Now that the nation is in the throes of a global pandemic, and millions of Americans have lost their employment-based health insurance [3] coverage, GOP senators are in trouble [4] for their long-running efforts to repeal the Affordable Care Act (ACA).

Most of the GOP senators up for reelection this year voted three times to repeal the ACA in 2017. And all of them voted for the huge GOP tax giveaway bill in 2017 that zeroed out the ACA's individual mandate and paved the way for the case pending before the Supreme Court that would overturn the ACA entirely.

Republican candidates had a rough 2018 election season, in large part due to their repeated efforts to take away health insurance subsidies and Medicaid from millions of Americans. Voters saw Democrats as far more capable on health care issues [5], and the party gained 40 seats in the House of Representatives. And some polls show that health care is the #2 issue [6] on voters' minds in the November election.

This dynamic explains why Americans for Prosperity Action (AFP Action), the independent expenditure arm of the premier political advocacy organization in the vast, right-wing network of billionaire industrialist Charles Koch, is spending millions of dollars on TV and digital ads alleging that several vulnerable GOP senators are fighting for high-quality, low-cost health insurance options for their constituents. The evidence that the super PAC uses to support its claims is thin, and the ads obscure the fact that these Republicans, who represent states including Colorado, North Carolina, and Texas, repeatedly voted to repeal the ACA with no meaningful plan to replace it.

Remarkably, one of the main selling points presented by AFP Action is several senators' support for extended "junk" health insurance plans—plans not subject to the ACA's numerous patient protections, including a requirement to cover pre-existing conditions.

"Junk" Health Plans

AFP Action's ads hinge on the senators' votes in favor of bare-bones, short-term health plans, while ignoring their votes to repeal ACA.

Such plans, often referred to as "junk" plans [7], cost less than typical ACA marketplace plans, but they are not high-quality, as AFP Action claims. Democrats opposed a Trump executive order that extended their potential duration precisely because they don't meet ACA standards. The Trump administration promoted "junk" plans after Republicans' many efforts to repeal the ACA failed.

Sen. Tammy Baldwin (D-WI), who was the primary sponsor of S.J.Res. 63, an August 2018 resolution disapproving of Trump's executive order, told CMD that junk plans are insufficient.

"It is just false to say that these junk plans provide high-quality care or preserve pre-existing conditions protections and the essential health benefits provided by the Affordable Care Act," Baldwin said. "Trump's junk health insurance plans don't have to cover prescription drugs, mental health services, substance abuse treatment, maternity care, or people with pre-existing conditions."

"Short-term plans appeal to enrollees who assume they won't need much health care," said Steffie Woolhandler, a distinguished professor of public health and health policy in the CUNY School of Public Health at Hunter Collegeand co-founder of Physicians for a National Health Program. "These plans can harm their enrollees by leaving them with huge unpaid medical bills should an unexpected health problem arise, such as injury in a traffic accident, new cancer diagnosis, or infection such as COVID-19.

Woolhandler explained how the use of "junk" plans can damage the health insurance system overall.

"Short-term plans can also harm people who enroll in traditional plans, because short-term [plans] siphon off healthier people who anticipate using little medical care, leaving the traditional plans with a sicker, higher-cost ‘risk pool' from which to collect its premiums. For this reason short-term plans tend to force traditional plans to raise their premiums."

Nicole Tardif, communications director at AFP Action, reasserted to CMD that these short-term plans offer "quality care."

"Short-term, limited-duration health care plans provide not only flexibility, but assurance that Americans can access quality care, regardless of employment status," said Tardif. "They allow individuals to pay for the coverage and services they need at a price they can afford. Short term plans provide alternatives to the one-size-fits-all options mandated under the ACA and are particularly helpful right now [to] those that have lost their jobs due to the COVID-19."

Tardif cited short-term plans in El Paso, Texas, that are allegedly much less expensive than plans on the ACA marketplace.

One of the key offerings of the ACA was access to subsidized health insurance for those who aren't eligible for insurance coverage through their employers. Americans who earn below a certain annual income are eligible for the insurance subsidies, which are scaled to each individual's income level. All GOP Senate incumbents that AFP Action is supporting with health care-focused ads voted to repeal the ACA on a number of occasions.

In 2017, most Republican senators voted to repeal the ACA, the 2009 law that has insured nearly 20 million people and expanded Medicaid in numerous states.

At the time, the Congressional Budget Office estimated that if one bill, known as the "skinny repeal," passed, 16 million fewer Americans would have health insurance in 2026, and health insurance premiums would be 20 percent higher than under the ACA.

