Daniel Béland, Philip Rocco and Alex Waddan

For voters in the New Hampshire primary held on February 9, Obamacare matters. In town halls and coffee shops across the state ahead of the vote, Republican hopefuls Ted Cruz, Donald Trump, and Marco Rubio have pledged to repeal and replace the landmark legislation. Meanwhile, Democrats Hillary Clinton and Bernie Sanders have been locked in a tense battle over whether or not to expand the vision of health reform to include a switch to a single-payer system. 

The continued focus on Obamacare, also known as the Affordable Care Act (ACA), is hardly surprising because, since its passage in spring of 2010, the law has been at the centre of partisan division in U.S. politics. It helped mobilize Republicans in the 2010 mid-term elections and saw the GOP committed to repeal the law in 2012, despite the fact that it was modeled on a reform enacted in Massachusetts in 2006 and signed into law by then-Governor Mitt Romney, who became the 2012 Republican presidential nominee. Obama’s reelection in 2012 meant that there was no repeal of the law, despite repeated efforts by congressional Republicans to pass measures to this effect. Yet, Republicans continued to condemn the law and the partisan division over the merits of the ACA was not confined to political elites. The Pew Research Center’s polls have consistently shown that more people disapproved the law than support it but, with a sharp division between Democrats and Republicans, the former strongly supportive of the law, and the latter overwhelmingly opposed to it. It is unsurprising, therefore, that the  Democratic and Republican presidential hopefuls respectively praise and condemn the essence of the ACA. Amidst this enduring partisan polarization over the ACA, it is interesting to discuss the views of individual candidates, and the likelihood they would follow through on their promises if they ever enter the White House.

Elsewhere we have argued that a Republican president may, in fact, find it easier to allow the ACA to remain in place but pass more responsibility to the states to shape matters as they see fit. That type of solution to the “replace” part of “repeal and replace”, a slogan which is standard fare from Republicans opponents of the law, gets little expression in the heat of the campaign. All the party’s remaining candidates going into the New Hampshire primary had stated positions calling for the repeal of the ACA, all emphasizing that greater choice and market competition rather than government regulation was the way to simultaneously improve the quality of care and contain costs. The candidates offered various degrees of detail of how they achieve this goal, with the top three finishers in Iowa making few explicit commitments about their intentions. In the summer of 2015, Florida Republican Senator Marco Rubio did offer an outline of a plan to replace the ACA, which he denounced as ‘fatally flawed’ and based on an ‘outdated philosophy’. While the denunciation of ObamaCare was regular conservative rhetoric, Rubio did suggest reforming the two major public health insurance programmes in ways that could offer a Democrat opponent in the general election an opportunity to counter-attack. In particular, his suggestion that the Medicare programme for seniors, with its single payer model of funding, could be turned into a ‘premium support system’, might leave him vulnerable to criticism. This is the case because Medicare is one of the most popular federal social programmes in the United States.

The other leading contenders in Iowa, Texas Republican Senator Ted Cruz and businessman Donald Trump, found themselves grilled about their health care plans in the build-up to and the aftermath of that state’s caucuses. At a pre-caucus event, Cruz was asked how he would replace the ACA by a questioner who told how his brother-in-law had only been able to afford insurance as a result of the ACA, but by the time he had a medical checkup he had multiple untreatable problems. Cruz replied with stock criticisms of the ACA but no alternative plan. Trump, for his part, was asked on ABC’s This Week programme what his plans were. His response suggested that something would be done: ‘If somebody has no money and they’re lying in the middle of the street and they’re dying, I’m going to take care of that person.’ While clearly distancing himself from anything resembling a single payer plan, Trump may, in fact, be less than a fully-fledged conservative on the issue, as he had already ridiculed candidate Ben Carson’s suggestion that Medicare be ended. In a general election campaign, however, he would surely be pushed to be more specific than promising ‘something terrific’.

If debate on the Republican side has been simultaneously strident and skimpy, the argument between the leading Democratic candidates took a strange, wonkish, turn in the build-up to Iowa. As Sanders’ challenge took on a more serious hue than perhaps expected, the Clinton camp, in the shape of Chelsea Clinton charged that Sanders plans for reform would ‘dismantle’ the ACA and ‘strip millions and millions and millions of people off their health insurance’. Given Sanders’ longtime commitment to a single payer plan, guaranteeing all Americans access to health insurance, this was a surprising allegation. The logic was that Sanders had previously advocated a plan calling for universal coverage, but which gave states some responsibility for designing how this would work. According to Clinton, this would empower Republican Governors to refuse to operate any kind of plan, jut as many of them had refused to participate in the expansion of the Medicaid programme, which had been a central tenet of the ACA (on this issue see our recent book Obamacare Wars).

This was, in reality, a disingenuous attack, but both Clinton and Sanders could face tricky questions about health care in a general election campaign. Opponents could rekindle memories of ‘Hillarycare’ from 1993 and she would need to fend of GOP criticisms of the ACA and respond to conservative accusations that the law has been responsible for rising insurance premiums in a more effective manner than when she labeled the rises of ‘glitches’ in a Democrat debate. Sanders, on the other hand, would find Republicans piling on to his ‘Medicare for all’ plan as another step towards ‘socialized medicine’.

What is clear is that arguments about health care policy are likely to continue to rage, mostly producing more heat than light with all candidates potentially vulnerable to criticism. Yet, however unhelpful the campaign rhetoric might be to voters, the policy consequences of the election outcome could be significant. For instance, even if outright repeal is unlikely due to the popularity of key elements of the ACA and a lack of consensus on Republican alternatives, the advent of a Republican president could lead to a gradual erosion of the reform on the ground, through the granting of waivers to Republican-controlled states, who could then implement policies that would challenge the very logic of the 2010 reform. A Democratic victory in the November presidential election would help preserve the ACA, but, unless that victory was accompanied by what seem unlikely sweeping gains in congressional and state-level elections, key challenges in the implementation of the law would remain.

While voters in New Hampshire and in the states to follow may have difficulty deciding which candidate will bring about better prospects for health care in the US, they are well acquainted with the Obamacare wars. They have been since long before the campaigns rented office space and hired canvassers. And, at least for now, it looks like there’s no end in sight.


Daniel Béland is Professor and Canada Research Chair in Public Policy at the Johnson-Shoyama Graduate School of Public Policy, University of Saskatchewan.

 Philip Rocco is a Postdoctoral Associate at the Health Policy Institute, University of Pittsburgh Schools of Health Sciences. Alex Waddan is senior lecturer in American politics at the University of Leicester. They are the authors of “Obamacare Wars: Federalism, State Politics, and the Affordable Care Act“ (University Press of Kansas, 2016).

Image: Will O'Neill CC BY-NC-ND