Krugman: Democrats are credible on health care

Ted Cruz, the unexpectedly endangered Republican senator from Texas, recently warned that Beto O'Rourke, his Democratic opponent, would turn the state into California, with “tofu and silicone and dyed hair.” Does Cruz really think every blonde in Texas - and every middle-age man with remarkably little gray - is natural, and nobody has had work done?

Meanwhile, Sen. Joe Manchin, D-West Virginia - which went for Donald Trump by 40 points - seems to have the edge in his re-election campaign. His secret weapon? Defense of the Affordable Care Act, which drastically reduced the number of uninsured residents in his state.

These two races epitomize how the 2018 campaign is playing out. On one side, Republicans are running almost entirely on identity politics - white identity politics - rather than policy. True, they're running a lot of ads about immigration, but not about immigration's actual effects. Instead, they're all about a mythical wave of crimes committed by scary dark people.

On the other side, Democrats are running on policy issues, above all health care, promising to protect people with pre-existing conditions while also protecting and perhaps expanding Medicare.

But politicians make lots of promises, which are often empty. For example, Republicans promised that the Trump tax cut would lead to soaring wages, which hasn't happened. So are Democrats really credible on health care?

Almost five years after Obamacare went into full effect, the answer is a very clear yes. It hasn't worked perfectly, and its successes haven't come in quite the form its proponents expected. But it has delivered huge progress, especially in states run by politicians who are trying to make it work.

It's worth remembering what Republicans said would happen before the Affordable Care Act went online: that it would fail to reduce the number of uninsured, that it would blow a giant hole in the budget, that it would lead to a “death spiral” of rising premiums and declining enrollment.

What actually happened was a dramatic fall in the uninsured, especially in those states that expanded Medicaid. The budget costs of expanding Medicaid and subsidizing other insurance have been significant, but estimates for 2019 suggest that these costs will be around $115 billion - much less than half the revenue lost due to the Trump tax cut.

What about that death spiral? Premiums on the health exchanges established by the Affordable Care Act initially came in much lower than expected, then rose sharply when the people signing up for those exchanges turned out to be fewer and sicker than insurers had hoped. But the markets have now stabilized, with only modest premium increases for 2019 and insurers returning to the exchanges.

And while the exchanges are covering fewer people than projected, Medicaid is covering more than expected, so that overall gains in coverage have been surprisingly on target. In early 2014, the Congressional Budget Office projected that, under Obamacare, by 2018 there would be 29 million uninsured U.S. residents. The actual number is … 29 million.

What's particularly impressive about Obamacare's stabilization is that it's happening despite desperate attempts by Trump and his allies to sabotage his predecessor's achievement. Republicans have repealed the mandate that was supposed to induce people to sign up for coverage while still healthy, and the Trump administration has done all it can to increase risks and drive insurers out. Yet Democrats built their system so well that it's still standing despite everything thrown at it.

Of course, Obamacare would be doing even better if it were run by people who weren't trying to kill it. Look at what's happening in New Jersey, where a Democratic governor and Legislature have used their powers to undo most of the Trumpian sabotage: 2019 premiums will actually drop 9.3 percent, even as they rise modestly in the nation as a whole.

And on the other hand, if Republicans hold Congress this November, they will simply kill Obamacare outright, taking coverage away from millions. If you have a pre-existing medical condition, or a job that doesn't come with good insurance, be very, very afraid.

Now, Obamacare is hardly a perfect system. It was always an awkward compromise reflecting the political constraints of the time, and many Democrats - including Barack Obama himself - are now suggesting moving beyond it to “Medicare for all,” although it's not clear exactly what that would mean.

But the Affordable Care Act really did achieve a lot. And this achievement bears strongly on the current political debate. Basically, Democrats have earned a lot of credibility on health care: They delivered what they promised, and they have showed that they can build systems that work.

Republicans, on the other hand, aren't just lying about their health plans - pretending, for example, to protect people with pre-existing conditions when they aren't. They've also been utterly wrong about everything, and have learned nothing from their mistakes.

So are Democrats justified in running as the defenders of American health care? Yes.

Paul Krugman is a columnist for the New York Times.

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