his term, during the coronavirus pandemic, President Joe Biden told states to re-examine policies authorized by Trump “that may reduce coverage under or otherwise undermine Medicaid or the ACA,” including work requirements. By August 2021, between judicial rulings and administration waiver withdrawals, those requirements were gone or on hold.

But they’re back with a vengeance in the One Big Beautiful Bill that Republicans enacted this summer, now as a national mandate to start January 1, 2027. Leonardo Cuello and Joan Alker, Georgetown University professors who study health care policy, deemed the work mandate “one of the worst things the law does—and that is a high bar.”

3. Losing their man card.

A third and final own goal is the conservative fantasy that real men don’t need insurance, and the insistence by some (Kristi Noem comes to mind) that the Medicaid expansion shouldn’t cover able-bodied, single men. But why not? They are likely working—at low-wage jobs that don’t offer insurance. They could get cancer or have an accident, just like anyone. They could be forced into medical bankruptcy. This is a decency issue, a productivity issue, a family finance issue, and a hospital survival issue. It’s also common sense.

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ALL THREE OF THESE EXAMPLES are bad politics, especially since Democrats have managed to raise public awareness of why health costs are soaring and, equally unlikely, New York’s democratic socialist Mayor-elect Zohran Mamdani won “Small Business Saturday” with a video about naming a “Mom & Pop Czar” to slash red tape and regulations—starring him eating an egg sandwich at a deli.

The politics are also bad for the GOP given Trump’s winning coalition last year. Exit polls show he carried majorities of men, people without college degrees, and people with modest family incomes of $30,000 to $99,999.

What do Republicans get out of these decisions? Well, they stand to save nearly $1 trillion in federal spending over a decade, largely because so many workers and small businesses insured through the ACA marketplaces or Medicaid expansion won’t be able to afford the skyrocketing premiums or handle the process required to stay enrolled. That trillion or so will help Trump & co. realize their true priority—tax breaks predominantly for wealthy individuals and corporations.

Trump is nothing if not a loyal friend to the exceedingly well-heeled, no matter what the cost to everyone else. That, too, is terrible politics, and there’s no sign he and most Republicans are rethinking anything at all.