Health care is likely to be one of the most important issues in the 2020 presidential and congressional elections.
Earlier this month, a Texas federal district judge ruled that the entire Affordable Care Act (ACA) is unconstitutional. This decision will definitely make health care a more salient issue in 2019 and 2020.
The decision, in a case brought by Republican governors and attorneys general in 20 states, will certainly be appealed. Legal experts believe it is likely that the decision will be overturned, either by the Fifth Circuit Court of Appeals or by the Supreme Court.
The ruling once again puts Republicans on the defensive on the issue of health care. One reason Democrats gained 40 seats in the House in November is that Democratic candidates successfully portrayed their Republican opponents as wanting to take away health care protections enjoyed by the American people, with no alternative in place.
The Affordable Care Act, enacted by Congress in 2010, includes much more than “Obamacare,” the subsidized insurance plans available to those who are not covered by health insurance offered by an employer. The provisions in the ACA, all of which were struck down by the judge in Texas, set standards for the health care plans offered to almost all Americans.
Among these provisions, which polling by the Kaiser Family Foundation indicates are supported by very large majorities, are prohibiting insurance companies from denying coverage because of a person’s medical history (“pre-existing conditions”), allowing young adults to stay on their parents’ insurance plans until age 26, eliminating out-of-pocket charges for many preventive and screening services such as mammograms and colonoscopies, and gradually closing the Medicare prescription drug “doughnut hole,” so people over 65 will no longer have to pay the full cost of their medications once they reach the gap.
The Affordable Care Act also provides federal funding for states to expand the Medicaid program to cover persons above the poverty line but not able to cover the cost of health insurance by themselves. This includes many people working full-time in low-wage occupations such as food service and retail sales.
To date, 34 states have decided to participate in the Medicaid expansion. The voters in another three states — Idaho, Nebraska and Utah — approved referendums on the November ballot to expand Medicaid over the objection of Republican elected officials.
The states that are not participating in the Medicaid expansion are, in many instances, the same ones whose elected officials brought the lawsuit against the ACA in Texas. One such state is Wisconsin, where Gov. Scott Walker’s opposition to Medicaid expansion in particular, and to the ACA in general, was one of the reasons he lost his bid for re-election in November.
Democratic candidates won a majority of the votes cast across all 99 districts of the Wisconsin Assembly in November, but won only 36 seats. After the election, the gerrymandered Republican majority in the Wisconsin Legislature passed, and Walker signed, a bill prohibiting the newly elected Democratic governor from withdrawing Wisconsin’s participation in the anti-ACA lawsuit.
President Trump tweets that Republicans will replace the ACA with “GREAT” health care at low prices, insurance that will cover those with pre-existing conditions. However, Trump appears to have little or no understanding of how health insurance actually works, and the ACA replacement plans that Republican House and Senate members developed last year could not even get a majority of votes in the Republican-controlled Senate.
Democrats have their own disagreements over health care policy, in particular whether to continue with the ACA framework of regulating employer-provided insurance and using Medicaid and subsidized “Obamacare” plans to cover those who do not have health insurance through work, or whether to move toward a single public option, “Medicare for all” type plan. This issue will likely become a major point of contention in the Democratic presidential primary campaign in 2020.
Eric L. Davis is professor emeritus of political science at Middlebury College.