Last week's election results in Kentucky and Virginia dashed any hope that attacks on Obamacare might finally be losing their political currency. Healthcare providers and payers should brace themselves for a full year of well-funded assaults on the law.
There was never any doubt that the many presidential candidates running in the wide-open Republican primaries would call for repealing and replacing the Affordable Care Act. The law has almost no support among the tea party and social conservative voters who dominate the GOP electorate in the early primary states.
But after the King v. Burwell decision last June upheld exchange plan subsidies, there was hope that victories by ACA supporters in off-year general elections in two Southern states might finally mute criticism of the law. It would have sent a clear signal to the campaign professionals running next year's general election for the GOP that such attacks aren't a winning issue with the broader electorate.
Instead, the pendulum swung the other way.
The dominating win by outsider businessman Matt Bevin in the race for the Kentucky governorship and the failure of Virginia Democrats to win control of the State Senate tells GOP funders and their super PAC allies that attacking the ACA can be a winning strategy with general election voters. Attacking Kentucky's successful insurance exchange and Medicaid expansion was a centerpiece of Bevin's campaign.
Democrats will argue the results were not indicative of broader public opinion. In an off-year election, only 31% of Kentucky's 3.2 million registered voters turned out. Democrats still outnumber Republicans by a wide though shrinking margin in the state, and they are disproportionately concentrated in groups that fail to turn out in off-year elections.
But Bevin's 52.5% to 43.8% margin (an independent siphoned off less than 4% of the vote) shows subsidized coverage expansion still isn't popular, even among some of the people it was designed to help. Bevin focused his attack on the financial burden imposed on states by Medicaid, which enrolled 80% of the half million Kentuckians who signed up for insurance through Kynect, the state exchange.
Next year, he told voters, Kentucky will have to begin picking up part of the Medicaid expansion tab, eventually growing to 10% by 2021. “It's financially untenable,” he said during the runup to the election. “We are already fast on the road to insolvency as a state.”
The economic reality is far different, of course. The billions poured into the state through the federal government's share of Medicaid is a huge boon to the local economy and eventually translates into lower costs for the privately insured, who subsidize charity care. Try putting that explanation on a bumper sticker.
The ACA is not the main issue on voters' minds. The state of the economy will dominate the debate during next year's primaries and general election.
While the official unemployment rate may be down to 5.1%, this has been the most joyless recovery in the nation's post-World War II economic history. People are working longer, more pressure-packed hours than ever before. Those not earning promotions haven't had a raise higher than inflation in more than a decade.
Structural changes in the economy have taken their greatest toll among less educated workers, which is leading to unprecedented social problems. A report published last week in the Proceedings of the National Academy of Sciences showed that white, middle-aged Americans are now seeing rising annual death rates for the first time in modern American history. A startling rise in drug and alcohol poisonings, suicides and chronic liver diseases more than offset marginal improvements in the death rates from lung cancer and heart disease.
These conditions can be ameliorated when people have access to care through health insurance. But it's no cure.
President Barack Obama expended a huge amount of political capital in getting the ACA passed. It contributed to the Democrats losing both houses of Congress. Republicans steadfastly opposed to the ACA now sit in 32 out of 50 governors' mansions and control 30 out of 50 state legislatures, a complete turnaround from when Obama first got elected.
He can argue until the cows come home that Republican opposition stopped him from fixing the economy. But until the economic fortunes of this nation turn around, the insurance expansion created by the ACA—a bandage on that larger problem—will be at risk.
