President Donald Trump has an Obamacare problem.
His administration restarted its efforts to kill the health care law this week, backing a lawsuit that argues all of the Affordable Care Act is unconstitutional. Now, Trump faces a question that has confounded Republicans in recent years: if courts toss out Obamacare, how do you replace it with an alternative that expands coverage, cuts costs and keeps the law's most popular parts in place?
The White House has no easy answers. When the GOP tried several times to repeal Obamacare in 2017, voters overwhelmingly disapproved of the plans. Americans grew to like the existing law more when they saw projections that the Republicans' alternatives would leaves tens of millions more people uninsured or increase costs.
Democrats flipped 40 House seats and control of the chamber in last year's midterms in large part by criticizing the Republican push to repeal the ACA. After the drubbing, Republican leaders in Congress have had little appetite for reopening the Obamacare fight, instead focusing on several top Democratic presidential candidates' calls for a government-run "Medicare-for-all" health care system.
Then Trump jumped into the fray in recent days. Focusing on health care ahead of a pivotal 2020 election, in which Republicans will try to defend the White House and a Senate majority and retake House seats, carries massive political risk. There's little evidence to suggest voters trust Trump and the GOP to come up with a health care plan if the president gets his wish and the Supreme Court scraps Obamacare.
"The one lasting effect of the repeal and replace debate is that the ACA is actually more popular than ever. That will make it harder to talk about repealing and replacing it," said Larry Levitt, senior vice president for health reform at the Kaiser Family Foundation. "The repeal and replace debate in 2017 did the one thing that seemed impossible: which was to make the ACA popular."
For Democrats, Trump's decision to make health care front and center of the political debate again is a welcome change of topic for the party after special counsel Robert Mueller concluded the Russia probe. After a two-year investigation, Mueller did not establish that members of the Trump campaign conspired with Russia's interference in the 2016 presidential election, putting Democrats on the defensive.
House Speaker Nancy Pelosi quickly jumped on Trump's latest moves against Obamacare, announcing a vote in the coming week to condemn his attempt to kill the law. And 2020 Democratic presidential candidates see health care as a winning issue as the campaign heats up. Sen. Kirstin Gillibrand, who officially launched her campaign the day Mueller's key findings were released, said the debate over health care is a fight the party welcomes.
"If it's a fight for healthcare this administration wants, it's a fight they'll get—and we will win," Gillibrand said.
Since his administration backed the lawsuit to scrap Obamacare on Monday, Trump has talked about vague plans to come up with a superior health-care law. On Friday, he said his administration would come up with "a plan that is way better than Obamacare."
"We're always going to take care of people with pre-existing conditions," Trump told reporters in Florida, referring to perhaps the most popular piece of Obamacare, which the administration-backed lawsuit would end. "I said it before, the Republican Party is going to be the party of health care."
After 2017, voters may not want the GOP in charge of health care. While the Republican plans to repeal Obamacare took various forms, all of them fared poorly in public opinion polls.
The GOP passed one form of health care overhaul in the House, then came one vote shy of approving a different version in the Senate. Trump has repeatedly attacked GOP Sen. John McCain, even after his death last year, for helping to stop Republicans from scrapping the ACA.
After a months-long slog through multiple plans that divided the Senate GOP caucus, Senate Majority Mitch McConnell appears to have little desire to take on Obamacare repeal again under a divided government. On Thursday, he told Politico that he looks forward to "seeing what the president is proposing and what he can work out with [House Speaker Nancy Pelosi]."
McConnell may have good reason not to enter the fray ahead of next year's elections. Overall, 60 percent of the public considered it a "good thing" that the Senate did not pass its Obamacare repeal plan, while 35 percent called it a "bad thing," according to an August 2017 Kaiser Family Foundation poll. While Democrats and Republicans answered largely as expected, 62 percent of independents said it was a "good thing" that the plan did not pass.
In July of that year, 61 percent of Americans had an unfavorable view of the GOP's health-care plan, versus 28 percent who saw it favorably, according to a Kaiser survey. Forty-four percent of those surveyed said they had a "very unfavorable" view. At the same time, 50 percent of the public saw the ACA favorably, while 44 percent had an unfavorable view.
Republicans did succeed in scrapping one key part of the ACA as part of its 2017 tax reform law: the individual mandate, which required most Americans to buy health insurance or pay a penalty. The divisive provision was designed to keep younger, healthier people in the insurance market to reduce overall costs.
While the Republican repeal plans differed throughout 2017 as the GOP debated what could pass, every version involved large cuts to public health spending. Those reductions largely came through rolling back Obamacare's expansion of Medicaid, the federal-state insurance program for low-income Americans.
The House-passed plan, for example, was expected to lead to 23 million more uninsured Americans by 2026, according to the nonpartisan Congressional Budget Office. It also included a provision that could allow states to loosen protections for people with pre-existing conditions.
Trump has not put forward a specific health care plan since his administration backed the lawsuit to scrap Obamacare. Based on what he has supported in the past, though, it could prove tough for him to come up with a plan that meets his lofty promises.
In a CNN interview Wednesday, Vice President Mike Pence's chief of staff, Marc Short, said Trump "will be putting forward plans this year that we hope to introduce into Congress." He did not lay out specific proposals, beyond wanting to allow consumers to buy insurance across state lines, "reduce premiums" and "provide more freedom."
Short noted that the administration does not expect a court decision, or a need to replace Obamacare, until the summer of 2020. The Supreme Court has already upheld Obamacare twice.
Trump's fiscal 2020 budget provides one potential road map for the White House. The administration proposed hundreds of billions of dollars in cuts to Medicaid and Medicare. It would set up Medicaid block grants to states, echoing a plan from Sens. Lindsey Graham, R-S.C., and Bill Cassidy, R-La., that the CBO estimated would lead to "millions" more uninsured. The White House did not respond to a request to comment on whether the proposals outlined in the budget were its preferred plan to overhaul the health care system.
Kaiser's Levitt doubts Trump will have an easier time crafting a replacement plan now than the GOP did in 2017.
"There are no signs yet that somehow the magic on how to do this without the downsides and trade-offs has been discovered," he said.
Trump could find himself in a tricky political situation if he pushes a health care overhaul while trying to win re-election next year. House Democratic candidates across the country hammered GOP lawmakers last year for votes to repeal the ACA.
For example, Rep. Andy Kim, D-N.J., defeated Republican Rep. Tom MacArthur, who authored a divisive House amendment that would have allowed states to get waivers allowing insurers to charge some consumers more. Rep. Antonio Delgado, D-N.Y., defeated then-GOP Rep. John Faso in a swing district race in large part by drilling into the Republican's vote to get rid of Obamacare.
Those candidates and numerous others won House seats and governor's offices using health care as their primary issue.
Democrats spent elections from 2010 to 2016 defending against Republican attacks on Obamacare. As they saw last year, it's often better politically to be in the position of criticizing their opponents' actions than defending their own.
Trump could fare better next year if he chooses to frame the health care debate in terms of some Democrats' plans to transition to a government-run system, rather than making the election about his own proposals. In a statement Thursday, White House press secretary Sarah Huckabee Sanders signaled the administration could do just that.
"We will protect people with pre-existing conditions, lower prices for care and prescription drugs even further, end surprise medical bills, and make sure Americans get the absolute best quality of care. Our Nation deserves a great healthcare system that puts American patients first and puts people — not the government in control of their healthcare," she said in a written statement.
Of course, following through on those promises involves crafting a specific plan. That could prove to be the biggest headache for Trump.