Watching Republicans continue to pull out the stops to end or severely hobble the Affordable Care Act is beginning to feel like watching someone bang their head against a brick wall, over and over. The head is bloody, but the wall is just fine.
GOP efforts over the last year to repeal the ACA. and President Trump's very public efforts to sabotage it, were on the ballot in more ways than one last week. Four major repeal votes in Congress and repeated efforts to cut funding and raise premiums were very much on Americans' minds as they voted in some key states and as the nationwide ACA open enrollment period began.
In Virginia, exit polls showed that health care was far and away the most important issue on voters' minds, at 39%. Democrat Ralph Northam, now governor-elect, took the reasonable position that we should be fixing, then building on, the ACA's coverage gains. Exit polls showed him with a 77% to 23% advantage over his opponent on the issue. For all the talk of race and immigration, terrorism and trade, health care security carried the day and the repeal candidate did not.
A big strike against repeal.
In Maine, there was an even more direct test of the ACA as the vote to expand Medicaid coverage to Americans up to just above the poverty level was on the ballot. Maine's legislature had passed the bill five times only to be vetoed by Maine's Republican governor Paul LePage. Mainers voted to support the proposition by an 18-point margin.
One interesting interpretation of that vote is far more Mainers voted for it than are set to directly benefit from it. That's Strike 2 against the idea that Americans want to see the ACA repealed.
Finally last week, the law that Trump has repeatedly termed "dead" opened its fifth season with a bang. The outpouring of demand for coverage was a massive vote for the ACA. Enrollment in the first few days set records, increasing by 79% over prior years. Every major metric released by the Trump Administration was up significantly.
These results represent something beyond what they might in normal years. They come despite a calculated and methodical effort to push premiums higher, decrease awareness, reduce assistance and sow confusion.
Why are we seeing these results? It simply turns out that the rhetoric out of the Trump administration is false. Affordable options, while reduced for some due to Trump's tampering with cost-sharing reduction payments, that make policies more affordable, are still strong for many. Four in five enrollees can find plans for under $75 a month. The majority of people who qualify for subsidies can even find a plan at no premium. And while competition is down this year, in contrast to the doomsday propaganda, 75% of consumers have multiple insurance companies to choose from.
It turns out that despite epic Washington battles, people just care about getting coverage for their families. Strike 3 on what Americans think of repeal.
Last week's events are harder for the GOP to dismiss than what they tried over the summer. Republicans could publicly blame angry town halls on activists mythically paid as part of a George Soros-funded plot. They could dismiss as inaccurate the bipartisan Congressional Budget Office's predictions of huge coverage losses under repeal. Trump and GOP leaders could blame the failure of repeal on John McCain and a handful of other senators.
Dismissing what happens when people vote — whether the ballot box or with their pocketbooks — is another matter entirely.
My sense is that a good number of Republicans understand that last week was a strong signal of things to come and would be happy to have health care repeal behind them. Twelve Republican senators publicly back a bipartisan compromise to modestly improve the ACA that was put forward by Sens. Lamar Alexander and Patty Murray and is supported by all the Democrats. Possibly more Republicans support it privately.
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Yet Trump and a number of Republicans in Congress have continued to persist with repeal, albeit slightly below the surface. Trump's executive order, signed last month, is designed to allow insurers to get around ACA pre-existing condition protections. Massive proposed tax cuts for the wealthy with no plan to pay for them are designed to back into cuts to Medicaid and care for low-income populations. And Trump and GOP leaders continue to threaten that full repeal will come back in early 2018.
Having had responsibility for the last years of ACA in the Obama administration, I'm quite wary of all the ways Trump can manipulate the rest of the open enrollment period to suppress access to coverage. They have already cut the time period in half and without enough contact center staff, a number of people won't get covered in the last minute crush. I still anticipate press conferences touting the ACA's failure in our future, and I expect the administration won't hesitate to find ways for that to happen.
Whether this is tone deafness, misplaced fealty to a handful of major donors or his tribal hatred for all things Obama, Trump will continue to cause many in the GOP to keep hitting their heads against the ACA wall. There's now reason to think that brick wall in some form is here to stay. Trump's loyal repeal army in Congress, however, may not be.
Andy Slavitt, a member of USA TODAY's Board of Contributors, is a former health care industry executive who ran the Affordable Care Act and the Centers for Medicare and Medicaid Services from 2015 to 2017. Follow him on Twitter: @ASlavitt