ONE OF THE MORE STARTLING REVELATIONS about Donald Trump’s push to pass his “big, beautiful bill” came from a meeting he held with some House Republicans on July 2.
The purpose of the meeting was to shore up support among moderate and swing-district Republicans feeling skittish about the legislation’s massive spending cuts. To ease their anxieties, NOTUS reported, Trump reaffirmed his commitment not to touch Medicaid.
Some of the House Republicans evidently found this unnerving, and understandably so, given that the emerging legislation included roughly a trillion dollars in Medicaid cuts. “But we’re touching Medicaid in this bill,” one House Republican reportedly told Trump.
Neither the NOTUS article nor a subsequent report in the Washington Post revealed Trump’s response, leaving open the question of whether he did not know how to answer the criticism or simply did not know what the GOP bill would actually do.
Normally, the possibility that a president could be so ill-prepared to defend his signature legislation would seem difficult to fathom. But it’s entirely in character for Trump, and something that’s been seen before.
In 2017, when he was lobbying GOP lawmakers to pass a bill that would have repealed the Affordable Care Act and radically restructured Medicaid, Trump eschewed substantive appeals and rarely—if ever—showed even cursory knowledge of health policy. He just kept telling Republicans he was counting on them to deliver a political win.
Back then, he didn’t get his wish. This time around, he did. And while this legislation does not do the damage that most of the 2017 repeal initiatives would have—Obamacare’s basic architecture is still standing, among other things—it still represents the largest cut to federal health care programs in history.
So what changed? And how much should Trump’s success alter our preconceptions of what effective leadership looks like?
These questions have been on the mind of many people who were around for both efforts, and that includes me. Many of the factors contributing to the collapse of the Republicans’ Obamacare-repeal efforts in 2017—as I reported in my book The Ten Year War—were again at play in this latest effort. These included not just Trump’s refusal to engage on substance, but also congressional leadership’s failure to work out factional differences beforehand, and an extremely rushed legislative process. Quite obviously those issues weren’t enough to prevent success this time.
But would-be reformers of health care tend to learn from past failures. It was true of the LBJ-era Democrats who created Medicare by taking lessons from Harry Truman’s doomed national health insurance initiative. And it was true of Obama-era Democrats, whose singular purpose in designing the Affordable Care Act was to avoid the mistakes of Bill Clinton’s ill-fated universal coverage attempt in the 1990s.
Now it looks like Trump-era Republicans have done something similar. They have learned from their past mistakes—or, at least, they have managed to avoid them—although it’s difficult to know to what extent they were adapting intentionally, and to what extent Trump’s chaotic approach to governing happened to work in their favor this time.
THE STORY OF HOW REPUBLICANS enacted such sweeping health care cuts in 2025 should probably start with something they did in 2024—or, more precisely, with something they didn’t do. They didn’t talk about health care.
Neither Trump nor GOP candidates further down the ballot mentioned the subject regularly during the campaign.1 And when they couldn’t avoid the topic entirely—say, because they got a voter question about it—they’d typically respond with bland platitudes about the importance of making medical care cheaper.
The signs of greater ambitions were there, though, and they were not especially hard to spot for anybody paying attention. Project 2025 sketched out some of the health care cuts that would end up in the GOP legislation; Trump himself sent out a handful of social media posts indicating he remained interested in attacking Obamacare. But warnings that health care for millions was at risk in the 2024 election mostly generated eye rolls from the media and political establishments, especially when those warnings came from Kamala Harris.
Things were rather different in the 2016 campaign, when Trump talked constantly about repealing Obamacare, frequently starting off campaign rallies with a pledge to get it done. And while Hillary Clinton’s warnings sometimes provoked the same kinds of dismissals that Harris’s did eight years later, Trump put to rest any doubts about his intentions just days after the election, when he and congressional leaders announced that repeal would be their top legislative priority for the new year.
Even then, Republican leaders had some sense (though perhaps not enough) that the full scope of their agenda would alienate a lot of voters, especially those who had come to rely on the Affordable Care Act or Medicaid for health insurance. That’s why they dispensed with the months-long committee process that you would expect for such a massive legislative undertaking—the kind of process that Democrats had used to write Obamacare in the first place—instead going with perfunctory hearings in the House and then taking legislation straight to the floor in the Senate.
But the Republicans’ expedited process still took about half a year, during which their legislation’s popularity kept sinking as the public became more and more aware of what they were trying to do. For this year’s “big, beautiful bill,” GOP leaders moved even more quickly—and more stealthily—to make sure that didn’t happen again.
Even as House Speaker Mike Johnson was working furiously behind closed doors to negotiate legislation, he and Republican leaders avoided bringing up health care except when reporters asked about it directly. And, even then, they’d repeat Trump’s mantra that they were not going to cut Medicaid or Obamacare—except, they’d sometimes allow in a follow-up comment, to reduce some waste, fraud, and abuse.
