While President Trump is seemingly the foremost issue in every election at every level in every state this year, in at least one battleground state, something else — the Affordable Care Act’s expansion of Medicaid — has become a key motivating factor in getting people registered and motivated to turn out.

The campaign there provides us a window into something important Democrats would do well to remember if they’re fortunate enough to take control in Washington in January. This election can be seen as the culmination of a decade-long debate over health care in the United States — one that Democrats have clearly won.

The New York Times reports on what’s happening in North Carolina:

Democrats believe they have a chance of gaining control of the State Legislature for the first time in a decade, which would make it possible to expand Medicaid to cover half-a-million more low-income adults here after years of Republican resistance.
The health care issue is paramount up and down the ticket in North Carolina, with left-leaning national and in-state groups using it to motivate Democratic voters — especially those who stayed home in 2016. Many of them belong to the demographic who would become eligible for Medicaid, the free government health insurance program, if the legislature voted to expand it as the Affordable Care Act allows.

Along with 11 other states that have been dominated by Republicans, North Carolina refused to accept the Medicaid expansion despite the fact that the federal government picks up 90 percent of the cost and copious research has shown that accepting the expansion not only saves states money but also boosts their economies. But in deep red America, Republican officials would prefer to shoot themselves in the foot if it means they can prevent their own poor constituents from getting health coverage.

A good number of voters in North Carolina seem to have simply had enough, as they have in other places; ballot initiatives to accept the Medicaid expansion passed this year in Missouri and Oklahoma. Given how close things are in North Carolina, this issue has the potential to win Democrats not only the state legislature but also a Senate seat and the state’s electoral votes for Joe Biden.

Now let’s step back and review a bit of history:

  • 2010: After a political debate that lasts nearly a year, Democrats pass the ACA without a single Republican vote in either house of Congress. Republicans immediately predict it will be a disaster and pledge to repeal it.
  • 2011-2017: Republicans hold votes to repeal the ACA on at least 70 separate occasions, and file multiple lawsuits trying to get the Supreme Court to declare the law unconstitutional on increasingly ridiculous grounds.
  • 2016: Republicans win the White House and hold their majorities in the House and Senate. They now have the chance to follow through on the promise they’ve been making for years, but they realize they forgot to come up with the “replace” part of “repeal and replace.” They toss a slapdash replacement plan together without any hearings and barely any debate, as they are greeted with angry protests from people not wanting their health care taken away. The bill fails in the Senate when John McCain of Arizona gives it a dramatic thumbs-down.
  • 2018: Running in significant part against the Republican effort to destroy the ACA, Democrats win a sweeping victory in the midterm elections.
  • 2016-2020: Republicans begin claiming that they are the true guardians of the ACA’s protections for people with preexisting conditions, despite the fact that they’ve spent years trying to take those protections away.
  • 2020: When Democrats charge that Justice Amy Coney Barrett will rule in favor of the lawsuit — supported by 20 Republican states and the Trump administration — to declare the entire ACA unconstitutional, Republicans in Congress act appalled that anyone would even suggest that she might do so. “That’s outrageous,” says Iowa Sen. Charles E. Grassley at her confirmation hearing. “As a mother of seven, Judge Barrett clearly understands the importance of health care.”
  • 2020: Running once again on protecting the ACA, the Democrats (may just) win another sweeping victory.

This is the past decade of health-care politics: Republicans trying to take away people’s coverage and protections, but failing because public opinion would not allow it, while Democrats attempt to protect the ACA against those attacks and debate among themselves about how to fix the ongoing problems of the system.

Now imagine that Biden becomes president and Democrats do indeed win control of the Senate. What should they do at that point?

The simple answer is that Democrats need to figure out exactly what they want to do, and pass it.

And as it turns out, they pretty much know already, because they had a big debate about this subject during the presidential primaries. Biden’s plan won’t satisfy everyone, but it’s essentially the minimum consensus position among Democrats. Among other things, it creates a public option open to anyone who wants it, boosts ACA subsidies and allows Medicare to negotiate drug prices. If I had my way it would go a lot further, but it’s something pretty much all Democrats should be able to get behind.

Just as important, Democrats have to begin that process with the understanding that absolutely nothing Republicans say about health care needs to be treated with even an iota of seriousness. They’re going to lie about what they believe, what they want, and what the Democratic legislation will and won’t do, because that’s how they operate. There’s no point in negotiating with them, because every last one of them will ultimately vote against just about any legislation on the subject that Democrats offer.

It’s still going to be difficult, because the special interests that oppose health-care reform — insurance companies, drug companies, hospital chains — will fight it tooth and nail, probably investing hundreds of millions or even billions of dollars in a campaign to kill it.

But Democrats should never forget that we’ve been debating this for 10 years, and they won the debate. Now they need to act like it.

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