Obamacare dogged Democrats for years at the polls, toppling their congressional majorities and stoking partisan fires that still burn in Washington. But if Republicans are ultimately able to pass their own health care plan, they will face their own repercussions — and some will hit at a painful time.
Like the 2010 health law, the GOP bill would not take effect all at once. Many of the most politically tricky provisions are staggered over the coming years and would hit right as a promising group of freshmen Republican senators come up for reelection in 2020.
That reality may complicate Senate Majority Leader Mitch McConnell’s efforts to find 50 votes to repeal Obamacare. It’s not just vulnerable GOP senators up for reelection next year — like Dean Heller of Nevada — that McConnell has to worry about. It’s those like Cory Gardner of Colorado, Shelley Moore Capito of West Virginia and Joni Ernst of Iowa who will face voters in 2020.
In an interview after the latest version of the bill was released last week, Gardner reacted cautiously and noted his interest in easing any transition to a new health care system.
“It’s been a major focus point of mine that we talk about the glide path that we’re on, making sure states have the flexibility they need to keep Medicaid sustainable,” Gardner said.
A series of controversial policy shifts will take effect in the coming years if McConnell is able to scrounge together the votes. In 2019, insurers can begin charging older customers higher premiums than they’re permitted to under Obamacare. In 2020, the plan overhauls Obamacare’s tax credits, lowering or nixing payouts for some customers. And that year, state governments will begin assessing the impact of steep Medicaid spending reductions, slated to begin in 2021.
Democrats say they’ll be ready to pounce.
“If they pass the bill they’re screwed,” said Howard Dean, former chairman of the Democratic National Committee. “If you’re the Republican leadership, you don’t want these people to take a vote that’s going to kill them.”
Republicans are divided on just how difficult the politics of implementing their health care plan might prove. Though there’s widespread agreement that Obamacare created a multi-year problem for Democrats, failing to act on a long-promised GOP replacement could be worse for Republicans than leaving the Democratic law untouched, they argue.
“I think the larger danger is from the base. They are infuriated with Washington,” said Barry Bennett, a top adviser on President Donald Trump’s presidential campaign. “If you start being seen as part of the problem then all the enthusiasm leaks out.”
Josh Holmes, a veteran GOP political strategist and former chief of staff to McConnell, also said Republicans needed to act because they control all of Washington and would suffer politically if they didn’t address problems with health insurance markets under Obamacare.
But he acknowledged the bill’s risks.
“There’s no politically popular way to do big things anymore,” Holmes said. “Whether it’s health care, taxes, Social Security. They’re easily demagogued and anything other than the status quo is scary.”
Republicans enjoy a favorable Senate map next year, defending only eight seats to Democrats’ 25, but the parties’ fortunes are set to reverse in 2020. Republicans will have to hold onto 22 Senate seats that year, compared with 11 for Democrats.
Democrats were punished at the polls in 2010 immediately after they passed Obamacare but presumed the law would grow more popular over time. Instead, unintended consequences, like the crash and failure of the law’s enrollment website in 2013 and the waves of insurance policy cancellations that rattled consumers, revived angst surrounding the law.
“There is every reason to believe that ahead of the 2020 elections there will be even more implications that are tangible and being felt by voters in terms of rate increases,” one Democratic operative tracking the bill said, addressing future strategy on condition of anonymity. “Democrats will hold Republican senators accountable for this toxic health care proposal that spikes costs and strips coverage for hardworking Americans at every stage of this election cycle, and for years to come."
Gardner, who is publicly undecided on the bill, is in perhaps the trickiest position for that class of Senate Republicans. He hails from a state Hillary Clinton won in 2016, and recent polls suggest Coloradans are deeply opposed to the repeal bill. Rep. Mike Coffman (R-Colo), who is perennially targeted by Democrats, was one of the few GOP votes against a House version of the plan.
But Gardner is also chairing the National Republican Senatorial Committee, charged with electing more Republican senators in 2018 — and it makes bucking the party a more challenging proposition.
Gardner’s backers in Colorado say it’s important that he’s seen as central to the health care debate rather than on the sidelines, even if he votes for the bill and against popular opinion.
“[Voters] don’t have to always agree with you but they have to see you fighting,” said Ryan Call, former chairman of the Colorado GOP, who ran the party when Gardner was elected in 2014. “I think voters in Colorado appreciate the fact that he’s so engaged in trying to fix and promote legislation” rather than “sit back and try to take advantage of the way political winds are blowing.”
Several other Republicans elected in 2014 on promises to tear down Obamacare have also approached their leaders’ plan gingerly, including Thom Tillis of North Carolina and Steve of Montana. Sen. Bill Cassidy (R-La.) has sounded a more positive note lately but has also pitched an alternative plan that has buy-in from some moderate lawmakers.
Ernst sought her constituents’ feedback last month after declining to immediately endorse the first version of the repeal bill; after the modified bill was released last week, Ernst said she was still “working on” its treatment of Medicaid, which would see more than $700 billion in cuts over a decade.
If a single additional Republicans join Sen. Susan Collins (R-Maine) and Sen. Rand Paul (R-Ky.) — both of whom already oppose the measure — the bill is likely dead.
Many of the states where GOP senators will seek reelection in 2020 have accepted Obamacare’s massive expansion of Medicaid, which is slated to be phased out under the Senate GOP plan. Though that phase-out doesn’t begin until 2021, it will force tough choices much sooner than that for state governments, which will have to make decisions about Medicaid eligibility and possible cuts as fewer dollars come in from Washington.
But the bill is also facing pressure from the right. Paul opposes it because, he says, it doesn’t do enough to rip Obamacare’s architecture from the books.
Steve Deace, an influential conservative Iowa radio host, said senators facing reelection could face blowback if grassroots conservatives perceive they passed a plan that was less than a full repeal of Obamacare.
“Republicans … owe some significant percentage of the offices they currently hold to their promise to repeal it,” he said. “So here’s the question they should be asking themselves: If voters decimated Democrats for imposing Obamacare, what are they gonna do next year to the party which broke a 9-year promise to get rid of it?”
GOP leaders are constrained in how closely they can consider the political fortunes of senators beyond the immediate election cycle, said Tevi Troy, a veteran GOP health care advisor to presidential campaigns and a senior official in the George W. Bush administration.
“Every law has to go into effect at some point. As long as the implementation timetables are realistic for the agencies to manage, the politics work out in the wash,” he said. “The ultimate hope is that the new program will be successful, popular, and/or hard to get rid of so that these short term implementation date questions won’t matter.”