August 23, 2019 Atlanta - U.S. Representative Lucy McBath speaks as Vivienne Sacks (right), 5, holds a sign during “Protect Our Care Georgia Health Care Emergency” Press Conference at the Georgia State Capitol on Friday, August 23, 2019. Protect Our Care “Health Care Emergency” Bus Tour Continues With Stops in Maine, New Hampshire, North Carolina and Georgia. (Hyosub Shin / Hyosub.Shin@ajc.com)

Health care — still potent, but more complicated in 2020 election

On a recent sweltering August morning, Congresswoman Lucy McBath headlined a rally extolling the Affordable Care Act’s protections for patients. But the freshman Democrat, who represents a fast-changing swath of Atlanta’s northern suburbs, did not mention the 9-year-old law’s name from the podium even once.

“Families should not have to choose between paying for medicine and paying for a mortgage,” she told supporters gathered at the Georgia Capitol. 

It’s not a stretch to see why Democrats are homing in on health care in the lead-up to next year’s elections. The party used the issue as a cudgel in the 2018 midterms — and it worked.

But Republicans say this time things will be different. And the fine line McBath walked shows they may be onto something.

With the 2018 elections in the rear-view mirror, Democrats like McBath who leaned on protecting the ACA, also known as Obamacare, now know they found a winning pitch. Republicans know it too. The issue helped Democrats win a majority in the U.S. House and come closer than ever to winning back the governor’s office. And recent polls show health care remains a top issue for voters in general.

But 2020 isn’t 2018. For Democrats, it’s no longer as simple as saying they oppose repeal of the ACA. Now they have to be specific on what they support. That is creating rifts.

For Republicans, previous unsuccessful efforts to repeal the health care law have time to fade in the background. In the meantime, the Trump administration is trying, with mixed success, to take aim at high-profile consumer concerns such as high medical prices and surprise billing, where patients wind up with unexpected charges from gaps in their insurance. Candidates are taking his lead.

On the state level, Gov. Brian Kemp has made health care a central issue of his office, with Lt. Gov. Geoff Duncan, also a Republican, latching on to those efforts.

And just to spice things up, there is a wild card in the deck. By the time Georgia voters make their call in 2020, a lawsuit filed by GOP attorneys general — including Georgia’s — might overturn the entire health care law, including its now popular provisions protecting coverage for pre-existing conditions and other benefits.

At different points over the last several years, both parties have been able to successfully argue that the opposing side would take coverage away from people, and that’s what’s at stake if the court overturns the ACA, said Amy Steigerwalt, a political science professor at Georgia State University.

“Framing matters,” Steigerwalt said. “It’s going to have a really big impact …We’ll just have to see.”

‘Doable’ ideas

State and national polls consistently show health care remains top of mind among voters, with many worried about skyrocketing costs, dwindling rural health care services and the 15% of Georgia residents who remain uninsured.

Local voters say candidates better take note.

“Health care is unaffordable for somebody like myself being self-employed,” said Marietta consultant David Hilburn, 55. “It will affect how I vote in 2020.”

Yet they are divided on what exactly what should be done.

Cumming lawyer Andy Lipscomb would like to see a single-payer health care system, but he considers himself a “pragmatist” as he mulls the platforms of Democratic candidates for president.

“Given the threats the ACA was under more than two years ago with the votes to abolish it and the court challenges now, I think that we need to do what we can to strengthen” Obamacare, he said.

Beth Elam of Snellville worked in the health care field until she broke her back. A Republican-leaning independent, she thinks “Medicare for All” is “one of the worst things we could do in this country.” But she also likes how Obamacare has options for people who don’t receive insurance through work.

“I don’t have a problem with completely overhauling it, but I do think you need to have something out there for the people that weren’t covered and are now covered under Obamacare to have something that they can purchase. But not where you get fined if you choose not to have coverage for yourself,” she said.

The issue that resonates with a broad swath of voters is the rising cost of health care, “Even with polarized and tribal partisan affiliations,” said Audrey Haynes, a political science professor at the University of Georgia.

“Politicians from both sides need to be careful that they are aware of this” as they campaign, Haynes said. “Solutions to current problems and particularly ideas that seem ‘doable’ are likely to meet with more positive responses.”

Pre-existing conditions

Like last year, Democrats are lauding Obamacare’s protections for pre-existing conditions and other patient rights. But they’re divided on how to improve the system in a way they weren’t in 2018. Their party’s presidential candidates are debating the merits of improving the ACA or moving to a single-payer system like “Medicare for All,” and the discord is seeping to other races down the ballot.

