President Donald Trump has moved forcefully to push unprecedented limits on government health assistance for the poor, trying to follow through on conservatives’ long-held goals for reshaping the health care safety net.
That ambition has slammed into a brick wall amid the coronavirus — with the help of Republican states wary of cutting back health coverage for their poorest residents during a pandemic.
Voters in even the reddest parts of the country are approving or weighing Medicaid expansions as the coronavirus tears through communities and historic levels of unemployment leave workers without health coverage. And Republican governors aren't lining up for Trump’s two major moves to restrict Medicaid: work requirements for many adults and block grants to states instead of open-ended funding.
Now Republican experts who have led the party’s thinking on Obamacare alternatives acknowledge the conservative agenda is out of step with public demands. And the worst public health emergency in a century is now fueling a debate over how to frame the party’s health agenda around this moment, when Democrats enjoy a clear polling advantage on health care issues.
“The pandemic changes everything,” said Thomas Miller, a resident fellow at the conservative American Enterprise Institute. People, he said, are feeling vulnerable and asking the government, “What are you going to supply to me?”
As the November election approaches with millions out of work, there’s a growing recognition that more people will come to depend on that safety net. Nearly 1 in 4 Americans who aren’t on Medicaid themselves said it’s likely they or a family member will turn to it within the next year, according to a Kaiser Family Foundation poll this spring. Support for Medicaid expansion has also increased in states where Republican leaders have rejected it, with about two-thirds of voters saying leaders should extend coverage to hundreds of thousands more.
Work requirements sanctioned by Trump were only in effect in one state, Utah, before they were paused this spring as the virus wrought economic devastation. Elsewhere courts blocked them — or states hit hold precisely because they saw the legal trend.
Only one state, Oklahoma, has signed up for Trump’s offer to cap a portion of Medicaid spending for the first time in the entitlement program’s history. But that plan could be derailed by voters' approval of a ballot initiative ordering the state to expand Medicaid without tacking on conservative policies. Missouri voters may well follow suit in rebuking Republican leaders on a similar Medicaid expansion ballot measure next month.
Missouri will be the sixth state to have such a vote — and Medicaid expansion has carried in all of them so far, including particularly conservative states like Idaho and Utah.
Meanwhile, Health and Human Services Secretary Alex Azar said Trump won’t offer an Obamacare replacement before a Supreme Court ruling on the law, which is unlikely before the election. Republican lawmakers, who spent the first year of Trump’s presidency trying and failing to kill Obamacare, are largely distancing themselves from Trump’s embrace of the Supreme Court challenge that threatens the law's survival.
Trump has offered little reassurance there’s a strategy for preserving health care coverage for the more than 20 million who would lose out if the Supreme Court rules against Obamacare. The president has repeatedly pledged to provide cheaper and better coverage that protects people with preexisting conditions, but those promises are undercut by the party’s decadelong struggle to agree on a replacement.
Republican policy experts say the GOP during the coronavirus crisis has been left grasping for a health care platform when Democrats are dominating on an issue that is again top of mind for voters.
“What is the Republican health care agenda now? There isn’t consensus on that, there wasn’t a consensus in 2017 on that either, which is a big part of why repeal and replace failed,” said Avik Roy, president of the Foundation for Research on Equal Opportunity, a conservative think tank.
Conservatives have cheered Trump’s moves to rein in Medicaid and undercut Obamacare, saying they would lower costs and provide more affordable health insurance options. But those will provide more attack fodder for Democrats, who used health care to boost their fortunes in the 2018 midterm elections and are eager to spotlight Trump’s agenda this fall.
“It’s a more dangerous agenda than ever, it’s increasingly toxic with voters, and we’re holding Republicans accountable,” wrote Stewart Boss, spokesperson for the Democratic Senatorial Campaign Committee, in an email.
