As the coronavirus spreads during this U.S. presidential election year, claiming lives, inflicting economic damage worldwide, and putting massive strains on the American health care system, President Donald Trump’s competence in dealing with public health crises will be under a more intense microscope than usual.
But as this dynamic unfolds, a bigger health care debate will emerge from the background of the federal court system and move into the campaign spotlight. The 2010 Affordable Care Act (ACA), also known as Obamacare, has become ever more entrenched in states and insurance markets, as the law’s option to expand Medicaid (health insurance for low-income people) has been taken up in a large majority of states.
As a result, the law has gained popularity, with one poll earlier this year showing that 55 percent of surveyed Americans support the legislation. Meanwhile, 81 percent of surveyed voters ranked health care as very or extremely important in the 2020 campaign. Yet the Republican Party continues to seek the law’s abolition, with their most recent legal challenge threatening the ACA’s existence in its entirety.
And while the “Families First Coronavirus Response Act,” signed on March 18, expands Medicaid coverage and funding to the states to cope with the burgeoning crisis, it is significant reversal from the administration’s January proposals to allow states to cap Medicaid spending and potentially reduce benefits.
Democratic candidates, up and down the ticket, would be foolish not to highlight the contrasting records on health care in their 2020 campaigns.
ACA’s Increasing Popularity
After the ACA was passed in 2010, GOP members of Congress vowed to repeal and replace the bill, but legal and legislative challenges to date have failed.
In the meantime, the health care exchanges that comprise a core part of Obamacare were established, while Medicaid expansions have occurred in a vast majority of states. Between 2014 and 2017, 31 states expanded their Medicaid provision, and the program’s popularity has not waned under the Trump Administration. Since 2017, six more states have expanded Medicaid, while there are proposals with varying levels of progress in an additional five states.
As an overall result, the number of uninsured people has decreased significantly. For Republicans, the election year benefits of repealing Obamacare appear increasingly dubious. Consequently, Trump and other Republicans will take aim at Bernie Sanders’ Medicare for All proposal.
However, if Joe Biden defeats Sanders in the Democratic primaries, Republicans will likely find themselves having to defend their most recent legal challenge to Obamacare, which Biden wants to maintain and improve. This challenge has its origins in the 2017 Tax Cuts and Jobs Act (TCJA).
Politics of Challenging Obamacare
The TCJA offered a new legal path for challenging the ACA when it eliminated the penalty for not having insurance. Twenty Republican state attorney generals filed suit in 2018, and Texas District Judge Reed O’Connor found the entire law unconstitutional.
In January, the Supreme Court declined to fast-track the case to hear it in the final months of the 2019-2020 term, but then agreed to review it in the 2020-2021 term.
While the Supreme Court upheld the ACA on two previous occasions, it is unclear how they would vote this time with the ACA’s altered penalty structure. The court would also rule on the key question of whether the rest of the law stands if the individual mandate is ruled unconstitutional. The Trump administration has thrown its weight behind the lawsuit, arguing that the law be invalidated.
Since endorsing the Republican attorney generals lawsuit in 2019, the Trump administration’s actions suggest they remain committed to the GOP promise to repeal Obamacare, while also being aware that the political costs of such a position are rising. The administration initially planned to defend the law in court, but in March 2019, Trump reversed course, and the Department of Justice argued that the entire law should be struck down.
In a curious pivot, the Department of Justice modified its position four months later to argue that the law should be struck down, but only for the plaintiff states and not for the rest of the country. Senior administration officials then announced that in the event of repeal, they would ask the 5th Circuit to delay implementation of the ruling.
The administration’s inconsistent approach reflects the fact that it remains wedded to a repeal promise that looks less politically logical all the time.
The evidence surrounding the health benefits of Obamacare only reinforces how politically costly it will be to repeal the law. If Obamacare were struck down, the number of uninsured in the U.S. would increase by approximately 20 million. The expansion of Medicaid alone has increased the number of those insured, while also improving access to health care, as well as its quality and affordability. If ACA is repealed, millions of people would lose their coverage and its associated benefits.
Additionally, there is concern that the coronavirus spread could be significantly worse in states that have not expanded Medicaid.
Health Care in 2020
Democrats in 2020 running for president, the House, the Senate, and for office at the state level would be crazy not to constantly remind voters what they stand to lose if Republicans are returned to power in large numbers.
Such messaging will most likely be easier through the defense of the ACA, rather than an embrace of Sanders-style Medicare for All. While the latter proposal has enjoyed boost in popularity, it still generates skepticism among independent voters and would be more vulnerable to GOP claims of “socialized medicine.”
The benefits of Obamacare are easier to demonstrate, as the law has produced significant and recent gains in coverage and improved access to care. A drumbeat of attention on this issue would keep President Trump on the defensive and less able to address the issue he would rather discuss: immigration.
Additionally, while Republicans will hold on to several traditionally red states, messaging on health care may force the party to spend more time and resources on races in states they otherwise believed they could take for granted. For example, Arizona, Arkansas, Indiana, Louisiana, Montana, Ohio, Utah, and West Virginia have all expanded Medicaid, yet have state attorneys general who have sided with Texas to strike down Obamacare.
Down-ballot Democratic candidates, particularly those running for state attorney general in Indiana, Montana, Utah, and West Virginia, would do well to remind voters where the incumbent Republican attorneys general stand on the issue.
Finally, there is recent evidence that health care works as an issue at the polls. In the 2018 midterms, Democrats took back the House of Representatives and several key statehouse offices, while expanding Medicaid through ballot initiatives in multiple red states.
An overriding belief in small and limited government led the GOP to denounce the ACA as soon as it was enacted in 2010 and then strive to repeal it for years after that. Legislative and legal attempts to date have failed, although the Trump Administration has passed bureaucratic changes, which have undermined the law.
As implementation of the ACA has had time to develop, the benefits of the law have become more entrenched and noticeable, while the regulation has overall grown in popularity.
Republicans in 2020, with the albatross of the ACA litigation hanging around their necks, will try to tar all Democrats with a Medicare for All brush or focus on other issues, such as immigration, security, and the economy. Democrats should emphasize the benefits brought by the ACA while giving voters frequent reminders about what happens if Obamacare is struck down.