Two other 2017 bills, one to repeal and replace the ACA and another to partially repeal the law, would have left even more Americans uninsured. According to the Congressional Budget Office, the Better Care Reconciliation Act would have led to 22 million additional uninsured people by 2026, and the Obamacare Repeal and Reconciliation Act would have kicked 32 million off of their health insurance.

Cory Gardner

Sen. Gardner of Colorado faces a tough race to retain his seat against former governor and recent Democratic presidential contender John Hickenlooper. Polls have consistently shown a lead for Hickenlooper.

AFP Action is running several pro-Gardner ads, including one titled "Supporting Colorado Families," which claims that the senator is protecting his constituents' right to "make their own decisions on important issues, like improved access to high-quality, affordable health care."

 

The ad cites Gardner's vote against S.J.Res. 63 [8], which failed in a 50-50 vote, so Trump's rule remained in place. Collins was the only Republican senator to vote for the measure. The resolution would have nullified a rule issued by the Trump administration that increased the maximum durations of short-term health insurance plans, which was previously set at three months, to 12 months, with the possibility for renewal. Such plans were initially allowed only to cover short insurance gaps between long-term plans.

Despite a tough challenge from Democratic former governor John Hickenlooper this year, Gardner still opposes the ACA [9].

John Cornyn

"In the Senate, Cornyn is demanding greater access to better care at a price we can afford," states an AFP Action ad [10]. "Fighting for better healthcare. Protection private insurance plans," it concludes.

The ad does not cite any relevant legislation that Texas Sen. Cornyn has worked on or supported, but another one [11] cites his vote on H.R. 6201 [12], a March 2020 bill sponsored by Democrats called the Families First Coronavirus Response Act, which passed the Senate 90-8. Eight GOP senators not including Cornyn voted against it, and Gardner did not vote because he was in quarantine after potential exposure to COVID-19.

Cornyn "fought for care to be available at your fingertips by expanding telemedicine," claims the ad. But Cornyn did not sponsor or co-sponsor any amendment to the bill, which was written by Democrats. The Congressional Record [13] shows that during Senate deliberations, Cornyn did speak on behalf of the bill but did not mention "telemedicine," "telehealth," or "remote" medicine. The 44-page bill [14] itself only mentions "telehealth" twice.

During negotiations over the bill, Democrats proposed an amendment to expand the bill's emergency paid sick leave, family leave, and medical leave [15]. Cornyn voted against it and instead voted for an amendment to get rid of the bill's federally mandated paid sick and family leave [16] and require state unemployment systems, which were overwhelmed with millions of new claims, to cover the costs. Neither amendment met the 60-vote threshold necessary for inclusion in the bill.

Tardif told CMD that Cornyn co-sponsored other legislation to expand telemedicine such as the eTREAT Act [17] of 2018 and the Medicaid Substance Use Disorder Treatment via Telehealth Act [18], two bipartisan bills that did not make it out of committee.

An AFP Action ad that attacks Cornyn's opponent, Democrat MJ Hegar, claims she "wants a one-size-fits-all government-run approach that strips our families of their health plans." This claim is incorrect, as Hegar backs a single-payer option [19], which leaves private health insurance in place but offers people the chance to opt into government-run Medicare.

A single-payer option is popular in the U.S. A January 2020 poll by the Kaiser Family Foundation found that 68 percent [20] of Americans favored the policy.

In 2017, Cornyn voted for all three ACA repeal bills. The senator has voted to repeal or block the ACA 20 times [21], according to Texas Democrats, but now he tells people they can sign up for the ACA [22] if they lose their employer-based insurance.

David Perdue

"David Perdue is fighting to expand access to affordable health care, putting the care you need just a touch away," states an AFP Action ad supporting the Georgia Republican senator.

The ad cites two 2018 Senate resolutions: the anti-junk health insurance measure he voted against and S.J.Res. 52, an internet-related measure that has nothing to do with health care. AFP Action likely intended to cite S.J.Res. 52 [23] from 2019, a Democratic measure to halt the Trump administration's waivers that gave states "more flexibility" to design alternatives to typical ACA insurance plans. All but one Republican, Sen. Collins, voted against the resolution, which failed 43-52.

Unlike waivers in the Obama years, these waivers are permitted even if they end up increasing insurance premiums for some residents, and the waivers no longer require approval by the state legislatures. The Commonwealth Fund concluded that with this guidance, "the Trump administration takes another step toward undermining the ACA and its goals [24]."

Another ad [25] backing Perdue lists the Families First Coronavirus Response Act, the bill that passed the Senate 90-8. Perdue was not a co-sponsor but did co-sponsor the failed amendment that would have axed the bill's federally mandated paid sick and family leave.

