Despite this victory, the bill will likely face months of deliberation in the Senate, where legislators on both sides of the aisle have already deplored its hostility to the poor, the old, and the 24 million who stand to lose coverage. Yet the biggest obstacle goes beyond legislative politics. It’s the subtle but unmistakable shift in perspective that Obamacare triggered among the public: for the first time in history, most Americans—60 percent, according to a January 2017 poll by the Pew Research Center—believe that it is the government’s responsibility to ensure access to quality health care. So even though Republicans have full control of the government, they have found it acutely difficult to push through a plan that growing numbers of Americans philosophically oppose .
If conservatives can stomach keeping Obamacare’s exchange spending and using it to boost federal Medicaid spending by $390 billion, they could possibly get moderates to go along with repeal of the regulations that are increasing premiums and destabilizing the individual market. If moderates can let go of regulations to which they have no particular ideological attachment, they could deliver to states $390 billion for use in tackling preexisting conditions, opioid addiction, and other challenges — money that would otherwise go to insurance companies.