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The fight to stop Obamacare repeal is won. The fight against sabotage will be much harder.

Democrats saved Obamacare. Can they stave off sabotage?

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Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

Republicans failed to repeal Obamacare. Now who’s going to make it work?

Democratic politicians, grassroots groups, and the donor class poured their blood, sweat, tears, and money into stopping the Republican crusade to repeal the Affordable Care Act this summer. They succeeded. The law is still here.

But the ACA is still in mortal danger. President Trump has already taken steps that will increase premiums next year. He can stop enforcing key provisions like the individual mandate. Open enrollment, which begins November 1, is particularly at risk: Advertising to sign people up for the Obamacare marketplaces has been cut by 90 percent, and in-person assistance was slashed by 40 percent.

With the government pulling out, there may not be anyone to take up the cause. There isn’t the same energy or galvanization in the Democratic grassroots or donor class to offset these cuts. I spoke in recent days with half a dozen Democratic operatives, and that was the consensus.

“The coffers have not opened for anybody. There’s nobody sitting on a secret stash to do enrollment work,” said one operative working on pro-ACA projects, who, like others, did not want to be named discussing a sensitive topic like donor relations.

“Enrolling people is just different. You’re not fighting back; you’re not crushing something. You’re helping people sign up for health care,” this person said. “You have to make three connections to be able to understand how critical this work is for the ACA to survive.”

Trump’s sabotage has real consequences. One pro-Obamacare advocate put a figure on the cuts: 1.1 million fewer people enrolled in health coverage next year. That’s the best-case scenario.

Why Democratic donors didn’t rush to offset Trump’s ACA cuts

Longstanding nonprofits like Families USA and startups like Get Covered have undertaken the work to fund advertising and support enrollment education in the wake of the administration’s budget cuts. Social media activists, like former Obama administration official Andy Slavitt, are regularly tweeting information about open enrollment, which runs this year from November 1 to December 15.

But they have known from the start that they’d be woefully unable to fully fill the vacuum the Trump administration created. The health department slashed the law’s marketing budget by $90 million. That’s simply too much money.

When I spoke with Lori Lodes, the co-founder of Get Covered, back in September, she said a national TV campaign should have at least $15 million behind it. But that already seemed an unrealistic goal for the group.

“There is no way that anything we do or anyone else does can fill the footprint of what the administration should be doing,” she told me then.

A few contributing factors to the donor disengagement, based on my conversations in the past week:

  • It is simply unprecedented for the federal government to actively sabotage an existing federal program. Donors don’t intuitively think of this as their job.
  • There has been a general Democratic malaise since the 2016 election, especially among big-dollar donors.
  • Health care-focused donations also fell off after the ACA was passed in 2010.
  • There is some tension between giving money for short-term pro-Obamacare initiatives and giving to the 2018 House and Senate campaigns.

"There’s no question on the progressive side, I do think there’s a lot of compartmentalization between what donors and operatives think about political and advocacy work,” one Democratic operative working on 2018 campaigns told me. “Most donors are not directly affected by this issue, except to the degree that some of them own businesses and it costs them money.”

“Democratic donors are donors despite their own economic interest all the time,” this person said. “But does it affect them? Does it affect their family members? Probably not.”

You also can’t discount the general ambivalence among donors who spent a lot of money to try to stop Donald Trump from even being elected. Now they’re being asked to pour more money into try to stop the Trump White House from undercutting a law they had hoped was safe.

They have a full plate of issues too. It’s not just health care. There is immigration, after Trump signaled an end to the DACA protections for certain undocumented immigrants. Tax reform is heating up. Foreign policy fears, particularly over the Iran deal, run deep.

“I think it is part of like, 'Oh, my god, I just emptied out my wallets and now Donald Trump is president,’” the campaign operative said. “Democratic small donors are fired up. The big-money Democratic donors are just now starting to say, 'All right, we have to do this again.'“

But perhaps the most interesting tension is between short-term support for Obamacare this fall and helping Democrats win elections in 2018. It’s not an either-or proposition — these donors have a lot of money. But there was still, in my discussions, a question of priorities.

“Which is a bigger priority,” is how a third operative put it, “making ACA work in the short term or investing in flipping Congress back and presumably the White House in 2020 and securing it for the long term?”

Nothing will make Obamacare safer from Trump than a Democratic House or, less likely, a Democratic Senate being elected next year — even if there is some harm done in the meantime.

“I don’t think it’s fair to blame it on the donor community,” the person working on pro-ACA projects told me. “At the end of the day, the only thing that’s going to protect the law is Democrats taking a branch of power.”

Who is the constituency for Obamacare right now?

We shouldn’t overstate it: Pro-Obamacare groups have found support. They’re up and running and doing real work that will help people get signed up for coverage this fall. There are big nonprofit organizations, like the Robert Wood Johnson Foundation, that have long been philanthropically engaged on health care and still are.

Insurance companies, the for-profit enterprises that stand to benefit from millions of Americans signing up for their product, are expected to step up to fill some of the gap that the Trump administration has left behind. But for much of the year, the health insurers have not been eager to cross the White House and Republicans in Congress. Aggressive and overtly pro-Obamacare campaigns probably aren’t in the mix for open enrollment.

This left me with a question: Who exactly is the constituency for Obamacare right now?

Republicans are still bent on its repeal and replacement. The Trump administration is clearly willing to do everything in its power to make the law worse. That, of course, is not a big surprise. The GOP has been running these scorched-earth campaigns against Obamacare for nearly a decade now.

Democrats, meanwhile, have successfully defended the ACA. But what will they do now? The donor class, clearly, hasn’t been eager to step in on actually helping the law function. Lawmakers themselves have spent the past few months since repeal failed talking about ideas that might be long-term goals — a public option or, more boldly, a single-payer system — but aren’t achievable in the near term. Democrats are more willing with President Obama out of office to talk about Obamacare’s flaws, and bold ideas to fix it, and they’ve started to dream even bigger about a universal health care program.

There are the insurance companies, which have a direct financial interest in making the ACA function. But it probably isn’t helpful to the law’s long-term future to have health insurers, hardly the darlings of public opinion, be its primary defenders.

“I think making insurance companies the linchpin of Obamacare is not a good place to go,” one of the Democratic operatives told me.

The most obvious answer is the 10 million people who buy private insurance on Obamacare’s marketplaces every year. They need and most likely want the law to work.

But the law, after its somewhat unlikely salvation this summer, has been left in this strange limbo. The people and groups working to support it are undoubtedly earnest and committed. They will do what they can. But they would need the resources to do all the work that must be done to combat Trump — and they just haven’t materialized yet.

“There are a large number of organizations and entities and stakeholders who are extremely invested in it,” the operative working on pro-Obamacare projects said. “I just don’t think that necessarily translate to dollars.”

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