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Real change begins with immediately repealing and replacing the disaster known as Obamacare,” Donald Trump said during one of his final campaign rallies of the 2016 race. “We’re going to repeal it. We’re going to have a really great plan that’s going to cost much less and be much better.” While Trump has kept few of his campaign promises, this one is coming half-true—if not necessarily the way Republicans had planned. Congress failed to repeal the Affordable Care Act, but Trump has attacked the law in subtler, nonetheless devastating ways. For many Americans, Obamacare has effectively ceased to exist. “Across the country, the details vary but the story is the same. The Trump administration has been rolling back sections of the Obama-era health law piece by piece,” The Wall Street Journal reported on Wednesday. “The result is that the country is increasingly returning to a pre-ACA landscape, where the coverage you get, especially for people without employer-provided insurance, is largely determined by where you live.” As for a “really great plan that’s going to cost much less,” Trump has been less successful. Last month, he rolled out a rule allowing small businesses to band together to provide cheaper health care to employees—without all of Obamacare’s coverage protections. But on Thursday, Politico reported that the National Federation of Independent Business, a business group that has advocated for so-called association health plans for two decades, won’t be creating such a plan because Trump’s rule is unworkable. Other trade groups are reportedly tepid, too. In short, the health care system in America, after modest improvements under Obama, is becoming a chaotic mess under Trump—and his political opponents are poised to capitalize on it. On Thursday morning, 70 Democrats in the House of Representatives launched a Medicare for All caucus. The roll includes a few expected names—Representative Keith Ellison of Minnesota—but also more recent converts to the cause, proving the policy no longer belongs to the fringe. In 2017, 122 House Democrats co-sponsored Representative John Conyers’s Medicare for All bill before he resigned amid a sexual harassment scandal. As Trump’s attacks on the ACA increase, so has Democratic support for a sweeping alternative. Since Trump took office in 2017, the administration has repealed the Affordable Care Act’s individual mandate and expanded access to short-term, limited-duration health plans, which can’t be renewed and offer limited coverage to beneficiaries. Without the individual mandate, SLDI plans can look like sensible, affordable options for consumers—and that means fewer Americans will have health insurance that covers their basic needs. It also influences premiums. As Axios reported in May, ACA premiums have increased by 34 percent since 2017, and the Congressional Budget Office estimates that they’ll increase by another 15 percent next year. Meanwhile, the administration cut spending for ACA outreach. If people don’t know how to enroll in the ACA, they’re less likely to do so at all. For Republicans concerned about their electoral prospects, Obamacare is no longer such a reliable foe. In 2017, roughly 350,000 Virginians faced the prospect of losing their ACA plans when Optima Health followed the examples of Aetna and Anthem and threatened to pull out of the exchange market. The move would have left nearly half of all Virginia counties without an ACA insurer, with the losses concentrated in Virginia’s western counties—among the poorest in the state. At the time, insurance companies cited market instability for their decisions, and they blamed the Trump administration for causing it. Trump has repeatedly threatened to cut subsidies for the ACA, and insurers worried that would put their profit margins at risk. Anthem eventually agreed to cover Virginia’s so-called bare counties. But the crisis may have pushed state Republicans away from Trump, at least on the issue of health care. The General Assembly passed Medicaid expansion in 2018. “When you lost all the coal jobs, a lot of people lost their healthcare,” Republican State Representative Terry Kilgore told Belt magazine last month. “People were working but were going to jobs paying $8 to $15 per hour with no healthcare benefits. We need more healthcare options and a healthier workforce.” Kilgore voted for Medicaid expansion. Medicare for All’s popularity with Democrats can be traced back to Senator Bernie Sanders’s bid for the Democratic nomination in 2016, which brought national attention to the policy. Its appeal has only grown since then, as Democrats have seen how easily a Republican president can weaken the signature achievement of the Obama presidency. Single-payer health care, whether it’s Medicare for All or some other approach, hasn’t proven to be the campaign-killer that some moderates have warned of. Insurgent candidates like Alexandria Ocasio-Cortez and Ben Jealous have embraced the policy, and so have some Democrats running in red states. This opening for Democrats may crack even wider as the material consequences of gutting the ACA become clear. As the Journal reported in March, “Health-insurance premiums are likely to jump right before the November elections, a result of Congress’s omission of federal money to shore up insurance exchanges from its new spending package.” Fearful of the political damage, Republicans are now scrambling to fix the problem. On Thursday, The Hill reported that the GOP House “is planning to vote next week on several GOP-backed health-care measures that supporters say will lower premiums.” Whether or not Republicans succeed there, they have handed Democrats an opening ahead of the midterms, one that may crack even wider as the material consequences of gutting the ACA become clear. That awakening is already underway, if polling is any indication. Health care topped all issues, even the economy and immigration, in a YouGov/Huffington Post survey in April of registered voters’ priorities ahead of the midterm elections; it consistently ranks in the top three. That’s perhaps less surprising in light of a Navigator Research poll this week that found half of Americans say health care is main cost concern. In an ominous sign for the GOP, independent voters said they trusted Democrats more than Republicans, by an 18-point margin, to bring those costs down.

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