As I’ve argued (see here or here), Republicans might say they hate government bureaucracy, but when they have the chance, they weaponize it against people they don’t like, especially poor people. In the case of health insurance, they’ve done things like add work requirements to Medicaid, which set up a maze of bureaucratic hurdles recipients have to navigate, and if they make a mistake or two, they lose their health coverage.

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So it’s important to understand the magnitude of this report: For the first time since the Affordable Care Act was passed, the number of Americans without health insurance has actually gone up. We’re moving backward.

I contacted Andy Slavitt, who ran Medicare and Medicaid under President Barack Obama, and asked him if he thought the increase in the uninsured could be directly attributed to Trump administration actions. Here was his response, which began with a reference to the fact that the administration has all but ceased public efforts to encourage people to sign up for health insurance on the ACA exchanges and reduced the amount of time they have to do it:

No question. A modest amount of promotion (comparable to Obama-era levels) and there would be 2 million more insured in the exchanges. ... Medicaid enrollment is down everywhere, largely in immigrant populations and other groups where states have made enrollment more challenging (this has traditionally happened when state governments flipped), and of course they turned down partial expansion waivers in Utah and Idaho. If Virginia and Maine hasn’t expanded Medicaid, the numbers would be even worse.

This is all driven by an ideological belief Republicans have that if someone gets health coverage from a government program, that’s a fundamentally bad thing. In fact, it’s even worse than if they had no insurance at all, which is why we should craft the system to get as many people off these programs as we can.

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As Slavitt’s quick summary shows, the administration has used a multipronged approach to achieve that end; it also includes things like promoting “junk insurance” plans that cover almost nothing. Now that Democratic presidential candidates are advocating for a significant expansion of public insurance, either through Medicare-for-all or a public option that allows anyone to join a public program if they want, Republicans argue that such an expansion would be a horrific nightmare of misery and despair.

When they say that, we should keep in mind that over a third of Americans already get their health insurance from a government plan. There are different ways to count that number depending on whom you’re including at a given moment, but it’s vast: The Census puts it at 111 million Americans with federally provided coverage (and their survey probably undercounts the number), while if you added up figures from the Centers for Medicare and Medicaid Services you’d get something closer to 125 million. Either way, you have a large chunk of the population getting government insurance — and by and large, they like it a lot.

This is a fact that causes Republicans no end of annoyance, not only because they want those programs to serve as few people as possible, but also because it creates an ongoing political problem for the GOP. That’s true in two ways: Democrats are able to attack Republicans for trying to undermine these extremely popular programs, and over the long term, the popularity of government insurance is a refutation of the entire conservative anti-government philosophy.

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That popularity constrains Republicans from moving too dramatically to destroy government health insurance even when they have total control of government, as we saw in their failed attempt to repeal the ACA in 2017. And they vacillate back and forth between attacking government involvement in health care and pretending that they favor it, because they know it’s what even their own voters want.

Whenever moderate Democrats try to win in conservative districts, they choose health care as the issue that will do it for them, as we just saw in the North Carolina special election that was held on Tuesday; Democrat Dan McCready built his campaign on the issue of prescription drug prices and got within a couple of points of winning in a district President Trump took by 12 points in 2016.

Wary of frontal assaults on existing government health programs, Republicans take steps that are more piecemeal and limited, which enables them to take away coverage from people by the thousands and not by the millions, as they might prefer. But over time it adds up, as the Census report shows.

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So now there are 27.5 million Americans without health coverage, and in 2020, the voters will have a fundamental choice. All the Democrats, whatever the specific reform plan they’re advocating, want that number to be zero. Trump and his party want that number to keep going up. As long as he’s in office, it probably will.