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Republicans Killed Much Of Obamacare Without Repealing It

Saturday was the deadline for Americans in most states to enroll in health plans for 2019 through the marketplaces set up by the Affordable Care Act. When Barack Obama was in office, the federal government, including the president himself, spent the days and weeks before the deadline constantly urging people to sign up. But this year, like in 2017, President Trump and the federal government did little outreach.

That hands-off approach to ACA enrollment isn’t an accident or an oversight. It’s part of an intense, sustained, nearly nine-year-long Republican campaign to stop or limit the implementation of the ACA, better known as Obamacare. (A group of Republicans filed a lawsuit against the ACA minutes after President Obama signed it into law on March 23, 2010.)

“Virtually no major health reform has become the subject of a partisan assault so quickly after its passage,” said Philip Rocco, a Marquette University political science professor and co-author of the 2016 book “Obamacare Wars.”

You’ve probably read about the many attempts by Republicans on Capitol Hill to repeal Obamacare, most notably the failed push last year. But the anti-Obamacare movement is way broader than just the effort to undo it with legislation in Congress. It is not a single, top-down operation, but rather different parts of the conservative movement taking actions in their own spheres in opposition to the law.

Conservative-leaning groups and Republican elected officials have filed numerous lawsuits challenging various planks of the law. (In one of those lawsuits, a federal judge ruled the entire ACA unconstitutional on Friday. That ruling does not immediately go into effect and maybe never will, as legal experts expect other judges to overturn it. But there’s also now the very real possibility that the case ends up before the Supreme Court.)

Republicans in Congress have done away with some parts of the law and cut funding in other areas. GOP-controlled state legislatures and Republican governors have opted out of some of Obamacare’s key provisions. The Trump administration is using its executive powers to essentially rewrite some parts of the law, and it’s taking a largely hands-off approach to some parts it doesn’t like, like the enrollment process, that might benefit from a supportive federal government.

This campaign has curtailed Obamacare in some ways we can clearly measure:

Fourteen states have not yet opted in to the Medicaid expansion, leaving about 4 million eligible Americans unable to enroll. A lawsuit brought by GOP elected officials and a conservative-leaning business group led to a 2012 U.S. Supreme Court ruling that states did not have to extend Medicaid benefits to more of their residents, as the ACA had initially mandated.

Republicans currently control both houses of the state legislature in all 14 of these states, and the governor’s office in all but one (North Carolina). The biggest holdout is Texas, where the Kaiser Family Foundation estimates that more than 1 million additional people would be eligible for Medicaid if the state participated.

Twenty-eight states have completely opted out of running local Obamacare exchanges, which means all enrollment processes are left up to the federal government. As originally written, Obamacare gave states the option of running their own insurance marketplaces. Like with Medicaid, more conservative states have been chosen not to participate. Of the 28 states that leave their health insurance marketplace entirely up to the federal government, Trump won 24. And of the 22 that are involved in running their own exchanges, Hillary Clinton won 16.

Why does this matter? Well, states that run their own insurance exchanges can also run their own enrollment drives — which means extra staffing and promotional efforts — and they can also create their own deadlines for signing up. So in California, residents can enroll for health care through Jan 15, giving them a full month longer than, say, Texas or other states that don’t have their own Obamacare marketplaces and rely completely on the federal government.

Federal spending to promote ACA enrollment has been cut from $163 million to $20 million. The Trump administration has cut money both from government programs designed to increase Obamacare enrollment and from grants that are given to nongovernmental groups to help people enroll. In Obama’s last year in office, the federal government spent about $100 million in advertising to encourage people to enroll in ACA plans and gave out $63 million to groups who were supposed to boost enrollment. This year, the Trump administration is spending $10 million on ads and giving to $10 million to these assistance groups.

When Obama was president, these outside groups were deeply involved in enrollment efforts, particularly in states that were hostile to the ACA. But these groups now get much less federal funding, which they say limits how much outreach they can do.

Those are the parts of the anti-Obamacare campaign where the effects are easiest to quantify. Here are some other effects where the numbers are less clear:

  1. The percentage of Americans without health insurance decreased from about 16 percent in 2010, before the ACA went into effect, to just under 9 percent in 2018. Experts attribute that drop largely to the ACA. But how many more people would have health insurance if Republicans had fully participated in the ACA by expanding Medicaid and starting state-level marketplaces in places where they have political power? How many more would sign up if the Trump administration were conducting extensive enrollment outreach at the federal level, like Obama and his team did?
  2. We know some people are not enrolling because they are confused about whether certain benefits still exist or if the law is still on the books. But how much of that confusion has been heightened by the constant efforts to render the law moot, whether by invalidating it in the courts or repealing it on Capitol Hill?
  3. Congressional Republicans and Trump got rid of the individual mandate, the requirement that many people who don’t have health insurance pay a fine. The Trump administration has started allowing the sale of more limited health insurance plans that don’t conform to Obamacare regulations. How many people will end up uninsured because they aren’t required to buy insurance? How many will end in plans that will probably have cheaper premiums than Obamacare but that also offer less coverage, potentially increasing their out-of-pocket costs if they get sick or hurt?

The Republican effort to dismantle Obamacare hasn’t just changed how the program works in practice — I think it has also changed the politics and policy of health care more broadly. The Democratic Party has strongly defended Obamacare since its passage. But many Democrats, particularly on the party’s left, have long been dissatisfied with the law, arguing there are still too many people either uninsured or paying very high costs for their health care. More centrist Democrats initially thought the ACA’s fairly modest approach would garner some Republican support — or at least avoid an outright war against the law. That bet was wrong. So now both the left and center-left of the Democratic Party are pushing proposals that would either let some Americans choose to enroll in a Medicare-style program or basically force all Americans into a broader single-payer health system.

We don’t really know exactly how a program written and designed like Obamacare originally was would truly work — and we probably never will find out. The Republicans have blocked, slowed or impeded so much of the law that what’s left in its place is something like Obamacare Lite or Obamacare Version 0.75. Republicans will probably keep trying to destroy the current system — and Democrats now want something new and improved.

Perry Bacon Jr. was a senior writer for FiveThirtyEight.