Obamacare Is Still Struggling. So Why Are Democrats Winning the Health Care Argument?

The GOP’s decadeslong refusal to offer a compelling health care alternative has given Democrats the political upper hand.


Looked at one way, the politics of Obamacare have barely changed in 10 years: The law is more popular now than it was under President Barack Obama, but even supporters still view it as flawed and fragmented, a placeholder more than a permanent solution. If anything, the COVID-19 pandemic has brought the law's defects to the fore, showing it to be expensive and unreliable, hobbled by intractable political arguments and poor drafting. Which is why mainline Democrats have emphasized familiar fixes—new legislation and proposals that would expand the law's reach, at considerable cost, offering subsidies to more people, and adding a new government-run insurance plan to the mix, an idea long favored by progressives but stripped from the original legislation. 

Republicans, meanwhile, are still fighting the law in court, with the White House backing a Texas-led challenge to a law the administration would normally be expected to defend. When the Trump administration asked the Supreme Court last week to strike down the entire law, the move made headlines, but not waves, because the argument it made was largely the same as the one it had proffered a year before, when it made the same request of a lower court

Perhaps the most striking point of continuity in the debate is the Republican insistence that a replacement of some sort will be ready should a court strike Obamacare down—and the concurrent refusal to say precisely what that replacement will be. Although Republicans in Congress and their allies have put forth any number of plans over the years, the party has never really rallied around a single idea or made a concerted effort to sell a plan to the public. One of the notable aspects of the GOP's 2017 repeal effort was its opacity, not only to the public but to Republican legislators, many of whom could not or would not explain how their proposed replacements were supposed to work. President Donald Trump himself has repeatedly promised that a cheaper, better Republican plan would be forthcoming, but has not specified what the plan will be.

That same sort of rhetorical slipperiness continues even now. Just last month, Trump declared, in his typically mushy-mouthed way, that "what we want to do is terminate it [Obamacare] and give health care. We'll have great health care," he said, "including preexisting conditions." Yet when CNN's Jake Tapper interviewed Health and Human Services Secretary Alex Azar last week, Azar dodged questions about the particulars. At first, Azar said the forthcoming GOP plan would cover preexisting conditions. When Tapper pointed out that the GOP's 2017 legislation softened preexisting conditions rules, Azar responded, "Well, Jake, you actually haven't seen what we would do, working with Congress, so you don't know what our preexisting conditions protections would look like." 

Azar was offering a model Republican health care dodge: First, insist the GOP will have a plan, then respond to criticism of previous plans by saying that the new plan is still in development, and therefore can't be criticized. The benefit of this approach is not only that it repels attacks, but that it also avoids the need for an affirmative defense of any specific policy. Just as you cannot attack a plan that does not yet exist, neither do you need to make a case for its virtues. 

Instead of making an extended public case for their own policies and attempting to win the public to their side, Republicans have largely chosen to fight through the courts and, under Trump, through administrative tweaks to Obamacare. Indeed, the closest Trump has come to defending his own health care policy is to argue that his administration has been a better steward of Obamacare than his predecessor, saying in May, "We've run it very well. And we've made it barely acceptable." There's some merit to this notion, but "I managed Obamacare better than Obama did" is hardly a case for an alternative, or for overturning the current law.  

I would say that Republicans have largely given up on arguing in favor of their health care policy ideas, but it's probably more accurate to say they never really started. Going back as far as the Clinton health care proposal in the 1990s, the party's focus has been on being the opposition rather than on developing a substantive alternative, on defending the status quo rather than championing a truly different path. 

As a short-term tactic, this has often proven effective. But as a long-term strategy, it leaves much to be desired, because it provides no off-ramp when the public believes the status quo has failed. And in the decade since the passage of Obamacare, that's roughly what has happened, as America's tangled, expensive mess of federal, state, and private health care programs have saddled Americans with underwhelming results, bureaucratic headaches, and billing and pricing practices that manage to be both inscrutable and unaffordable

Many of the system's problems are rooted in pre-Obamacare policies—the World War II-era decision to tie health insurance to employment through tax policy, the poorly designed payment systems adopted by Medicare, the joint federal-state funding mechanism for Medicaid. But by embracing the status quo, whether implicitly or explicitly, elected Republicans have often served more as defenders of this system and its flaws than as reformers. (Notably, one of the chief Republican arguments against Obamacare was that it would cut spending from Medicare.)   

Which is why Republican voters are, if anything, embracing Obamacare, voting to expand its reach in red states, even as the party's elected representatives continue to try to tear it down. And it's why Democrats are more trusted on the issue and have effectively used it to turn swing voters at the ballot box. Indeed, some Republicans even seem to be aware of this: After they lost control of the House in the 2018 midterm election, House Minority Leader Kevin McCarthy privately told other Republicans that the GOP's push to end parts of Obamacare was likely to blame. 

Yet the essential dynamic, in which Democrats push greater expansion while Republicans promise to offer some unspecified alternative (details to be determined), has persisted. And in the long run, that has probably given Democrats the upper hand. 

Which is why what appears to be political stagnation may be better understood as a slow and inexorable advance, in which Obamacare becomes more popular, the addition of a government-run public option becomes a mainline position rather than a progressive outlier, and the Democrats' left flank moves on to more radical proposals like Medicare for All. That the Democratic argument is essentially a case for doubling down on the policy flaws that have plagued U.S. health care for decades, pushing government financing and bureaucratic influence into ever more parts of the medical system, may not matter all that much, simply because it is an effort, however flawed, to convince people there's a better way. And in the court of public opinion, a bad argument wins over no argument just about every time.