Only rarely does a political era end so formally and so obviously. Usually, when a fight that’s defined a generation of D.C. warfare ends, it fades away quietly and pitifully, drained of salience and funds and interest. (See: deficit hawkery or the opposition to federal stem-cell research funding.) But in mid-June, when the Supreme Court rejected yet another GOP attempt to gut Obamacare, it was clearly, finally the end of the line for the war over the Affordable Care Act. That also meant the end of the line for a — if not the — top-tier political issue for the Democratic Party for the last decade.
At least it sure looks that way to them now. As relieved as they were to have ultimate confirmation that the law will really, actually, truly survive, they’ve relied on the existential struggle over it as a staple (and sometimes tentpole) issue in their campaigns against Republicans for several election cycles. Now they need something new to talk about heading into a challenging midterm year.
The result has been a month of head-scratching, focus-grouping, and quiet but urgent debating among top party officials and strategists. If 2022 will be the first elections in 12 years not to be largely defined by candidates as a referendum on the ex-president’s signature law or its components, they’re asking, then what will take its place?
As early as it feels to be having this conversation — 16 months before voters head to the polls — the stakes are undeniable both for the campaign to control Washington and for the party’s own coherence.
For one, keeping the focus on protecting Obamacare and, as a result, protecting coverage for citizens with preexisting conditions, has been a surefire way for Democrats to keep their coalition fully together against a Republican party sometimes cartoonishly eager to dismantle the law or at least that provision — even as the left and center-left’s internal debate over the future of health-insurance policy itself has only intensified and the fissures deepened. That’s been especially true since Bernie Sanders’s — and Medicare for All’s — rise in popularity circa 2016.
And second, the imperative of passing, then implementing, then protecting the law has been indispensable for Democrats ever since Barack Obama’s party was decimated amid the Tea Party backlash in 2010 and he subsequently won reelection to save the ACA in 2012. Even when health care hasn’t been the central talking point for pundits or on debate stages, like in 2016, it’s been by far the top go-to in Democratic candidate ads and mailers to their voters: My Republican opponent will vote to repeal Obamacare, the line has usually gone in recent years, and then your preexisting conditions will destroy your chances of getting covered. In 2018, party leaders debated whether to spend more on impeachment- or Russia probe-focused ads about Trump, but ultimately settled on a health-care-first strategy in battlegrounds. It worked. In 2020, health-care access ran through Joe Biden’s public appeals even while he focused primarily on pandemic management. That worked, too.
Now, however, some significant party figures are urging intensified focus on a range of other matters, at least for the time being. By far the most prominent issue on many of their minds is voting rights, a topic that becomes more pressing each day as GOP-led state legislatures tighten laws on voting access. Late last week, a group of civil-rights leaders, including the Reverend Al Sharpton, met with Biden and Kamala Harris to urge them to turn the issue into a top public priority with commensurate political muscle behind it, and shortly thereafter, Jim Clyburn, a top House Democrat and an important Biden ally, told Politico that the president should back a workaround to the legislative filibuster to ease passage of legislation that would protect and expand access to the polls. Not only do advocates of this focus want the administration zeroed in on legal fixes, they want the battle against Republican efforts to push voting restrictions put at the forefront of Democrats’ public appeals.
Though Biden has hinted repeatedly, including to the civil-rights leaders who visited him, that he’s willing to lean further in and amplify this effort, he has yet to turn it into an administration — or party — defining push, at least while he’s also trying to pass his infrastructure plan. Nonetheless, he’s been putting more of an emphasis on voting rights than some skeptics expected in recent days, including with an impassioned Tuesday speech in Philadelphia about Republican efforts to subvert democracy. It’s not voting-rights-above-all-else, but he’s orienting his political bully pulpit more toward that fight than the one some other Democrats have advocated for: a push for “human infrastructure” like child care and school funding. At the end of a long speech selling his proposal in Illinois last week, Biden closed by conceding it was hardly an effective political cudgel: “I know that’s a boring speech, but it’s an important speech.”
Nonetheless, no one is arguing for a focus on voting rights or social service funding to the exclusion of health care. (Not that this would be possible, anyway, given the ongoing Capitol Hill wrestling about Medicaid and Medicare expansion and broadened pandemic-era access.) In recent weeks, senior Democrats — focused on trying to preserve the party’s narrow majority in both houses of Congress — have been sending around a series of surveys and research documents demonstrating the potency of some sort of health-care argument in upcoming elections, even if its specifics are still being worked out.
One (typical) June survey conducted by the liberal Navigator group — and sent to many Hill and campaign offices — found that voters trust Biden and Democrats over the GOP by a 20-point margin on “improving health care,” according to a copy reviewed by New York. Another polling memo circulated this spring that was reviewed by people close to Nancy Pelosi and Chuck Schumer found that voters were still focused on health-care costs, even as headlines had moved on. “From a list of eight issues the president and Congress might focus on after addressing the coronavirus, ‘lowering the cost of healthcare and prescription drugs and making health insurance more affordable for more people’ stands atop voters’ priorities,” reads the memo, which was prepared by senior Democratic pollster Geoff Garin. Nearly two-thirds of voters still say health-care costs are a top-three priority for them, the memo continues.
The remaining debate, then, is how specifically to talk about coverage now.
