Democrats are hoping to ride a suburban backlash against President Trump to victory in 2020, as they did in 2018. But this suburban strategy could be seriously undermined by the positions their presidential candidates have taken on healthcare during the Democratic primaries.
Trump’s brand of populism has disrupted the political map, bringing more blue collar areas into the Republican fold while making white collar suburbs, where female voters in particular have been turned off by the president’s brash style, more fertile ground for Democrats. Even as Democrats have many factors working in their favor in these neighborhoods going into 2020, there’s another factor cutting strongly against them. Put simply, Democratic healthcare proposals that would disrupt or eliminate private insurance are like heat-seeking missiles targeting voters in these relatively well–off suburban communities, where residents overwhelmingly have solid (and private) healthcare coverage.
“The Democrats seem to be working very hard at pushing the suburbs and swing voters back into the Republican column and this is I think one of the two or three biggest issues if not the single largest issue,” Republican political strategist Karl Rove told me.
A Washington Examiner analysis of Census health coverage data from a selection of suburban areas considered important to the outcome of the 2020 elections found that not only do these communities have lower uninsured rates than exist nationally, but a disproportionate number of those who are insured have private coverage.
Sens. Bernie Sanders and Elizabeth Warren are running on healthcare proposals that would eliminate all current private healthcare plans within four years in favor of a new government plan branded “Medicare for all.” Though other candidates, such as Joe Biden and Pete Buttigieg, have advocated making a new government-run plan a choice, even a “public option” approach would be significantly disruptive to private insurance — just over a longer time frame.
Nationally, 10.5% of what the Census describes as the civilian noninstitutionalized population are uninsured (this is the total U.S. population but for those living in institutions such as prisons). Of those with insurance, 67.2% — or about two-thirds — have private insurance.
Yet in eight politically significant counties in Michigan, Wisconsin, and Pennsylvania with a high concentration of suburbs, the uninsured rate was half the national number — or 5.2%. And 81.3% of those with insurance had private coverage.
Typically, political campaigns want to run on policies that will benefit a wide number of people, while leaving most others no worse off. But in these crucial suburbs, Democrats will be advocating drastic solutions to help a small percentage of residents while severely disrupting the lives of the vast majority of the population. If Warren were the nominee, Republicans could run fact-check proof ads in every one of these areas saying she wants to eliminate their private coverage within her first term, and it would be true for most people who live there.
As part of this analysis I looked at counties in Pennsylvania (Bucks, Chester, and Delaware) that border Philadelphia; the so-called WOW counties of Wisconsin surrounding Milwaukee (Waukesha, Ozaukee, and Washington); and Oakland and Macomb counties in Michigan, which include suburban Detroit. Four of the Congressional seats that Democrats flipped in 2018 came from one of these counties, and they all figure to play a key role in next year’s election. Were Democrats to build on their 2018 performance in these areas and flip Pennsylvania, Michigan, and Wisconsin, they would win the White House. But a Democratic failure in these areas would likely mean a second term for President Trump.
It should be said that county-level data is a bit of a blunt instrument in measuring health coverage in suburban areas, as large counties can contain elements of rural or urban areas. In Ohio in particular, Mike Dawson, who runs the data-heavy Ohio Election Results site, suggested that it made more sense to look at individual suburbs in the state. Focusing on seven key suburban communities surrounding Cleveland, Cincinnati, and Columbus, I found that the numbers were even more pronounced. These communities had an uninsured rate of just 3.4% on average, with 85.9% of those with insurance having private coverage.
One of these places is Westerville, an affluent suburb that had been traditionally Republican, but shifted to Democrats during the Trump era. In an indication of how Democrats are eyeing the Columbus suburb, it was the site of the October Democratic presidential debate. In Westerville, 95.6% of the population is covered, and of those people, 84% have private insurance.
