President Trump clearly recognizes, at least in the abstract, that providing affordable health care is a political winner. During the 2016 campaign, he embraced his party’s push to repeal the Affordable Care Act (a.k.a. Obamacare) but couched it in sweeping, almost Bernie Sanders-ian language.

On “60 Minutes” in 2015, he declared that he would “take care of everybody . . . much better than they’re taken care of now.” How? He’d make a deal with hospitals, and the government would pay the bill. Up until a few days before his inauguration, his rhetoric was similar: “We’re going to have insurance for everybody.”

“There was a philosophy in some circles that if you can’t pay for it, you don’t get it,” he said in an interview with The Washington Post. “That’s not going to happen with us.”

As president, though, Trump has taken a different tack. After trying for much of 2017 to develop legislation that could replace Obamacare, he and his party settled for eliminating penalties for not carrying health insurance. The coverage mandate was a central component of the legislation, meant to ensure that healthier people were paying into the system, while at the same time protecting people in the event of a sudden emergency. (Trump has since pointed to that change as an indicator that he functionally repealed Obamacare, as promised. That’s not the case.)

No replacement legislation that would meet Trump’s lofty goals ensued. Instead, he and his administration last year tried to further undercut the law by supporting a lawsuit filed by the attorneys general from 20 states aimed at finding Obamacare unconstitutional. That forced the question of Obamacare’s benefits into the national spotlight during the 2018 election — and probably not to Trump’s or Republicans’ benefit.

Why? Well, as soon as Trump took office, public opinion on Obamacare flipped. With the law suddenly at risk, favorable views of the Affordable Care Act ticked upward. Since the 2016 election, negative views of the law have dropped. In fact, according to the Kaiser Family Foundation’s most recent poll, fewer people view Obamacare unfavorably than at any point since the law’s first year on the books.

Three-quarters of Republicans still view the law negatively, but most independents and three-quarters of Democrats view it positively. In November, the figures were similar, though opinions among independents were more mixed and Democratic views slightly more positive.

As the election approached, health care was the most common subject of political ads, especially for those supporting Democratic candidates. Search interest in the subject in September was far higher than it had been in 2017 — despite the legislative fights that year — and was the most-searched political issue in three-quarters of House districts.

On Election Day, the importance of health care was revealed in exit polling. Four in 10 voters said that health care was the most important issue, and Democrats won those voters by a 3-to-1 margin. In other words, a full 30 percent of the electorate said that they considered health care to be the most important issue and then voted for a Democrat in their local House race. In contrast, only 17 percent of the electorate viewed immigration as the most important issue — despite Trump’s late-campaign focus on the subject — and then went on to vote for a Republican.

That lawsuit against the ACA was a key part of Democratic rhetoric. It allowed the party to argue that Republicans wanted to eliminate the mandate that people with preexisting conditions be provided coverage, a politically unpopular position. (And one that would hit red states harder than blue states.)

The lawsuit wasn’t decided before the election, though, as U.S. District Judge Reed O’Connor waited until December to offer his ruling. His decision? The law was unconstitutional. That decision has been stayed pending an appeal.

In January, the Kaiser Family Foundation asked Americans how they felt about the ruling. By a margin of 51 percent to 41 percent, Americans said they disapproved. Then the pollsters asked those who said they approved whether they still approved after hearing that the decision would eliminate protections for those with preexisting conditions. Suddenly a third of those who said they approved of the decision no longer did, with disapproval rising to 64 percent. When told that those under 25 would be dropped from their parents’ insurance were Obamacare to be invalidated, disapproval rose from 51 percent to 60 percent.

The aforementioned appeal of O’Connor’s decision is moving forward. On Monday, the Trump administration weighed in on the appeal: It supports throwing out the law entirely.

It’s hard to overstate what a strange political decision this is for Trump. He’s up for reelection next year and, as he showed in 2016, understands that health-care coverage is an important issue to voters. Yet his Justice Department formally backs throwing out Obamacare — without any replacement legislation ready to go.

After O’Connor’s ruling, Trump praised the decision, saying that with Obamacare apparently gone, he wants “a STRONG law that provides GREAT healthcare and protects pre-existing conditions.” This is precisely the assertion that Trump made during the 2017 effort to overhaul Obamacare. But, at that point, despite controlling both the House and the Senate, Republicans couldn’t come up with a solution that could be passed into law.

A law that provides great coverage and protects those with preexisting conditions would be very popular. The problem is that crafting such a law is far harder than it seems, and Trump has already shown he can’t get it done. And without that in place, he’s risking a scenario in which millions of people lose much-needed coverage, just as the 2020 election heats up.

This isn’t even Trump’s only area of vulnerability on health care. After voters in several states passed ballot initiatives expanding Medicaid coverage under a provision of the ACA, Republican lawmakers have sought to weaken or undercut those measures. Trump’s budget proposal for 2020, released earlier this month, includes substantial proposed cuts to Medicare and Medicaid — funding that in 2016, he also recognized as politically important.

During the 2017 fight to overhaul Obamacare, Trump at times embraced throwing out the law entirely under the assumption that it would force Democrats, eager to maintain the law’s protections, to come back to the table on more-favorable terms. That may be the bet he’s making now, that he can actually get compromise legislation if the law is declared unconstitutional — and that he can avoid blame for its death. Which is another reason that his administration calling for it to die makes little political sense.

Trump once said that “nobody knew health care could be so complicated.” In reality, everyone knew it was, which is why President Barack Obama, in pushing for the ACA, embraced a coverage strategy that had been proposed by right-leaning think tanks. His and the Democrats’ long-standing assumption was that Obamacare would eventually be a political winner, even if it was not popular over the short term.

In 2018, it was. And if you’re curious whether it will be in 2020, we leave you with the thoughts of House Majority Whip James E. Clyburn (D-S.C.) and Sen. Susan Collins (R-Maine), who’s up for reelection next year.


The nature of the change to the individual mandate was clarified.