No policy decision during former President Barack Obama's first two years contributed more to the Democratic loss of the House of Representatives in 2010 than the party's drive to pass the Affordable Care Act.
Now, no policy decision in President Trump's first two years is boosting Democratic hopes of recapturing the House majority more than the failed Republican effort to repeal the ACA.
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The backlash against the GOP attempt to rescind the ACA represents a stunning shift in the politics of health care. Signed into law by Obama in early 2010, the ACA expanded health coverage to roughly 20 million previously uninsured Americans and imposed comprehensive changes in the operation of insurance markets -- all in the direction of requiring greater sharing of risk between the healthy and sick and balancing an individual requirement to obtain health insurance with a guarantee that coverage would be available.
After confidently attacking the law in four consecutive elections, Republicans for the first time this year are playing defense. They are especially struggling to defend the provisions in the House-passed repeal bill, and a separate lawsuit by attorneys general and governors from 20 Republican states, to unravel the law's requirement that insurers provide coverage, with no surcharge, to patients with preexisting health conditions. Over half of all Democratic ads in House and Senate races over roughly the past month have dealt with some aspect of the health care debate, far more than in the past, according to ad tracking by the Wesleyan Media Project. "Health care is the defining issue of the election," Jesse Ferguson, a Democratic strategist who is consulting for several liberal groups on the issue, including Protect Our Care, says flatly.
This shift in the law's political fortunes reaffirms the belief of many political scientists -- and the fears of many conservative thinkers -- that government benefits are hard to revoke once they have been established. It also represents a delayed vindication for the ACA's advocates, who long argued that voters would warm to it once it was fully implemented.
"It took more time than you'd like from a political standpoint," said David Axelrod, the chief White House political strategist for Obama when he passed the law. "I remember, and I'm sure there are many senators -- and more to the point former senators -- who would tell you that I came to the caucus and talked about the fact that however unpopular this is now, when it is implemented it will be popular. It's an axiom of politics that I think is true: it's much harder to take away things after they are in effect than it is to demonize the unknown, especially at a time of great cynicism about government."
What's less clear, though, is whether this fall's Republican tactical retreat on the law means that it has outlasted the GOP efforts to undo it. After the strong backlash during the campaign, some party professionals believe it is unlikely that Republicans could muster the votes for another effort to fundamentally repeal the law, even if they maintain control of the House and Senate next month. But Senate Majority Leader Mitch McConnell recently declared that Republicans could make another run at undoing the law if the November election leaves them in control of both chambers, and Vice President Mike Pence has made a similar declaration. Other GOP Senators, such as Nevada's Dean Heller, have also promised another try at dismantling the ACA if the party holds the House and expands its Senate majority.
Fear of messing with health care
Long-time Republican strategist Bill Kristol, founder of the Weekly Standard magazine, led conservative efforts against Bill Clinton's universal health coverage plan in the 1990s. Now he sees public reluctance to change the health care system much in any direction.
"Whichever party is on the offense on health care, is trying to change the status quo, is running a risk, because people for all their general dissatisfaction with the system, they are mostly reasonably content with their health care, and very nervous about it getting worse," Kristol says. The Republican effort to repeal or retrench the ACA has already extended much longer than the struggle over any other modern safety net program. After Franklin Roosevelt signed Social Security into law in 1935, for instance, Alf Landon, the Republican presidential nominee in 1936, ran on repealing the law. But after Landon won only two states, Wendell Willkie, the GOP presidential nominee in 1940, ran on expanding Social Security. Although Congressional Republicans continued some rearguard actions against the law through the 1940s, the party never again proposed complete repeal.
Medicare and Medicaid, the giant federal health care programs for the elderly and the poor respectively, became politically impregnable even more rapidly. In his 1964 campaign, GOP presidential nominee Barry Goldwater denounced Medicare as a step toward socialism. But after Lyndon Johnson and the Democratic Congress passed Medicare and Medicaid in 1965, neither a meaningful number of GOP Congressional candidates, or, more importantly 1968 presidential nominee Richard Nixon, ran on repealing the new programs. No GOP presidential nominee ever did, though Democrats have sharply attacked Republicans whenever they have proposed to reduce spending on the program, or to change their structure by transforming Medicare into a voucher system or Medicaid into a block grant (as outgoing House Speaker Paul Ryan has done).
The contrast with the ACA is striking. Both Mitt Romney in 2012 and Trump in 2016 pledged to repeal the law, the first time two successive nominees had promised to undo a new entitlement. After the 2016 election delivered Republicans unified control of Congress and the White House, legislation to scrap the ACA passed the House and fell just one vote short in the Senate, when the late John McCain dramatically turned a thumbs down on the bill. In all, though, just three Senate Republicans and 20 in the House, voted against rescinding the law. GOP lawmakers were able to zero out the financial penalty for not obtaining health insurance in passing their tax reform last December, after which Trump tried to declare: "Essentially, we are getting rid of Obamacare" even though the vast majority of the law has remained intact.
The Republican determination to erase the ACA reflected not only their philosophical disagreement with the law, but a conviction that opposition was good politics. And indeed through the law's first years, more Americans consistently expressed an unfavorable than favorable view of it. But those attitudes had already started to shift by the time the GOP began its repeal drive in 2017 -- and the repeal effort itself accelerated the reversal.