The emerging preference atop the party is to focus on the health-care affordability measures in Biden’s initial COVID-19 rescue package and Republicans’ universal opposition to that legislation. They also want to highlight health-related pieces of Biden’s budget proposal, like drug pricing reform and adding vision, dental, and hearing coverage to Medicare, having found in their own polling that the elements of the plan aiming to expand post-pandemic access — which are likely to be considered on a party-line vote — are, again, among the most popular. “One of the things we learned in 2018 and 2020 in particular was 80 or 90 percent of our ads were positive, about what Biden’s vision and agenda was, and part of it was his health-care plan. People wanted to know what he was for, and I don’t think the D.C. insiders and media have made that turn and recognized how important that is,” said John Anzalone, Biden’s pollster.
Drug-pricing reform, in particular, is likely to be central to the messaging. “Our case in ’22 needs to start with why we should be reelected. And what we’ve done to reduce health-care costs, and hopefully what we’re about to do to reduce prescription drug costs, will become top proof points for why the Democratic conference delivered for the people,” said Jesse Ferguson, a top party strategist who worked for the House campaign wing amid the GOP backlash to the ACA’s implementation. “It’s not only the negatives about the damage Republicans would do to health care but actually a proactive argument about what Democrats have done to reduce health-insurance prescription drug costs.”
In recent months, party researchers have been looking for ways to reach independents and Americans who don’t usually side with them after disappointing down-ballot results in 2020. According to party strategists briefed on the findings, some have concluded that focusing on the affordability of medication is an obvious way to make inroads among these voters. “When you’re in a focus group, you’re going to hear a lot about co-pays and deductibles and surprise billing and prescription drugs,” said Anzalone. “It doesn’t go away, and Americans feel like they’re nickeled-and-dimed in the health-care system, and they have a certain level of anxiety of access to insurance, and they also feel that employers have put more and more burden on them.” Among independent voters, Democrats are favored on matters of health care over Republicans by a 30-point margin, according to the widely circulated polling memo.
In recent weeks, Pelosi has renewed a push to reform drug pricing on the Hill, and in 2021’s highest-profile bellwether race, the Democratic candidate has been following this general tack too. Terry McAuliffe, a longtime party insider and the Democratic nominee for governor in Virginia, made the first policy rollout of his general election campaign this summer a push to stand up a new health-care exchange for the state and build a Medicaid “buy-in” for it. The announcement made sure to note that McAuliffe, a former governor and DNC chair, also planned to “partner closely with the Biden administration” to secure federal funding for state reinsurance programs — a sign of the president’s popularity among target voters focused on health care — while announcing his support for drug-pricing transparency measures. He pointed out that his opponent opposed Biden’s COVID-relief bill, “even though it ensured people who lost their jobs would still receive health-care coverage and provided 41,000 Virginians without insurance essential tax credits to assist with the cost of health-care coverage.”
To Anzalone’s eyes, an argument like this is more of a natural progression from Democrats’ previous line than one might think. An important hinge point for the evolution of the party’s health-care case occurred in 2018, he suggested. In race after race that year, Democrats’ most effective arguments on the matter were less about the ACA directly than they were “about the anxiety,” he said.
On this, much of the party’s Sanders-aligned progressive wing — which would mostly prefer to be having a more expansive conversation about fundamentally reforming the health-care system — agrees. This, though, is where party leaders draw the line, usually arguing that progressives’ case for entirely revamping the existing system and replacing it with a universal Medicare scheme is political poison in swing districts like the ones that will determine control of Congress next year.
It’s a familiar fight, but to some lawmakers and strategists on the party’s left, enough time has passed and enough political ground has shifted that voters are willing to hear about bigger-picture reforms. The 2020 midterms, they argue, are fundamentally different from 2018’s in large part because Trump is no longer a threat, but also because the ACA has been saved — not to mention that Democrats now control Washington, giving them an opportunity for real progress.
“One of the mistakes that Democrats have made over time is to make the health-care debate a reductionist debate, and we did this in far too many House races in the last couple cycles, where the whole argument was about preexisting conditions,” said Mark Longabaugh, a Democratic strategist and ad-maker who helped guide Sanders’s 2016 campaign. “There’s no question the public always supports protections for preexisting conditions, and it always tests as high as any argument. The problem is Democrats are missing a huge opportunity to put a bigger frame on health care.”
Progressives have been eager to force this issue in individual races around the country wherever they can, absent a serious legislative fight over Medicare for All on Capitol Hill itself.
Longabaugh has been working with Nina Turner, the longtime Sanders ally who is now narrowly favored to win a highly contested primary for a Cleveland-area House seat in an upcoming special election. On the ground in the district, he said, the campaign’s most resonant ad so far has been one where Turner explains how her mother passed away at 42 without insurance, and how that inspires her fight for a Medicare for All policy. “Wealth should not dictate whether you have access to health care,” she says, closing the spot.
Turner’s campaign has become a sore point for some party leaders, some of whom — like Clyburn — have endorsed her main opponent, even as local institutions like the Cleveland Plain Dealer have backed her. (Those who share Clyburn’s perspective are wary of Turner as a result of to her opposition to Hillary Clinton and then Biden, but they also insist now is no time for an internal party fight over building a new health-care system entirely.)
For years, including when Sanders ran in 2016 and 2020, they liked to argue that his push for Medicare for All ran too close to a rebuke of Obama — and that it distracted from Democrats’ existing attempts to protect health care from GOP assaults.
In 2021, though, “We’ve passed from the period where reforming any sort of health care as it exists was some sort of implicit criticism of Obama and Obama’s system,” Longabaugh said. “That was just a matter of timing.” Still, Turner may have less appetite to force the issue than Democrats like Clyburn fear as they formulate a new health-care push of their own. In endorsing her, the Plain Dealer pointed out she had recently conceded that the debate over Medicare for All may be best had first in the states. In other words, far from Washington, and from its infighting.