A decade after President Obama took office pledging to extend healthcare protections to all Americans and setting off an unprecedented partisan battle, the fight is effectively over.
Years from now, the 2018 midterm election is likely to be recognized as the moment that cemented the Affordable Care Act’s position alongside other pillars of the American healthcare system, such as Medicare.
Most immediately, the Democratic takeover of the House of Representatives precludes any new Republican campaign to repeal the law, at least for another two years.
More profoundly, these elections revealed the depth of public support — in red states and blue — for core parts of the 2010 law, often called Obamacare. And they offered a sharp warning to politicians who threaten the law’s protections.
Voters in deeply conservative states, including Idaho, Nebraska and Utah, strongly backed ballot measures to expand Medicaid and extend government health coverage to their poorest neighbors, an option made possible by the law.
At the same time, Republican candidates across the country, facing withering attacks from their Democratic opponents, went out of their way to insist they would champion safeguards for Americans with preexisting medical conditions — even after long trying to repeal those protections.
These safeguards, once isolated to a handful of states, were enacted nationwide for the first time through the healthcare law and guaranteed by financial assistance to help low- and moderate-income consumers buy health coverage.
Now President Trump and other GOP leaders, many still smarting from their failed push to repeal the law last year, no longer even make a pretense of offering an alternative to the current law.
“The American people have given us divided government,” Senate Majority Leader Mitch McConnell (R-Ky.) said Wednesday, acknowledging that repeal is no longer an option. “I think the message is: ‘Figure out what you can do together, and do it.’”
To be sure, antipathy to the healthcare law remains high among many conservatives.
The two political parties still hold starkly divergent views of where to take American healthcare, with many Democrats eyeing ways to open up the government Medicare or Medicaid programs to more people, and Republicans looking for ways to scale back government regulation of healthcare, as the Trump administration has already started to do.
Republican leaders also continue to harbor dreams of dramatically scaling back federal spending on Medicaid and Medicare. Trump’s own 2019 budget envisions hundreds of billions of dollars in cuts to Medicaid.
GOP governors and state attorneys general, meanwhile, continue to push a lawsuit, backed by the Trump administration, to wipe out the healthcare law and its preexisting condition protections nationwide. The case is currently before a federal judge in Texas.
Such retrenchments have long been at odds with public opinion.
Even when the healthcare law itself could barely get the support of four in 10 Americans, polling by the nonprofit Kaiser Family Foundation showed that as many as 75% of Americans liked its key components, such as expanding Medicaid and prohibiting insurers from turning away sick consumers. Medicaid, in particular, has proven remarkably popular, even among Republicans.
But until this week’s elections, it was unclear what price Republican politicians would pay if they tried to take these protections away.
The verdict was devastating.
Voters on Tuesday punished GOP lawmakers like New Jersey Rep. Tom MacArthur, a lead architect of the House Republican plan in 2017 to roll back requirements that health plans offer comprehensive coverage to people with preexisting conditions.
MacArthur was among more than two dozen House Republicans who lost their seats Tuesday.
In Texas, Republican Sen. Ted Cruz, another leading proponent of scaling back protections for preexisting conditions, managed to hold on to his seat against a spirited challenge from Democratic Rep. Beto O’Rourke.
But Cruz prevailed by just over 200,000 votes, whereas the Republican gubernatorial candidate in Texas beat his Democratic opponent by more than 1.1 million votes.
“Sen. McConnell has said out loud what many Republicans have been thinking,” said Jennifer Young, a veteran GOP lobbyist and senior official at the Department of Health and Human Services under President George W. Bush. “Many Republicans are more than ready to shift their attention to other healthcare priorities.”
Elsewhere, Republican politicians such as Nebraska Gov. Pete Ricketts simply tried to get out of the way of popular pushes to expand Medicaid coverage.
Ricketts, who once railed against the Affordable Care Act and resisted expanding Medicaid coverage in Nebraska, never took a position on this year’s Medicaid ballot measure. It passed 53% to 47%.
In Idaho and Utah, Medicaid measures won 61% and 54% of the vote, respectively.
Idaho’s measure got an eleventh-hour boost when the outgoing Republican Gov. Butch Otter endorsed it, noting: "We cannot continue to let hardworking Idahoans go without healthcare."
With Democratic gubernatorial victories in Kansas and Wisconsin on Tuesday, it is now possible that as many as five more states could soon be expanding Medicaid coverage through the Affordable Care Act.
That would leave only a dozen holdouts, mostly clustered in the Deep South.
Whether those states will embrace universal coverage for their residents is unclear. But the tide of public opinion is moving away from those who continue to resist it.
Exit polls Tuesday showed that nearly six in 10 voters said it should be the responsibility of the federal government to make sure all Americans have healthcare coverage, a core principle of the law Obama signed eight years ago.
The exit polling tracks with other surveys that have shown the share of Americans backing such a role for the federal government has increased steadily over the last decade.
“Republicans are going to find that they oppose coverage at their own political peril,” warned Brad Woodhouse, executive director of Protect Our Care, a liberal advocacy group formed last year to fight GOP efforts to roll back the healthcare law.