Hitting Congress Where It Hurts: Preserving The Affordable Care Act Through Targeted Advocacy

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Without our intervention, living in Trump's America with HIV will mean a return to the routine discrimination of the past and a Medicaid program that demands that people get sick first before they can get better. Therefore, starting on January 20th and going forward for at least the next four years, the words "bipartisan" and "compromise" need to be purged from your political vocabulary and your consciousness.

To be clear, I don't mean purged in a metaphoric or hyperbolic sense. I mean quite literally purged -- carefully excised from the folds of your brain's grey matter and banished from consciousness until 2021 or such a date when our nation is no longer helmed by a egocentric autocrat with a pathological aversion to honesty and selflessness. There is no reasoning with unreasonable men, nor is there any sense in bargaining with the deceitful and duplicitous. Donald Trump and a sizable portion of congressional Republicans have proven themselves unworthy of our trust and, if we want to preserve things such as access to health care for people living with HIV and all other Americans with pre-existing conditions, we must be unyielding in our opposition, unwavering in our demands and unified in a common strategy.

Up until now, the primary line of attack aimed at politicians who seek to dismantle the Affordable Care Act (ACA) has been based on the premise that opponents of the law care about the health and wellbeing of their constituents. Democratic representatives and progressive advocacy groups, rightly convinced that they are occupying the ethical high ground, have unleashed a barrage of attacks against their Republican opponents for championing the repeal of the ACA with no viable replacement plan waiting in the wings. They cite the estimated 30 million Americans who stand to lose their health insurance and document the tens of thousands of people who would die due to the ACA's repeal, yet the GOP's plans for repeal continue to go ahead as planned because these arguments hold little sway over those who control the fate of our nation's health care system.

Outlining the benefits of the ACA is certainly useful in drumming up support for preserving President Obama's signature health care law, but it is not a strategy unto itself. The fact of the matter is that public opinion is overwhelmingly in favor of keeping most of the provisions of the ACA, with more than 80% of Americans supporting the maintenance of ACA pillars such as allowing children to stay on their parents' insurance until age 26, providing financial aid to working class families so they can purchase insurance and expanding Medicaid. All of these aspects of the ACA impact people living with HIV, but none more so than Medicaid expansion. Medicaid is the single largest source of insurance coverage for people living with HIV and is estimated to cover over 40% of Americans with HIV who are in care. If the Trump administration and Republican leadership in Congress are able to get what they want and fund Medicaid through block grants or a per capita spending limit, millions of people and thousands upon thousands of people living with HIV could lose their health insurance.

Making Americans of every political stripe aware that Trump and Republicans in Congress are going to take away all of these beloved programs is vital, but by itself it will not protect our access to care. To have any shot at maintaining affordable health care for people living with HIV and all Americans with pre-existing conditions, we're going to have to launch an offensive on the one thing these congressional ACA opponents truly care about: their job security.

The Mitch McConnell's and Paul Ryan's of this world care little about whether their health care policies inflict suffering and death on their constituents, but they are very concerned with the health of their own careers, and any successful campaign to stop the repeal of the ACA in whole or part must be based on this fact. If we can effectively harness all of the fear and anger that much of the country is feeling over the GOP's dismantling of the ACA and direct it squarely at the members of Congress who are most vulnerable to pressure, we might be able to protect our basic right to health care.

Of course, the first order of business is identifying the pressure points within both the Republican and Democratic parties that are going to have to be hit repeatedly if the ACA is going to survive. Below, I have divvied up all of the senators who, for one reason or another, look particularly vulnerable to outside pressure, and they fall into four categories:

  1. The Moderate GOP: Although the era of the Rockefeller Republicans has been dead and gone for a while now, a small handful of Senate Republicans could still qualify as moderates insofar as health care is concerned. In the 115th Congress, we have three such senators: Lisa Murkowski (R-AK), Susan Collins (R-ME) and [Dean Heller]((R-NV) https://www.heller.senate.gov/public/index.cfm/contact-form). All three senators are worth expending considerable energy on, but Sen. Heller might be the most crucial target as he is up for re-election in two years in a state that just voted Democrat Catherine Cortez-Masto into the Senate.
  2. The Replacements: Perhaps the biggest section of the Republican party that can still be dissuaded from voting to repeal the ACA are those who are uncomfortable with the current absence of a viable plan to replace it. Before voting on the budget resolution that paved the way for repeal of portions of the ACA last week, Sen. Murkowski and Sen. Collins were joined by three of their slightly more conservative colleagues, senators Bob Corker (R-TN), Rob Portman (R-OH) and Bill Cassidy (R-LA), in sponsoring an amendment that would have extended the deadline for repealing the ACA from January 27th to March 3rd, providing the GOP with more time to craft a replacement. It is important to target these senators, as they all seem to have enough common sense to realize that repealing the ACA without a replacement would be a political disaster.
  3. The Medicaid Expansionists: Of the 20 million Americans who have been newly insured under the ACA, about 14 million of them have received coverage through Medicaid expansion. This has come about, in part, because of the willingness of GOP governors such as John Kasich (R-OH) and Jan Brewer (R-AZ) to institute Medicaid expansion in their states almost entirely on the federal government's dime. For senators such as John McCain (R-AZ), Shelley Moore Capito (R-WV) and Marco Rubio (R-FL), being left holding the bag for Medicaid expansion repeal is an unwelcome prospect, and this should be leveraged in the coming weeks and months as the battle over the future of the ACA takes place. It is crucial that the HIV community put the screws to this particular group of senators, considering how vital a robust Medicaid program is to the health and wellbeing of people living with HIV.
  4. Blue Dog Dems: 23 of the 33 senators who are up for reelection in 2018 are Democrats, with nine of those 23 eligible Democratic Senate seats being located in states that voted for Trump. This being the case, there will be many senate Democrats such as Claire McCaskell (D-MO), Joe Donnelly (D-IN), Heidi Heitkamp (D-ND), Bob Casey (D-PA), Joe Manchin (D-WV) and Jon Tester (D-MT), who will feel pressured to drift to the right and potentially throw the ACA under the bus in an attempt to look more appealing to voters back home. We must make sure that these middle-of-the-road Democrats understand that taking part in any action that leads to the repeal of the ACA would constitute a cardinal sin for which they would not be able to make amends.

Any successful defense of the Affordable Care Act and all of the basic protections that enable people living with HIV and others with pre-existing conditions to access quality health care will be built around vigorous and unceasing contact with Congress. Facing the imminent prospect of a president who has provided absolutely no strategy for addressing the HIV epidemic in America and shown no predilection for listening to his own advisors, much less the people he has been elected to serve, ordinary citizens like you or I will have less chance than ever of impacting the actions of the executive, which makes unified action among the HIV community aimed at Congress all the more important. The names of each and every vulnerable senator listed above have been hyperlinked so that clicking on them will take you directly to their respective contact pages. Make sure that by the time the next four years are over, every legislative aide and staffer who answers the phones or goes through the inboxes of those senators has seen your phone numbers and e-mail addresses so often that they can recite them from memory.

Drew Gibson is a social worker and freelance writer based out of Cincinnati, Ohio. You can follow him on Twitter at @SuppressThis or visit his blog "Virally Suppressed," which covers a multitude of issues related to public health and social justice.