The true scope of their proposed cuts didn’t become fully clear until late May, when Johnson and his allies finally released legislative text. Up until that point, it was possible to believe Republicans would limit themselves to narrower cuts totaling just a few hundred billion dollars, which one wavering Republican, Don Bacon of Nebraska, had said was the most he could support. (Like all but two of his copartisans, he ultimately voted for the full cuts anyway.)
House GOP leaders didn’t wait for the shock to wear off, pushing instead for a full vote in five days, with committee markups that were even more perfunctory than their rush-job 2017 antecedents. The Senate then proceeded to complete its deliberations in just five weeks—once again, not even releasing final language until days before a final vote. By contrast, the final Senate votes in 2017 didn’t come until the chamber had been considering legislation for nearly three months.
Did this year’s speed and stealth make a difference? It’s impossible to be sure, but it certainly seems likely. Cuts to Medicaid are extremely unpopular, as even Republican public-opinion experts have warned. But as of June, only one in ten voters even knew that Republicans were considering such cuts, according to polling by the Democratic-aligned firm Priorities USA.
THE STORY OF HOW REPUBLICANS succeeded is also a story of how Democrats failed. And part of that story, again, is something missing from the 2025 debate: a sitting president.
By the time Republicans began working on repeal in 2017, Barack Obama was gone from the scene and was mostly keeping out of public life. But in the two-and-a-half month interregnum between Election Day 2016 and Inauguration Day 2017, the former president and his allies used his visibility to make sure the public understood that insurance coverage for millions of Americans—and regulatory protections for millions more—were at stake.2
In 2025, plenty of Democratic leaders did their best to have the same kind of impact. (The leaders in both houses of Congress talked constantly about health care.) So did groups like FamiliesUSA and organizations like the Center for American Progress that had played key roles in alerting the public to the perils of repeal in 2017.
But they all struggled to get media attention—partly because all but a handful of high-profile Democrats just aren’t adept at driving the conversation these days, and partly because even relatively friendly outlets just weren’t that interested. Even MSNBC gave more coverage to lingering questions about Joe Biden’s presidency, according to a study by the left-leaning group Media Matters.
To be fair to the media—and to the partisans who tried and failed to rally public opposition against GOP health plans—it wasn’t just Biden’s legacy soaking up part of the political conversation. It was all of the other controversies that Trump has unleashed since taking office, from the wild, unpredictable swings on tariffs, to the brutal crackdown on immigration, to the assault on universities and medical research, to the ongoing persecution of political enemies. And that’s not even the whole list.
Every one of these calamities has demanded coverage and attention, and at times felt more urgent than any other subject—including, yes, a cut of historic proportions to government health care programs. Diverting public attention in this way may have been an unintentional side effect of Trump’s uninhibited governance since retaking office rather than an intentional bid to pass health care cuts that the public would hate. But it worked out to the GOP’s advantage all the same.
So did the decision to package health care cuts as a series of smaller, seemingly technical adjustments and to make them part of a much bigger bill that included other proposals, especially a massive tax cut that for most Republican lawmakers was their single biggest priority for the Trump presidency. Again, it’s unclear whether this was a deliberate strategy to confuse and divide opposition, or simply Trump thinking signing one big, beautiful bill would make for a better media spectacle. Either way, it almost certainly helped.
EVEN GIVEN ALL OF THOSE CIRCUMSTANCES, it’s hard to believe legislation would have passed if not for one other, very important factor: the way the Republican party itself has changed.
The repeal legislation of 2017 ultimately died in the Senate when three Republicans voted no: Susan Collins and Lisa Murkowski, who objected to what the legislation would do, and John McCain, who objected to the way Republicans were trying to ram it through Congress without a more formal and structured debate.
This time around, nobody made a fuss about the process, even though it was even less deliberative and more obviously designed to avoid public scrutiny. And while four Republican senators objected to the substance—enough to kill the legislation—one of them was Murkowski, who ultimately voted yes after GOP leaders promised to insulate her home state of Alaska from the bill’s effects.3 The other, Josh Hawley, fell in line without extracting any such guarantees for his home state of Missouri.
The ironic thing is that today’s Republican party is less philosophically committed to downsizing health care programs than its 2017 incarnation was. Cutting and refashioning entitlements was a lifelong cause for then-House Speaker Paul Ryan, as it was for a significant chunk of the party leaders of a decade ago.
But what the GOP has lost in ideological fervor, it has gained in cultish loyalty. Everywhere you look—not just in Congress, but in the executive branch and the courts too—it’s just a lot harder to find Republicans who will defy Trump. And when you have that kind of hold over your party, passing legislation gets a lot easier, no matter how unpopular it might be—or how bad for the country.
Case in point: The topic barely came up at the 2024 convention in Milwaukee, as Phil Galewitz of KFF News noted at the time.
Obama was especially effective at using a limited series of media appearances—including a high-profile interview with Ezra Klein and Sarah Kliff, both then at Vox—to suggest voters demand seeing the GOP alternative to Obamacare before supporting repeal. Trump eventually promised Republicans would make their plans clear, setting up a politically devastating comparison in which every GOP alternative led to massive coverage losses.
Collins is the only GOP senator who voted no on both repeal in 2017 and the health care cuts in 2025.