Make no mistake: Health care will be on the ballot this November. But not in the way ardent progressives imagine.
Democrats running for president have spent a lot of time debating so-called Medicare for All, with some supporters of Bernie Sanders claiming that any politician who doesn’t demand immediate implementation of single-payer health care is a corporate tool, or something. But the reality is that whatever its merits, universal, government-provided health insurance isn’t going to happen anytime soon.
I say this because even if Democrats take the Senate in addition to the White House, the votes for eliminating private health insurance won’t be there; nor will the kind of overwhelming public support that might change that calculus. In practice, any of the Democratic candidates — even Sanders — will, if victorious, end up building on and improving Obamacare.
On the other hand, if Donald Trump wins, he will probably find a way to kill Obamacare, and tens of millions of Americans will lose health coverage.
Let’s talk for a minute about Obamacare. There’s a sort of perverse alliance between Republicans and some progressives, both of whom are determined, albeit for different reasons, to see the Affordable Care Act as a failure.
These downbeat assessments are made easier by the fact that the ACA left much of its implementation up to the states, and that national performance has been held down by states that have done their best to sabotage health reform.
But look at states that have tried to make the law work, and what you see is a huge if incomplete policy success. Take the case of California. In 2010, before the ACA went into effect, 21% of nonelderly Californians were uninsured, above the national average. By 2016 the uninsurance rate had dropped to 8%. And Californians with preexisting medical conditions saw an enormous improvement in their health and financial security.
Now, 8% uninsured is still too many, and even those with insurance often face high out-of-pocket costs. But relatively minor improvements in the law, especially a modest increase in the generosity of insurance subsidies, could substantially improve both the quality and the quantity of coverage.
Does pointing out the possibility of incremental progress mean giving up on a truly universal system? No. By all means let’s make something more ambitious, such as Medicare for All, a long-term goal. But this goal shouldn’t stand in the way of policies that would immediately benefit millions of Americans, and save thousands of lives.
And while we debate the ideal health system, we mustn’t forget that Trump and his allies are as determined as ever to undo the progress we’ve made.
It’s true that so far repeated Republican attempts to destroy the Affordable Care Act have failed. In 2012, the Supreme Court rejected claims that the whole law was unconstitutional. In 2017, a Republican-controlled Congress narrowly failed to repeal Obamacare. And a variety of narrower efforts to undermine health reform and send insurance markets into a “death spiral” have fallen short: Markets seem to have stabilized, and one by one, states that initially rejected Medicaid expansion have been relenting.
But the people who want to take away your health care haven’t given up.
The latest attempt is a lawsuit claiming that the 2017 tax cut, which reduced the penalty for not having insurance to $0, somehow made the entire Affordable Care Act unconstitutional. It’s a ludicrous claim, both in terms of substance — would the law suddenly become constitutional if the penalty were a penny? — and because it’s clear that this was not legislators’ intention.
But the Trump administration has joined the suit and a partisan Republican judge has indeed ruled that the ACA as a whole should be struck down.
Clearly, this case is headed for the Supreme Court. But Trump doesn’t want it heard until after the election.
Why does Trump want to leave this court case hanging? Partly because his side would probably lose. As I said, the lawsuit is ludicrous, although, given the partisanship of Republican-appointed judges, it might prevail anyway.
Beyond that, however, Trump’s political health care strategy is to flat-out lie about what he has done and is trying to do. On Monday he made the breathtakingly dishonest claim that he is “the person who saved preexisting conditions” — breathtaking because he has tried at every stage to remove the protections for Americans with preexisting conditions created by the Affordable Care Act.
And while Trump, who lies constantly, often seems to pay little penalty for those lies, this one — which touches the lives of millions of voters — would be thrown into sharp relief if the case were heard by the Supreme Court. He wants to take away your health care, but he doesn’t want you to see him doing it until the election is behind him.
So that’s the real health care issue this year. Will it be expanded coverage under a Democrat — it probably doesn’t matter much which one — or will it be tens of millions of newly uninsured Americans under Trump?
Paul Krugman, Ph.D., winner of the Nobel Memorial Prize in Economics, is an Op-Ed columnist for The New York Times.