The battle over health care — something that has become a defining feature of the 2018 midterm elections — has, in the final stretch of the campaign, come down to Republicans and Democrats making two different but equally emphatic assurances to voters.
Democrats are running on the argument that Republicans, if they retain majorities in Congress, would take another stab at repealing and replacing the Affordable Care Act, and would aim to kill some of the law’s most popular planks — including its protections for individuals with pre-existing health conditions.
Republicans, meanwhile, insist that they have never, and would not ever, attempt to undermine the Obamacare provision that helped people with pre-existing conditions access more affordable health coverage. They’re issuing a warning of their own: if Democrats take control on Capitol Hill, they will push plans that would dramatically expand government health care programs — paving the way to ruin them at the expense of the seniors and families who need them most.
This dynamic has played out across each of Minnesota’s battleground U.S. House races, with candidates trading heated barbs in debates and deep-pocketed outside groups dropping millions of dollars worth of TV ads to persuade voters that the other candidate’s views are not only wrong but would destroy the entire U.S. health care system as we know it.
So who’s telling the truth?
Did Republicans really protect people with pre-existing conditions?
A live debate between the candidates in Minnesota’s closely-watched 3rd Congressional District, GOP Rep. Erik Paulsen and Democrat Dean Phillips, illustrated the battle over which party is really protecting people with pre-existing conditions.
Phillips hammered Paulsen on his support for the American Health Care Act, the GOP’s bill to repeal and replace Obamacare, saying the congressman voted “many times” to make it harder for people with pre-existing conditions to access care.
“The claim that I don’t support pre-existing conditions is patently false,” Paulsen responded. “In fact, the bill I voted for clearly states out — it’s clearly printed in the bill — nothing in this act shall be construed as permitting health insurance issuers to limit access to health care to individuals with pre-existing conditions.”
“I talk about that every time I talk about need to reform health care,” the congressman said.
There’s a good reason he’s talking about it: three out of four Americans say it’s “very important” that Congress keep the ACA’s provisions that ensure people with pre-existing conditions can access health care, according to the Kaiser Family Foundation, which tracks public opinion on health care issues.
Obamacare prohibited insurance companies from denying care, or making care prohibitively expensive, to individuals who were seeking coverage while dealing with a variety of chronic conditions, from depression and diabetes to cancer and asthma.
In devising the AHCA, Republicans were under pressure to rework their bill once initial versions were seen as insufficiently supportive of pre-existing conditions protections. Ultimately, the legislation’s final version did not explicitly allow insurers to deny people coverage, but the overwhelming majority of experts and observers agreed that key components of the bill would have led to decreased access to care for millions of people with pre-existing conditions.
The Republican bill granted states the opportunity to apply for waivers that could exempt them from two planks of Obamacare which were designed to shore up protections for people with pre-existing conditions: essential health benefits and community rating.
The essential health benefits provision, under Obamacare, requires insurers to cover 10 benefits, from prescription drugs to prenatal care, in any health care plan they offer. Community rating is a provision that prohibits insurers from charging any individual more based on their individual health status, which is important for patients with pre-existing conditions.
States might want a waiver to exempt insurers from these provisions in order to keep them from leaving their state’s individual insurance market — something many insurers have done when costs have grown too high. But because these provisions are aimed at keeping insurers from charging too much to cover people with pre-existing conditions, removing them would make health care prohibitively costly for people with these kinds of conditions.
According to Karen Politz, a senior fellow at the Kaiser Family Foundation, “The bill explicitly said to states, if you want to waive protections, they can. It set up an explicit process for approving those waivers. It just kind of shifted the decision making to states.”
Proponents of the AHCA said that the federal government would be strict about granting waivers, but many health experts believed otherwise, and predicted that the Trump administration would be eager to undermine Obamacare. The nonpartisan Congressional Budget Office, in scoring the AHCA, found that it would lead to millions of people with pre-existing conditions losing health care coverage.
‘They can read polls’
While Republicans like Paulsen defend their votes on the AHCA, non-incumbent GOP candidates like Pete Stauber in the 8th District are avoiding their party’s health care proposal like the plague and instead emphasizing promises to safeguard pre-existing conditions protections.
In a TV ad featuring his son Isaac, who has Down syndrome, Stauber says his son’s challenges are “why I support requiring insurance companies to cover pre-existing conditions. Anyone telling you otherwise is lying.” (Stauber has criticized Obamacare but has declined to say if he would have voted for the AHCA.)
According to Thomas Miller, a senior fellow at the center-right American Enterprise Institute think tank who advised former Sen. John McCain’s 2008 presidential campaign, there’s a good reason behind Republicans’ focus on pre-existing conditions: “They can read polls,” he told MinnPost.
Miller compared the 2018 election to the 2010 election, in which Republicans hammered Democrats on the just-passed and unpopular ACA, while attracting little scrutiny for their own positions. “The Democrats are on the attack, and they don’t have to be accountable for what may have gone on in the past,” he said. “It happened to be Republicans’ turn to own some baggage in out-year elections. They’re caught between where they were, and where they need to be.”