AFP Action portrays [26] Jon Ossoff, the Democratic challenger to Sen. Perdue in Georgia, as a leftist who wants to "take away your health care plan" and wants the government to "take control of your health care." Like other moderate Democrats, Ossoff supports a public option [27] only.

Perdue voted for all three ACA repeal bills in 2017 and also pushed for cuts to Medicaid and Medicare [28] to help pay for the enormous tax cuts for wealthy Americans and large corporations that Republicans were planning at the time.

All 11 pro-Perdue ads on AFP Action's YouTube page attempt to cast the senator as a fighter for his constituents' health care.

Thom Tillis

AFP Action features North Carolina Sen. Tillis, who voted for all three ACA repeals, in an ad [29] that claims he supports "expanding our health care options," "lowering costs," and "making sure you get the care you need when you're sick."

Votes against the ACA indicate that Tillis tried to do the opposite of what the ad claims; the millions who would have lost their insurance would have had fewer, more expensive options and a much harder time getting the care they needed.

The ad says that Tillis knows a "one-size-fits-all government takeover that rips private insurance for millions of North Carolinians is not the answer," while his Democratic opponent, Cal Cunningham, supports [30] only a public health care option.

Another ad [31] cites Tillis' vote against the resolution opposing expanded junk health insurance plans, again vaguely referencing its telemedicine provisions. "Quality care—where and when you need it," states the ad.

Tillis voted for all three ACA repeal bills in 2017.

Steve Daines

Montana GOP Sen. Daines, who also voted for all three ACA repeal bills in 2017, gets the same treatment from AFP Action that others received. The super PAC touts his support for junk health insurance [32] plans, which the ad describes as "quality, affordable health care."

Another ad [32] references S.J.Res. 52 from 2019, the Democratic measure to halt Trump's 2018 ACA waivers, which Daines voted down. As it cites this resolution, the ad claims that Daines ensured "rural communities get the care they need, too."

Roger Marshall

Kansas Republican Rep. Marshall is running for Senate this year, and AFP Action portrays him as a true fighter for quality, affordable health care. An ad [33] boosting Marshall claims that under the policies of his opponent, Barbara Bollier, "millions of families would lose their health plan," resulting in "fewer options, less access, skyrocketing costs." Marshall, allegedly, wants people to control their health plans, and the ad promises better quality, more access, and lower costs.

The ad cites Marshall's vote for the Families First Coronavirus Response Act, which passed the House 363-40. Forty Republicans voted against the bill, but Marshall joined 139 of his GOP colleagues to approve the legislation.

In an apparent error, AFP Action also cites Marshall's actions on S.J.Res. 63, a Senate resolution that Marshall, in the House, would not have voted on, as well as S.J.Res. 62 [34] of 2019, a North American Trade Organization resolution that never made it to the House.

After CMD alerted AFP Action to apparently incorrect citations in the ad, the group corrected the errors. The video is now "unlisted" on YouTube, meaning it remains online but no longer appears in searches of the site.

Marshall supported a bipartisan 2018 House resolution [35] to expand the use of health savings accounts. The resolution passed the House but saw no action in the Senate. He also backed a GOP bill [36] that year to allow Americans to use tax credits to purchase "catastrophic" insurance plans. The bill also passed the House but did not move forward in the Senate.

In May 2017, Marshall voted for the American Health Care Act, a repeal of the ACA that narrowly passed the House but did not receive a vote in the Senate.

Wealthy Backers

So far in the 2020 election cycle, AFP Action has spent over $21.1 million [37] on independent expenditures, according to a tally from ProPublica. The group has devoted over $6.2 million to ads backing Tillis. AFP Action's spending totals for Senate races as of Sep. 21 are as follows:

• Tillis: $6.2 million
• Cornyn: $3.8 million
• Perdue: $2.7 million
• Daines: $2.3 million
• Marshall: $1.2 million
• Gardner: $895,000

In addition to advertising, AFP Action has spent a considerable amount on canvassing [38], as Democrats have largely avoided in-person electioneering.

The biggest donors by far to AFP Action are Koch Industries ($7 million) and Freedom Partners Action Fund ($6.5 million), another Koch-funded super PAC. The biggest individual donors include Arkansas chicken farming executive and Donald Trump megadonor Ronald Cameron [39] ($3.5 million), brothers Richard and Marvin Gilliam of the Cumberland Resources coal fortune ($1.7 million), electrical parts manufacturing heiress Mary Alice Bergan ($1.7 million), transportation magnate Clarence Werner ($1.5 million), and Ethelyn and Richard Haworth ($1.5 million), a married couple whose wealth comes from the office furniture maker Haworth, Inc.

 

Image credit: KOMUnews [40]/Flickr, Gage Skidmore [41]/Flickr, U.S. House