Democrats ran on Obamacare and, finally, sailed to victory.
The party that bet on surging enthusiasm for the Affordable Care Act flipped control of the House Tuesday night in what could amount to a major reset of the political direction on health care.
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Democrats also made gains at the state level, with wins in gubernatorial races that could prompt new expansions of Medicaid and energize lawmakers, who can claim they have a mandate to further build on a law that serves as the bedrock of their domestic agenda. But Republicans kept – and enlarged – their Senate majority.
“I still remain stunned at where we are on health care right now,” said Brad Woodhouse, a Democratic party official during the law’s passage and now executive director of the pro-ACA group Protect Our Care. “It vindicates the notion that everyone should have access to affordable health care, that the system works better when more people are in it.”
The validation of a law that cost Democratic candidates for almost a decade puts the party in an almost unimaginable position two years after Donald Trump’s election made repeal seem inevitable. Democratic leaders already plan to investigate the Trump administration’s efforts to undermine and dismantle parts of the law, and intend to pass bills shoring up Obamacare’s consumer protections — including safeguards for patients with preexisting conditions — and its insurance markets.
The biggest unknown hanging over the law, however, is a federal court case in Texas in which Trump’s Justice Department and Republican attorneys general from 20 states are trying to abolish Obamacare — or at least its consumer protections. Democrats seized on the case during the campaign, holding rallies featuring people who struggled to obtain insurance before Obamacare due to a health condition and vowing to fight against any effort in Congress or the courts to repeal the ACA.
“We didn’t agonize, we organized,” House Minority Leader Nancy Pelosi said. “We understood that we had to work together the save the Affordable Care Act.”
Democrats held a 16-point lead among registered voters asked who they trust more on health care, according to a Washington Post/ABC News poll conducted between Oct. 29 and Nov. 1. Independent voters broke for Democrats over Republicans on health care by a 48-28 split.
An NBC News exit poll conducted Tuesday night showed 41 percent of voters listing health care as their most important issue, far more than any other single issue.
The Trump administration, meanwhile, continues to steer the law rightward, enacting conservative policies like work requirements for Medicaid recipients and expanding skimpier alternatives to Obamacare plans that Republicans say will test whether patients really prefer the law’s comprehensive coverage.
Democrats’ trek out of the health care wilderness was a long one, marked by a series of painful electoral losses and culminating in the election of Trump, who vowed to kill Obamacare as soon as he took office.
Democrats lost nearly 70 congressional seats in a 2010 wipeout that cost the party control of the House. Backlash to the newly enacted ACA fueled the rise of the tea party and stymied hopes for a continued progressive policy shift.
They would go on to lose the Senate in 2014, and then the White House, battered along the way by GOP warnings of “death panels,” rationed care and one-size-fits all solutions imposed by Washington.
“We all did it,” Republican strategist Rick Wilson told POLITICO. “I myself worked on plenty of ads that said, ‘You will lose your doctor. You will have to go to a government DMV-like clinic.’ But those terrors never happen. We’re not in the world we predicted.”
The tide turned only after the public got a glimpse of a Republican health care strategy they disliked even more. The GOP’s shambolic repeal effort exposed the party to some of the same demons that dogged Democrats, leaving Republicans defending a series of unpopular bills in the face of angry protests.
“Everybody has a story about themselves or somebody they love being victimized because they had a pre-existing condition, getting denied coverage or having their coverage be ludicrously expensive,” Wilson said, citing focus groups he conducted on the issue as early as 2009. “So of course, what did the clown parade in Congress do as soon as they had a majority? They voted to make sure pre-existing conditions were gone. Sure, why not? Touch that hot stove.”
In a mirror image of the angry anti-ACA scenes of 2009 and 2010, Democrats stormed Republican town halls in 2017, staged dramatic protests in the halls of Congress, and helped stop the repeal effort in its tracks.
The GOP has since recalibrated toward the center, insisting in the months leading up to Tuesday’s elections that it now supports most of the ACA’s most popular benefits — particularly the safeguards for sick people they previously derided as too costly.
“Republicans proved definitively they could neither repeal nor replace the ACA, but they succeeded at one thing,” said Tom Miller, a resident fellow at the conservative American Enterprise Institute. “They made it popular relative to what they were proposing.”
Few have experienced that political whiplash more than former Rep. Tom Perriello, a liberal Democrat from Virginia who was unseated in 2010 after just one term amid the anti-ACA wave.
Constituents screamed at Perriello in heated town halls leading up to and following his vote for the ACA in 2010. A local tea party group made plans to burn him in effigy — though those plans were never realized. His brother’s house was vandalized after a right-wing website posted the address and urged residents to “express their thanks” for his health care vote.
Since then, Perriello’s state has embraced a core provision of Obamacare by expanding Medicaid to cover 400,000 additional low-income residents. And Democrats on Tuesday made gains in the state.
“I was a believer even in the dark ages,” Perriello said. “The Democrats were the adults in the room that were willing to vote for short-term disruptions that helped tens of millions of people over time.”
Now with eight years of perspective and the knowledge that ACA support would become Democrats’ secret weapon, some of the law’s initial advocates say they regret that the Obama administration didn’t try to go even bigger.
“The fundamental flaw of Obamacare was it was too fiscally responsible,” said Jonathan Gruber, a Massachusetts Institute of Technology economics professor who played a central role in the ACA’s construction.
The law could have had greater impact and potentially could have won more people over in the early days, he argued, if Democrats had quit worrying about courting Republicans and jammed through a more liberal bill that devoted millions of dollars more to expanding coverage.
Perriello agreed, lamenting that he didn’t lose his seat over an even bolder heath care overhaul.
“The first version [of the ACA] in the House that I got to vote on had a public option and the ability to negotiate drug prices,” he said. “People at the time said we went too far, but now we understand both on substance and politics that we should have done more.”
Obamacare skeptics still contend that the law hasn’t lived up to its supporters’ lofty rhetoric. Premiums are unaffordable for many people, doctor networks have narrowed and, in several states, ACA markets are more like a subsidized high-risk pool, unable to attract younger, healthier customers.
“At the end of the day, the vast majority of the American public does not have pre-existing conditions,” said Jason Pye, the vice president of legislative affairs at the conservative FreedomWorks. “We should be taking great strides to make sure people are covered, but there are other ways to do it.”
But Tuesday’s results showed a fundamental shift: a bipartisan majority of the public now believes health care is a right, and that the federal government should play a role in helping people access insurance.
Tens of millions of people have gained insurance coverage, bringing the national uninsured rate down from 18.2 percent in 2010 to 10.3 percent in 2018. Premiums have appeared to stabilize after years of sizable hikes, and next year average rates for benchmark plans are set to decrease. The law’s Medicaid expansion, meanwhile, is increasingly popular even in red states.
“The law worked exactly as designed,” Gruber said. “The law worked great, which is actually astounding given the political headwinds.”