In the 2014 elections, Republicans rode a wave of anti-Affordable Care Act sentiment to pick up nine Senate seats, the largest gain for either party since 1980. Newly elected Republicans such as Cory Gardner in Colorado and Steve Daines in Montana had hammered their Democratic opponents over the health care law during the campaign and promised to repeal it.
Six years later, those senators are up for reelection. Not only is the law still around, but it's gaining in popularity. What was once a winning strategy has become a political liability.
Public sentiment about the ACA, also known as Obamacare, has shifted considerably during the Trump administration after Republicans tried but failed to repeal it. Now, in the midst of the COVID-19 pandemic and the ensuing economic crisis, which has led to the loss of jobs and health insurance for millions of people, health care again looks poised to be a key issue for voters this election.
With competitive races in Colorado, Montana, Arizona, North Carolina and Iowa pitting Republican incumbents who voted to repeal the ACA against Democratic challengers promising to protect it, attitudes surrounding the health law could help determine control of the Senate. Republicans hold a slim three-vote majority in the Senate but are defending 23 seats in the Nov. 3 election. Only one Democratic Senate seat — in Alabama, where incumbent Doug Jones is up against former Auburn University football coach Tommy Tuberville — is considered in play for Republicans.
"The fall election will significantly revolve around people's belief about what [candidates] will do for their health coverage," said Dr. Daniel Derksen, a professor of public health at the University of Arizona.
The Affordable Care Act has been a wedge issue since it was signed into law in 2010. Because it then took four years to enact, its opponents talked for years about how bad the not-yet-created marketplace for insurance would be, said Joe Hanel, spokesperson for the Colorado Health Institute, a nonpartisan nonprofit focused on health policy analysis. And they continued to attack the law as it took full effect in 2014.
Gardner, for example, ran numerous campaign ads that year criticizing the ACA and, in particular, President Barack Obama's assertion that "if you like your health care plan, you'll be able to keep your health care plan."
But now, Hanel said, the ACA's policies have become much more popular in Colorado as the costs of health exchange plans have dropped. Thus, political messaging has changed, too.
"This time it's the opposite," Hanel said. "The people bringing up the Affordable Care Act are the Democrats."
Despite Gardner's multiple votes to repeal the ACA, he has largely avoided talking about the measure during the 2020 campaign. He even removed his pro-repeal position from his campaign website.
Democratic attack ads in July blasted Gardner for repeatedly dodging questions in an interview with Colorado Public Radio about his stance on a lawsuit challenging the ACA.
His opponent, Democrat John Hickenlooper, fully embraced the law when he was Colorado governor, using the measure to expand Medicaid eligibility to more low-income people and to create a state health insurance exchange. Now, he's campaigning on that record, with promises to expand health care access even further.
Polling conducted by KFF for the past 10 years shows a shift in public opinion has occurred nationwide. (KHN is an editorially independent program of KFF, the Kaiser Family Foundation.)
"Since Trump won the election in 2016, we now have consistently found that a larger share of the public holds favorable views" of the health law, said Ashley Kirzinger, associate director of public opinion and survey research for the foundation. "This really solidified in 2017 after the failed repeal in the Senate."
The foundation's polling found that, in July 2014, 55% of voters opposed the law, while 36% favored it. By July 2020, that had flipped, with 51% favoring the law and 38% opposing it. A shift was seen across all political groups, though 74% of Republicans still viewed it unfavorably in the latest poll.
Public support for individual provisions of the ACA — such as protections for people with preexisting conditions or allowing young adults to stay on their parents' health plans until age 26 — have proved even more popular than the law as a whole. And the provision that consistently polled unfavorably — the mandate that those without insurance must pay a fine — was eliminated in 2017.
"We're 10 years along and the sky hasn't caved in," said Sabrina Corlette, a health policy professor at Georgetown University.
Following the passage of the ACA, Democrats didn't reference the law in their campaigns, said Erika Franklin Fowler, a government professor at Wesleyan University and the director of the Wesleyan Media Project, which tracks political advertising.
"They ran on any other issue they could find," Fowler said.
Republicans, she said, kept promising to "repeal and replace" but weren't able to do so.
Then, in the 2018 election, Democrats seized on the shift in public opinion, touting the effects of the law and criticizing Republicans for their attempts to overturn it.
"In the decade I have been tracking political advertising, there wasn't a single-issue topic that was as prominent as health care was in 2018," she said.
As the global health crisis rages, health care concerns again dominate political ads in the 2020 races, Fowler said, although most ads haven't explicitly focused on the ACA. Many highlight Republicans' support for the lawsuit challenging preexisting condition protections or specific provisions of the ACA that their votes would have overturned. Republicans say they, too, will protect people with preexisting conditions but otherwise have largely avoided talking about the ACA.
"Cory Gardner has been running a lot on his environmental bills and conservation funding," Fowler said. "It's not difficult to figure out why he's doing that. It's easier for him to tout that in a state like Colorado than it is to talk about health care."
Similar dynamics are playing out in other key Senate races. In Arizona, Republican Sen. Martha McSally was one of the more vocal advocates of repealing the ACA while she served in the House of Representatives. She publicly acknowledged those votes may have hurt her 2018 Senate bid.
"I did vote to repeal and replace Obamacare," McSally said on conservative pundit Sean Hannity's radio show during the 2018 campaign. "I'm getting my ass kicked for it right now."
She indeed lost but was appointed to fill the seat of Sen. Jon Kyl after he resigned at the end of 2018. Now McSally is in a tight race with Democratic challenger Mark Kelly, an astronaut and the husband of former Rep. Gabby Giffords.
"Kelly doesn't have a track record of voting one way or another, but certainly in his campaign this is one of his top speaking points: what he would do to expand coverage and reassure people that coverage won't be taken away," said Derksen, the University of Arizona professor.
The ACA has proved a stumbling block for Republican Sens. Thom Tillis of North Carolina and Joni Ernst of Iowa. In Maine, GOP Sen. Susan Collins cast a key vote that prevented the repeal of the law but cast other votes that weakened it. She now also appears vulnerable — but more for her vote to confirm Brett Kavanaugh's nomination to the Supreme Court and for not doing more to oppose President Donald Trump.
In Montana, Daines, who voted to repeal the ACA, is trying to hold on to his seat against Democratic Gov. Steve Bullock, who used the law to expand the state's Medicaid enrollment in 2015. At its peak, nearly 1 in 10 Montanans were covered through the expansion.
As more Montanans now face the high cost of paying for health care on their own amid pandemic-related job losses, Montana State University political science professor David Parker said he expects Democrats to talk about Daines' votes to repeal cost-saving provisions of the ACA.
"People are losing jobs, and their jobs bring health care with them," Parker said. "I don't think it's a good space for Daines to be right now."