A public shift on the law
Polling by the nonpartisan Kaiser Family Foundation during the October of election years tracks the trend. In October 2010, just before the GOP landslide that swept the party to control of the House, Kaiser found that 44% of Americans viewed the ACA unfavorably while 42% viewed it favorably. The balance was even more lopsided among voters: exit polls that fall found that 56% of white voters, including not only 57% of non-college whites but also 55% of college-educated whites, supported repeal.
By the 2014 mid-term election, after the glitch-riddled 2013 launch of the ACA's federal website, Kaiser's numbers had tilted further toward opposition, with 36% favorable and 43% unfavorable. In the exit polls that fall, slightly more Americans said the law went too far than said it was about right or didn't go far enough.
By the November 2016 election, though, with the law's implementation almost completed, opinion began to shift. Through Obama's final two years, the Kaiser poll occasionally found as many, or more, Americans viewed the law favorably as unfavorably. And once the Republican Congress seriously began its repeal drive, the share of Americans expressing positive views of the law lastingly moved ahead of those who viewed it negatively; in this month's survey 49% of adults said they viewed the law favorably, compared to 42% who are unfavorable.
"If you look back at that time what we always said was that repeal would be unpopular and the law would get more popular as the benefits kicked in," said Ferguson, who served as communications director for the Democratic Congressional Campaign Committee in 2010, when the ACA backlash helped propel landslide Republican gains. "It just took longer and it was more painful than a lot of people hoped or expected. But the predictions weren't wrong."
Large racial and partisan gaps still color attitudes toward the ACA. Even in the latest Kaiser survey about three-fourths of Republicans still view the law unfavorably, as do half of whites (compared to about two-fifths with positive views.) But detailed results provided to CNN by Kaiser show that the law has gained more support among all the key groups of white adults since 2010. Compared to the October 2010 survey, opinion about the law among minorities in the October 2018 poll is virtually unchanged: 62% of non-whites supported the law then and 63% do now. But over that period, the share expressing a favorable opinion about it has grown among college-educated white women from 45% to 57%; from 39% to 48% among college-educated white men; 30% to 41% among white women without a college degree; and, more modestly, from 29% to 34% among white men without a college degree. Though most non-college whites still oppose the law, the gains among them are even more substantial when compared to 2014, when only about one-fourth of both blue-collar white men and women viewed it favorably. In the 2014 exit poll a majority of both non college educated and college educated whites still said the ACA went too far.
Focus on pre-existing conditions
The ACA's protections for pre-existing conditions have proven even more popular than the overall law: Kaiser polling has found that three-fourths of adults believe insurance companies should be prohibited from denying coverage because of such health needs, and nearly as many say they should be barred from charging such patients more for coverage. The House GOP's repeal bill explicitly authorized states
to allow insurance companies to charge patients with preexisting conditions more for their coverage. And the lawsuit against the ACA from Republican states also explicitly seeks to remove those protections; in its court filing the Trump Administration supported their legal position. On Monday, even as Republicans proclaim their determination to protect such patients, the Administration announced changes in ACA regulations that analyst say could also make it more difficult for consumers with preexisting conditions to purchase affordable coverage.
Democrats are stressing their commitment to defending protections for pre-existing conditions more than any other health care issue this year. But they are pushing on other fronts too. In several key governor's races -- particularly Florida and Georgia --Democrats are running hard on accepting the ACA's funds to expand eligibility for Medicaid, which Republican governors and legislators in those states have refused to do. Other Democrats vow to lower prescription drug costs, partly by ending the current ban on Medicare negotiating directly with pharmaceutical companies for lower prices. And some Democrats, like Scott Wallace, who is challenging Republican Brian Fitzpatrick in a suburban Philadelphia district, are directly warning that Republicans will launch another effort to repeal the ACA if they retain control of both chambers. "The ACA will never be truly safe until Democrats have the majority in the House and Senate," Wallace tweeted.
This Democratic offensive has forced Republicans -- including Missouri Attorney General Josh Hawley, the GOP's Senate nominee there, who joined the state lawsuit to unravel the ACA's regulations -- to insist they intend to protect patients with preexisting conditions by other means, though none have revealed a plausible plan to do so. The Democrats' renewed confidence on health care also encouraged many in their party to propose moving beyond the existing ACA. Several liberal candidates are pushing Sen. Bernie Sanders' plan to create a single payer government system that would eliminate private insurance; more modestly, others have proposed to allow working-age adults to buy into Medicare (which is now available only to seniors) as an alternative to the private companies offering insurance on the ACA exchanges.
Kristol predicts that a Democratic House looking to expand the ACA could run into the same hesitance about change that stung the Republican House when it tried to repeal it. "The great irony is the progressive wing of the Democrats want to be for 'Medicare for all' but the actual core of the Democratic message is a conservative message with a little 'c', which is don't mess with Obamacare [the ACA]," he says. "That is not consistent realistically with Medicare for all."
The debate on whether to expand the ACA will come into focus after November if Democrats take the House, Senate or both. On the more immediate question of whether or not Democrats make those gains, a far more important variable will be whether Republicans in swing states and districts can defend their efforts to unravel the existing law.
"The irony of the whole thing is John McCain saved them from themselves," says Axelrod, now a CNN senior political commentator. "It would have been catastrophic for them if they had [passed repeal] .The president may revile McCain for having done it; McConnell may have been unhappy about it; but the political ramifications of actually having reversed the Affordable Care Act would have been really dire for them and they are just getting a little taste of that now."