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.