Before Donald Trump launched his political career, the most catastrophic concern in the national discourse was Obamacare.
The earliest drafts of Barack Obama’s health care law provoked protests all across the country. Representatives feared loud reprisals from senior citizens at town hall meetings. Right-wing activists characterized the prospect of publicly subsidized health care coverage as a scheme for one-world government. The law helped doom the Democratic majority in Congress to the most overwhelming midterm election blowout in 30 years. Ultimately, Congress passed the Affordable Care Act on slim and contentious margins in both chambers. There were 178 Republicans in the House; they all voted against the ACA.
For almost a decade after Obama signed the ACA into law, the Republicans dedicated themselves to repealing Obamacare, the signature domestic achievement of Obama’s presidency. In June 2017—five months into Trump’s presidency—the Republican majority in Congress mounted their climactic effort to repeal the ACA. But the Republicans failed. The repeal vote faltered against opposition from three GOP senators, including the late John McCain, an Obamacare critic who nonetheless resented his party leadership’s chaotic provisions for replacing the law—which currently supports almost 9 million enrollees—with a viable alternative. In 2018, the Republican leadership has struggled to refocus its repeal efforts, and so the Obamacare debate rages on.
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Obamacare is a pivotal concern in McCain’s home state, Arizona, which now hosts a close midterm election contest to replace outgoing Republican Senator Jeff Flake. The race pits Representative Martha McSally—a Republican and longtime Obamacare critic—against Democratic Representative Kyrsten Sinema. In the House, McSally and her fellow Republicans have voted to repeal the ACA dozens of times. In contrast, Sinema isn’t just an Obamacare proponent. In her previous service as a state legislator, Sinema helped the Obama administration draft the ACA. For a decade, Obamacare has been the most contentious law in the land, but Trump’s divisive presidency has lately obscured its impact among voters, who rank health care as the most important issue of the 2018 midterm elections. Nationally, congressional candidates have turned the midterms into a culture war about Trump, “left-wing mobs,” Brett Kavanaugh, and a resurgent socialist movement. But the Senate race in Arizona underscores Obamacare as the dominant policy concern of the midterms. A decade after the law’s tumultuous passage, the Obamacare debate has shifted dramatically. For once, opposition to Obamacare has become a liability among Republican nominees. In conservative Arizona, most voters favor upholding the ACA over repealing it. It’s a popular law.
Accordingly, McSally has tempered her opposition to Obamacare, emphasizing “replace” over “repeal.” “We cannot go back to where we were before Obamacare,” McSally said in her only televised debate with Sinema, vowing to “protect people with preexisting conditions.” Her moderation would have been unthinkable as recently as four years ago, when she was first elected to the House, and she opposed Obamacare as “social engineering founded on mandates, taxes, and penalties.” In the House, McSally hasn’t led any productive efforts to reimagine Obamacare—she’s simply voted to dismantle it, in full and in part, including the ACA portions that prohibit insurers from discriminating against consumers with preexisting conditions.
The struggle to formulate a more conservative alternative to Obamacare has saddled Republican candidates with a vapid and unpresentable outlook on U.S. health care. The Republican leadership hasn’t solved McCain’s concern about the repeal efforts. Meanwhile, Democrats have rallied around their own, left-wing alternative to Obamacare in the form of “Medicare-for-all,” a proposal that would replace Obamacare’s subsidies and market reforms with a single-payer health care program run by the federal government. Bernie Sanders authored the original Medicare-for-all legislation. More than 120 Democratic lawmakers—and zero Republicans—have cosponsored the proposal. The Republicans have yet to produce a similar consensus among themselves.
The Senate race in Arizona has been remarkably quiet in national headlines. It’s the only major Senate race in which the major party nominees are both women. There’s been minimal nonsense. Crucially, Sinema and McSally both moderated their statements about Kavanaugh after Christine Blasey Ford said he sexually assaulted her; Kavanaugh’s appointment to the Supreme Court has proved less central to the Arizona race as it has in the final weeks of key Senate races in Texas, North Dakota, and Tennessee. The border-state immigration debate between Sinema and McSally is also far less stark than Beto O’Rourke’s left-wing campaign against Ted Cruz in Texas. Sinema has taken a conservative stance on immigration; she’s affirmed Trump’s calls for a new border wall at the U.S.-Mexico border in addition to backing inclusive immigration protections, such as the DREAM Act. So Obamacare is the pivotal issue. In Arizona, the election is a stark choice between electing a senator to uphold Obamacare or electing a senator to support an indeterminate GOP health care alternative that has yet to materialize in 10 years despite “repeal and replace” being the Republican Party’s most urgent political priority in this decade. (Well, apart from federal tax cuts.)
Obamacare has polarized the political discourse for a decade. It’s imperiled both parties—more recently, it’s forced a dominant Republican Party onto the defensive. In his memoirs, McCain resented the loud praise he received from his Democratic colleagues for “saving” Obamacare. He had meant to only buy more time for Republicans to “replace” Obamacare, McCain writes, underscoring the limits and perils of constructivism. “I’m not sure we’ll ever agree on a replacement,” McCain wrote, “and so perhaps all we can do is try to fix parts of Obamacare. I would prefer something more comprehensive, but that might not be attainable in the near future.” The Democrats are contemplating the near future, too. Their plan to “replace” Obamacare is socialized medicine. McSally and Sinema both oppose Medicare-for-all, but only one candidate serves a political party with a certified backup plan.