The GOP is eager to exploit the wedge.

They’re also taking action.

In the Georgia Capitol, GOP leaders pushed through more than 20 health care bills this spring. Kemp made a point of signing them in stacks before news cameras. Some were minor adjustments but some were big news. Most important was the law allowing Kemp to pursue “waivers” from the federal government to craft new Georgia programs with Medicaid and the ACA exchange. He ruled out expanding Medicaid to all Georgia’s poor under the ACA, but might use the waivers to effect a more limited expansion of health coverage.

“I campaigned on this issue. I made promises to people,” Kemp told the AJC in April. “And we have fulfilled our promises. I don’t really care about all the politics of Washington, D.C. We have moved the needle on health care in Georgia — but we are not done.”

Republicans are also highlighting their attempts in Washington to lower drug prices and end surprise billing, with little success so far. At the same time they are downplaying past efforts to replace Obamacare — even as President Donald Trump has said he’s again directed his administration to find an alternative.

And they’ve learned their lesson on Obamacare’s patient protections.

U.S. Rep. Buddy Carter, a Pooler Republican and a former pharmacist, recently took a leadership position with the House GOP’s campaign group, the National Republican Congressional Committee. In an interview with the AJC Carter underscored the party’s commitment to covering patients with pre-existing conditions and allowing young people under 26 to stay on their parents’ health care plans, both signature provisions of the Affordable Care Act.

“I adamantly believe that the only way we’re ever going to lower health care costs and improve health care services in this country is through competition,” he said.

State Sen. Brandon Beach, one of four Republicans competing to take on McBath in 2020, says Congress still needs to scrap Obamacare and start from scratch on “more affordable and accessible” plans, but that the last repeal fight taught him the importance of fighting for coverage for pre-existing conditions.

“That would be non-negotiable. We’re going to take care of pre-existing conditions and then negotiate on everything else,” he said.

In the Gwinnett and Forsyth-based 7th Congressional District, state Sen. Renee Unterman has made health care the centerpiece of her campaign but has approached the issue differently than many of her GOP peers who only want wholesale ACA repeal.

The former nurse said she wants to see major changes to Obamacare but that full repeal is difficult because it’s “too far down the railroad tracks.”

“There are specific things that I think the president is doing a good job of chipping away at, like transparency, drug costs, the opioid epidemic,” she said. “He’s really making a dent in some of the things that need to be done.”

Ruling pending

Democrats say Republicans still don’t have a plan for replacing the protections put in place by Obamacare.

An event in Atlanta highlighted that argument, the final stop in a national bus tour called “Save Our Care.” The tour was meant to draw attention to a Republican-led lawsuit making unexpected progress in the courts that could up-end the ACA. But the event’s key speaker, McBath, did not name the ACA in her speech. (Her aide pointed to her press release from the event, which mentioned the law once.)

McBath’s spot may represent all pitfalls of the current politics: Liberal passion and centrist concern over health care helped her swing a suburban congressional district from red to blue. But for 2020 she can’t risk alienating either those passionate liberals, who now may want to hear about “Medicare for All,” or the centrists who fear it.

The lawsuit may be one thing that unites them.

Filed by more than a dozen Republican attorneys general, including Georgia’s Chris Carr, the lawsuit argues, again, that the ACA is unconstitutional. Legal scholars didn’t give it much of a chance, but a Texas district judge ruled to strike down the ACA and the appellate judges who just heard it sounded sympathetic.

What it would do to the race if the U.S. Supreme Court rules for Texas, Georgia and the other plaintiffs is anyone’s guess.

Carr, who was a longtime political staffer and joined Georgia to the suit, said in this job he could not and would not consider politics.

“I want to make sure the people of Georgia and our nation have the best possible health care possible, and as attorney general (I’ve) got to make sure that it’s done in a constitutional way,” he said.

Jeremiah Olney, a Democratic strategist with Paramount Consulting in Atlanta, is eager to talk about the politics.

“If this lawsuit makes anything clear it’s that Republicans are perfectly comfortable with pulling the rug out from underneath people,” Olney said. “If that were not their intention they would have a plan in place. They’ve been pushing lawsuits like these for years. They don’t know what they want to do next.”

Carter said that in spite of the concerns, it’s still good for the ACA to be stripped away.

“We should never stop working for better outcomes, better health care, better choice, better protection for preexisting conditions not only in Georgia but of our nation,” he said.

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