Oakland University political science professor David Dulio has pointed to Macomb and Oakland as two of the crucial counties in Michigan in 2020. Macomb has a higher concentration of blue collar suburbs. Many union workers have been wary of plans to eliminate private coverage, because they spent decades negotiating for better benefits, often at the expense of smaller salary increases. Oakland, in contrast, is more upscale and white collar and has near universal coverage already — most of it private. In one particularly wealthy suburb, Bloomfield Hills, just 1.5% of the population is uninsured, and nearly 88% of those with insurance have private coverage. In these areas, Dulio said, people are likely to think, “Hey look, maybe we don’t want to have our really good health coverage taken away.”
This isn’t to say that this one issue will suddenly erase all of Trump’s problems with suburban voters. And with Trump at the top of the ticket, any well-tailored Republican messaging campaign can always be derailed by a bombastic tweet. That said, Democratic attacks on private insurance could, at the minimum, limit any gains in these areas that are crucial to their 2020 strategy.
Rove said that extreme Democratic healthcare positions would hurt the party in Senate races in Texas, Arizona, and North Carolina, prove “deadly” in Iowa, and “problematic” in the 31 districts that Trump carried in 2016, but that voted for a Democratic candidate in 2018 House elections.
He said that Republicans he’s spoken to are “excited about running against somebody who is for ‘Medicare for all’” but acknowledged, “they’re worried about the public option.” Given that the public option’s effect on private insurance would be more gradual and indirect, it would require more messaging on by Republicans to spell out how introducing a new government-run plan would erode private coverage over time.
Republicans would have to get more comfortable making the case against an optional government plan, Rove said. “Medicare for all who want it” — in Buttigieg’s formulation — would bring with it much of the baggage of “Medicare for all,” but carry additional problems. Rove said Republicans could argue against allowing 35 year-olds who have barely been in the workforce to enjoy the same benefits as retirees who paid Medicare taxes for decades.
Even though Americans may complain about aspects of the U.S. system (such as costs), polls show they are also generally satisfied with their own care and suspicious of radical changes. In recent history, both parties have miscalculated by conflating opposition to major changes among the electorate with the electorate agreeing with their ideological positions.
For instance, Republicans successfully ran against Obamacare in 2010, 2014, and 2016 — as the healthcare law made major changes to the system that resulted in millions of Americans losing coverage that they liked or seeing higher premiums. But when it came time to actually “repeal and replace” the law in 2017, Republicans faced massive blowback, because by that time, Obamacare had become the new status quo.
Based on the positions they have taken during the primaries, Democrats seem to have taken the lesson from the increased popularity of Obamacare that Americans have warmed up to the idea of government healthcare. In reality, Democrats won back the House in 2018 — not by having candidates embrace “Medicare for all” — but by hammering home the message that Republicans would disrupt the new status quo by bringing back pre-existing conditions. By embracing sweeping proposals that would do much more to disrupt the status quo than Obamacare did, Democrats are taking a major risk.
Though there isn’t detailed enough public polling on the effects that various healthcare proposals will have on the suburbs, what polling we do have has shown that swing-state voters are even more wary of “Medicare for all” style plans than the general public. Last month, a survey from Kaiser Family Foundation and Cook Political report found that 62 percent of voters in the swing states of Michigan, Wisconsin, Minnesota, and Pennsylvania described single-payer healthcare as a “bad idea.”
According to Rove, Republicans will have to accomplish three things on the healthcare issue in next year’s elections. One would be to make the policy argument against Democratic healthcare plans (noting the costs and effects on private coverage); next would to make a values argument against turning over so much control over personal decisions to the government; and also, they’d need to be able to present their own alternatives to address the healthcare issue.
He said the alternative doesn’t have to be a comprehensive bill, but a series of incremental steps — such as allowing small businesses to pool together risk to get the same discounts as larger employers, increasing the amount of medical expenses that can be tax free, and increasing hospital price transparency.
“We can’t simply say, ‘Socialist. Socialist. Socialist. Socialist,’” Rove insisted. “We have to be explicit in the defects and we have to help people understand why it’s wrong from our values perspective and finally — and this is the most difficult part — we at least got to give them a sense that we know the system has to be improved.”