It is becoming more and more difficult to make the case that the Trump administration "sabotaged" Obamacare. Although Democrats have repeatedly lobbed the charge at the Trump administration in response to a number of changes made to the health care law, the evidence increasingly suggests that Obamacare is working just fine. In some ways, it is working better than ever. And in the process, it is foreshadowing the health care debates of the future, and the rut that the politics of health care appears to be stuck in.
After years of double digit rate hikes, premiums have actually gone down, dropping about 2 percent for the most expensive plans, and about 1 percent for more typical plans, compared with last year. In more than 50 percent of counties that rely on the federally run marketplace to facilitate the law, premiums have dropped by an average of 10 percent. In part this is because of the law's subsidy structure, which increases the amount of federal subsidies if premiums rise, limiting the amount that beneficiaries have to pay.
Insurance companies, meanwhile, are offering plans in markets they had previously abandoned, like Tennessee. Last year, there was just one insurer operating in 78 of Tennessee's 95 counties, according to Kaiser Health News. This year, 49 counties have more than one, and some have as many as four.
All of this is happening during the first year that the law's individual mandate penalty, which imposed a tax on individuals who did not carry qualifying health coverage, has been zeroed out. And it follows the Trump administration's decision last year to end the payment of subsidies that were called for in the text of the law but not authorized by Congress, as well as the announcement of new rules allowing the sale of cheaper, less regulated plans.
It's true that enrollment is down this year compared with the same point last year, but this year's enrollment pattern may have diverged from last year's. As a Vox report notes, health insurers exiting the market last year caused many enrollees to get notices saying they had to find a new one. In addition, improvements to the economy may mean that more people are covered through their jobs. Sign-ups tend to spike near the end of the enrollment period.
It is possible, even plausible, that the Trump administration, which endorsed last year's repeal effort in Congress, meant to undermine Obamacare. But whether intentionally or inadvertently, the Trump administration's changes do not appear to have caused the law to collapse, or anything close to it. Instead, plans are cheaper and there are more choices.
So it's not much of a surprise that the law has become more popular. Nor is it a surprise that Republicans, who campaigned on repeal throughout the Obama administration, have largely abandoned their plans to wipe the law from the books. After the midterm election, which flipped majority control of the House from Republicans to Democrats, Senate Majority Leader Mitch McConnell (R–Ky.) admitted as much, saying he hoped to fix problems with the Affordable Care Act "on a bipartisan basis." Speaker of the House Paul Ryan (R–Wis.), in many ways the the GOP's chief advocate of repeal, is leaving Congress.
Since the passage of Obamacare, Republicans have not had much of a health policy endgame beyond repeal; "replace" was always a politically convenient mirage. Where the GOP will go on health care has been something of an open question.
But two years into the Trump administration, you can see the outlines of health care politics to come. Democrats, sensing an at-long-last victory on Obamacare and momentum on single-payer, will push to further expand the role of government in health care and coverage. Obamacare will stay on the books, with periodic tweaks. And Republicans—who, after all, helped conceive of the law's structure as a response to the Clinton plan in the 1990s—will come to defend, or at least accept, its existence, just as they have with Medicare.
Which means America will be stuck with the same flawed and fragmented system it has had for decades, and an all-too-familiar debate between one party that mostly wants to hold that system in place and another that wants to expand it. Republicans didn't sabotage Obamacare, but they have all but destroyed any small hope of large-scale reforms to our health care system.