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On health care, look beyond 2018

(Rebecca Zisser / Axios)

The electoral consequences of passing a health care reform bill won't end with the 2018 midterms. Major provisions of the GOP's bill, including its Medicaid cuts and tax credit changes, would begin to take effect in 2020 — a year when the presidency will also be on the line and Senate Republicans will face a much tougher map than they are in 2018.

If the politics of the Affordable Care Act taught the GOP anything, it's that a major health care overhaul can significantly affect elections many cycles down the road. But on the other hand, after campaigning for years on repealing and replacing the ACA, there will be a price to pay if the party can't pass a bill.

And, even without a bill, allowing the ACA to collapse is probably politically tumultuous for the GOP as well. As one former GOP Senate staffer summed it up: "What was learned [from the ACA] is when people are angry because the system's not working for them, that's not good for anybody."

Big picture: Republicans campaigned aggressively against the Affordable Care Act for four cycles: 2010, 2012, 2014 and 2016. Looking at the same timeline for today's Senate Republicans ...

  • Only two sitting GOP senators are considered vulnerable next year, Sens. Jeff Flake and Dean Heller. The map is much rougher for Democrats, 10 of whom are running for reelection in states Trump won.
  • But the tables turn somewhat in 2020. Republicans will have to defend eight seats that only flipped from Democrat to Republican in 2014. There are fewer vulnerable Democrats in cycle that year, and you can expect the Democratic base to be pretty fired up for the 2020 presidential election.
  • 2022 is a long way away, but it's not looking like an easy year for Republicans, either. And there's plenty of recent precedent for keeping a health-care fight alive for three cycles.

Why this matters: The House bill began implementing some of its biggest changes in 2020, right before voters head to the polls. These changes include caps on Medicaid funding; a reduced tax credit for older, low-income people; optional state waivers for the ACA's essential health benefits; and a phaseout of the ACA's Medicaid expansion.

That's part of the reason we're seeing a push in the Senate to phase out the Medicaid expansion over a longer period of time, lobbyists and former aides say. "The American public has a short-term memory...[Republicans] recognize there's a perfect storm in 2020," Chris Condeluci, a former Republican Finance Committee aide, told me.

Key questions: Do senators — particularly those who will be up for re-election after the GOP law begins taking effect — believe the bill would help their constituents? And if they don't pass a bill now, how long will their base punish them?

  • "I think they are just hoping it's more meaningful to that group to have made good on their promise to repeal/replace than anything else," said one GOP lobbyist and former Hill staffer. "But I honestly don't think the base cares as much about whether members made good on the promise [if] their premiums go up or they lose coverage."

What we're watching for:

  • A further delay in the implementation of major reforms that could cause disruption. Paired with more generous federal assistance, this could be enough to get hesitant members to yes. "Nobody has battles over things eight years off," said Bob Blendon, a health policy professor at Harvard, who added that "the worst thing is to run in 2018, which relies on activist voters, and say, 'We didn't do anything.'"
  • Members up for re-election in 2020 or later — like Heller, Bill Cassidy or Shelley Moore Capito — coming out against the bill, saying it hurts their constituents and they can't vote for it.