Obamacare in the Crosshairs, Again

Photo by Careilly5801, CC BY-SA 4.0 , via Wikimedia Commons

“The cost of Obamacare is out of control, plus, it’s not good Healthcare. I’m seriously looking at alternatives.”

The statement above was not made back in 2016. It’s from a Truth Social post by Donald Trump last weekend. The former president added, “We had a couple of Republican Senators who campaigned for 6 years against it, and then raised their hands not to terminate it. It was a low point for the Republican Party, but we should never give up!”

For those who don’t remember, Obamacare, officially known as the Affordable Care Act, was signed into law back in 2010. The program was plagued with problems during its 2013 rollout. Democrats suffered in elections from 2010 through 2016 in large part due to the law’s unpopularity. When Republicans rose to power in 2016, a key part of their platform was the promise to repeal Obamacare… which they didn’t have a plan to do.

Throughout 2017, Republicans tried to cobble together a plan to… do something to Obamacare since they didn’t have the votes to repeal it. Even with majorities in both houses of Congress, there weren’t enough Republicans to end a Democratic filibuster, and the details of plans to reform the ACA kept running afoul of moderate Republican swing votes in the Senate. Ultimately, the last reform plan, branded as a “skinny repeal,” was voted down with Senator John McCain casting the deciding vote.

One thing that Republicans did accomplish was to transform public opinion on Obamacare. A law and program that had heretofore been very unpopular suddenly flipped in late 2016 and, for the first time, approval rose above the water level. Today, Americans in the Kaiser tracking poll approve of Obamacare by a margin of about 20 points.

Since the death of “skinny repeal” in July 2017, Obamacare has been conspicuously absent from Republican talking points. It’s an especially obvious omission for those of who remember that “Repeal Obamacare” was the almost single-minded rallying cry of Republicans from 2010 through 2016.

Enter The Former Guy with a post that hints at another war on the ACA. That sound that you hear is Democrats chortling with glee.

Over the past few months, Democrats have had plenty of things to sweat about. There were a raft of polls showing that Trump was competitive with or leading President Biden. Americans are still feeling the pinch of inflation, even as the Fed brings it under control. The new Gaza war added to international unrest that already included the Ukraine war and Chinese saber-rattling in the Pacific.

One of the few things that Democrats had going for them was the albatross around the GOP’s neck, the abortion issue paired with the Dobbs decision. Now, the question is whether the presumptive Republican nominee is about to hand the Democrats another club with which to beat the GOP about the head and shoulders.

Obamacare celebrated its 10-year birthday this year to little fanfare. The dearth of analytical pieces delving into whether the Affordable Care Act worked may answer the question with their absence, but the Wall Street Journal recently ran an op-ed noting that Senators Elizabeth Warren (D-Mass.) and Mike Braun (R-Ind.) were complaining that insurance companies were buying other healthcare companies to vertically integrate the healthcare supply chain. This enables insurers to evade the ACA’s medical loss ratio profit cap by shifting profits to their subsidiaries.

Did Obamacare work? I think that depends on who you ask and what you expected it to do. The Affordable Care Act was ostensibly passed to help rein in healthcare costs. Analyses of the ACA range from finding “little evidence that they had produced the changes necessary to ‘bend the cost curve’” to claims that the law saved $2.3 trillion. A more median view estimates that the ACA saved at least some money and helped to slow the growth of healthcare spending.

A second goal was to eliminate the problem of uninsured Americans. Again, the results are mixed. The Kaiser Foundation reports that about 17 percent of Americans were uninsured in 2012. By 2022, that was down to just over 10 percent. That’s an improvement but a far cry from a solution to the problem.

For the record, I opposed the ACA and thought that the Supreme Court decision upholding the individual mandate was deeply flawed. In general, I oppose top-down solutions and mandates in favor of market-based approaches. I do think that the American health insurance system, based as it is upon healthcare that is tied to employers, is still badly in need of an overhaul that breaks that nonsensical link.

Obamacare proponents can point to changes made since the law’s inception for its failures. For example, in 2017, Republicans were successful in repealing the penalty associated with the ACA’s individual mandate. For those who don’t recall, the individual mandate was the requirement that every American buy health insurance and was one of the most unpopular provisions of the law. These tweaks almost certainly did have some effect on the success of the law in achieving its goals.

To be fair, the horror stories about the ACA never came to fruition either. A decade in, there are no death panels, no rationing of care, and no long waits for procedures as experienced in other “socialized medicine” countries. Republicans will claim that their tweaks to the law prevented these problems.

In 2024, however, the question won’t be whether the ACA is working, but whether people want the ACA to go away. Since 2017, the answer has been no. The onus will be on Republicans to bend the approval curve back toward the negative. They weren’t able to do that six years ago.

A big part of that difficulty was the lack of a coherent plan for what was to come after Obamacare. Apparently because no one expected Donald Trump to win in 2016, there was no Republican plan to reform healthcare. For the remainder of Donald Trump’s term, we kept hearing that a healthcare plan and an infrastructure bill were only a few weeks away. We’re still waiting.

If Republicans want to talk about messing with Obamacare, they would be well advised to construct a plan that at least sounds palatable to the voters who have come to rely on the Affordable Care Act for their health insurance. This year, the Obamacare exchanges set a record high for enrollment at 18.2 million, a small share of the country, but the prospect of the government tinkering under the hood of health insurance plans, including employer-based plans, is likely to be a turnoff for voters. Democrats learned this the hard way in 2010.

My instincts tell me that Trump’s new Obamacare onslaught will play well with the Republican base, for which Obamacare has never ceased to be a foe. That may give Trump a further edge in the primary, not that he needs one with an advantage of more than 40 points over his nearest opponent.

Or maybe not. The flip side is that low-income Republicans may have come to rely on the program for their insurance. I’ve seen firsthand that Republicans will decry social programs and entitlements… until you start talking about Social Security reform. We may find that Obamacare reform is a similar third-rail issue, but even then, I have my doubts that it would cause Republican voters to sour on Trump. Such is the strength of the personality cult.

However the issue plays in the primary, it seems likely that general election voters won’t be too keen on rolling back ACA reforms unless Republicans can come up with something that sounds better. I can guarantee that Donald Trump did not ensure that such a well-crafted plan was in place before posting his Truth Social message.

This lack of preparation is a main reason why Democrats are salivating at the possibility of Trump running on a platform of repealing Obamacare. The issue is a classic example of Republicans running on issues that rev up the base but hurt them in the general election.