“Republicans want to have it both ways,” said Larry Jacobs, the director of the Center for the Study of Politics and Governance at the University of Minnesota’s Humphrey School, who has written a book on health care politics. “They made a commitment to repeal the ACA; on the other hand, they’re on the political hot stove right now for repealing the popular part of the law that people have come to expect”
“If you voted for repeal, particularly what the House passed, this was a rolling back of, in effect, pre-existing conditions,” Jacobs said. “Here’s the best test of it: when the House bill that Paulsen and [Rep. Jason] Lewis voted for went to the Senate, the Senate dropped that component.” (Ultimately, the Senate rejected that bill by a one-vote margin in 2017, after moderates like Maine Sen. Susan Collins said it did not do enough to protect people with pre-existing conditions.)
To AEI’s Miller, Republicans don’t have much of a choice beyond simply affirming that they support pre-existing conditions, no matter what their big repeal and replace bill would have actually done. Miller questioned how much success they would have in that mission: “There are limits,” he said, “to relying on the combination of short-term memory loss and cognitive dissonance in electoral politics.”
Medi-SCARE for All?
Republicans’ plan to defend themselves on health care in the midterms has another key component: changing the subject.
In a single tweet, President Donald Trump more or less laid out the essence of the strategy. “All Republicans support people with pre-existing conditions, and if they don’t, they will after I speak to them. I am in total support,” he tweeted on Thursday. “Also, Democrats will destroy your Medicare, and I will keep it healthy and well!”
This is hardly a new talking point: Republicans and Democrats have, at various points, tried to scare voters into thinking the other party would ruin Medicare, the beloved government program that covers health insurance for seniors. What is new, however, is an increasing embrace of Medicare-for-All, or variations of it, in the Democratic Party.
The Kaiser Family Foundation has identified eight bills out of Congress that fall under the aegis of Medicare for All, and KFF’s Politz says that in 2018, slight majorities of the public have come to favor the general idea. (But that can depend on how it’s framed: “Universal coverage” is more popular than “socialized medicine,” for example, says Politz.)
The four Democrats running in Minnesota’s battleground House races all support some level of Medicare expansion: Phillips in CD3, Dan Feehan in the 1st District, and Angie Craig in the 2nd District have each advocated for a Medicare buy-in option. Several different pieces of legislation introduced in Congress propose offering a way for individuals to buy in to the program through the ACA’s insurance marketplaces; another bill limits the option to older people who are not yet 65 years old, the current threshold for Medicare eligibility.
Joe Radinovich, the Democrat running in the 8th, is in favor of the comprehensive brand of single-payer health care, championed by progressives like Sen. Bernie Sanders and 5th District Rep. Keith Ellison.
It’s that left-wing dream of single-payer that Republicans are choosing to focus on in their attacks, however. In a Star Tribune op-ed, Rep. Lewis argued that “the Obamacare architects are going for the full monty — a $32 trillion socialized-medicine scheme that doubles your payroll and income taxes, throws you off your employer-based plan and ends Medicare as we know it.”
“If Democrats take the House, real market-based health care reform is dead — and so is your plan,” he wrote.
There’s intense debate over Democrats’ Medicare expansion proposals, most of which center on how a massive expansion of government obligation would be paid for — probably a tax increase, which most proponents say should focus on the wealthy — and whether such a tax increase would offset high health care costs borne by individuals.
But in addition to raising concerns about a significant tax increase, Republicans are now arguing that expanding Medicare will make the program worse for the people who already have it. Conservative scholars, like those at the Heritage Foundation, have argued that Democrats’ plans will not control health care costs and will lead to poorer care for everyone receiving it through the government.
Experts like Tricia Neuman, director of Medicare policy at the Kaiser Family Foundation, are skeptical. “People may have different views about ‘Medicare for All’ and what it will do, but it’s hard to say they are robbing Medicare,” she told the Washington Post. “They would expand benefits, eliminate premiums, reduce cost sharing. Seniors would get more direct coverage at a lower cost… They would replace the current Medicare program with this new program, that part is true, but it’s replaced with something more generous.”
AEI’s Miller called the GOP’s line of attacks on Medicare a tried-and-true weapon. “That’s a more comfortable resting place for Republicans to talk about health care,” he said. “They know the sheet music. If you think this is a horror, here’s a greater horror.”
“To pile more people in tells a current senior, hey, I got a good deal and someone else is going to come in and take part of my deal,” he said.
“I think this is scare tactics on the part of Republicans to say Democrats would threaten Medicare by extending it to the whole country,” the U of M’s Jacobs said. “But it’s also the case that Democrats invited this criticism, because they’ve been rhetorically playing to progressives by saying they’d implement single-payer, though they’re vague about what it means.”
“Many of the charges made, that everyone is at risk and is going to die tomorrow, that’s an exaggeration. This is the nature of bipolar politics,” Miller says of the health care debate in 2018.
“So sure, do people seeking office, defending office, oversimplify and exaggerate? Welcome to elections every couple of years.”