Polling shows that Democrats maintain a comfortable lead over Republicans on health care, and Trump continues to poll poorly on his handling of the worst health crisis in a century. An election year messaging bill House Democrats approved two weeks ago, seeking a contrast with Trump’s health moves, would expand Obamacare’s insurance subsidies and also incentivize the remaining 13 Medicaid expansion holdout states to join the program.
A White House spokesperson defended Trump’s attacks on Obamacare while highlighting the president’s other recent health care initiatives enjoying more bipartisan appeal, like capping insulin costs for seniors and expanding telehealth capacity during the pandemic.
“A global pandemic does not change what Americans know: Obamacare has been an unlawful failure and further illustrates the need to focus on patient care,” said the spokesperson, Judd Deere. “It limits patient choice, forces Americans to purchase unaffordable plans, and restricts patients with high-risk preexisting conditions from accessing the doctors and hospitals they need.”
Trump himself has tried to grab hold onto other health care messages in recent weeks. After a federal judge last month upheld the administration’s new requirement that hospitals disclose secret prices they negotiate with health insurers, Trump claimed on Twitter the decision was “bigger than healthcare itself” — an apparent reference to the Affordable Care Act. The requirement isn’t scheduled to take effect until January, and it’s a major question whether the new transparency rule will force down health care prices as supporters claim it will. Hospitals are still trying to overturn the mandate in courts.
The president has also recently chided Democrats on drug pricing after discussions over bipartisan Senate legislation fell apart, but Republicans never fully embraced the plan. Pharmaceutical companies meanwhile raised prices on hundreds of drugs during the pandemic, defying Trump’s tough talk against the industry.
Some conservatives have argued that the pandemic has made their case for a Medicaid overhaul even more pressing. State budgets have taken a hit from lost revenues during shutdowns, and some have already trimmed Medicaid spending, which is typically one of their largest budget items. But they acknowledge the difficult optics of the agenda in this moment.
“We're a couple months before an election, so political factors are on everybody's mind. And you know, how does the media report things? The media tends to report Republican health plans as evil, trying to reduce coverage, weaken the safety net, and so Republicans are aware of that,” said Brian Blase, a former Trump aide who helped develop the administration’s alternatives to Obamacare coverage.
But Trump's biggest idea for Medicaid — block-granting a portion of Medicaid spending for the first time in the program's 55-year history — was already viewed skeptically by many Republican governors, despite longtime conservative support for the idea. Instead of receiving an open-ended payment based on need, states would receive a lump sum and more freedom from many program requirements. Supporters of the idea say states could better manage their Medicaid programs, but critics warn it would leave states with little choice but to cut enrollment and services during times of economic distress, as much of the country is experiencing now.
“The risk to states from a Medicaid block grant has always been unexpected events that increased health care costs or enrollment," said Larry Levitt, an executive vice president at the Kaiser Family Foundation. "The double whammy of a pandemic and economic crisis is likely to give states pause."
The pandemic, meanwhile, has been expanding use of the safety net. More people who lost workplace health insurance have been signing up for Obamacare plans, though Trump resisted reopening the health care law’s insurance marketplaces more broadly to the uninsured. The federal government is temporarily pouring more money into Medicaid programs as enrollment is expected to grow during the pandemic, and states are barred from paring their Medicaid rolls during the coronavirus emergency.
Some Republican lawmakers say they’re not abandoning their plans to rein in Medicaid and Obamacare — just putting them on hold.
The Republican Study Committee, the policy arm of conservative lawmakers, is working on the second phase of a 58-page framework for an Obamacare alternative it released last fall. The pandemic has delayed the schedule for finishing the plan, a spokesperson said.
Sen. Bill Cassidy, a Louisiana Republican who authored an Obamacare replacement plan that included an option for a Medicaid block grant, said there will be an opportunity to review major health care programs after the pandemic.
“When people are under duress, they really don’t like change,” Cassidy said. “But when things are going better, then they have a little bit more comfort level with change.”
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