The endless saga to repeal and replace Obamacare now playing out in Congress is causing deep anxiety among an overwhelming majority of America’s mayors, 86 percent of whom say they are “greatly concerned” that doing away with the insurance program would leave their citizens more vulnerable to health crises like opioid addiction and obesity.

And a majority doubt that President Trump, who made dismantling the signature policy of the previous administration one of his top campaign promises, has a clear plan to replace Obamacare if Congress manages to repeal it. If they had their way, most say they would prefer a single-payer plan.

“It seems unlikely that the President has any significant understanding of, or interest in health policy,” said Democratic Mayor Noam Bramson of New Rochelle, NY. “He will support whatever plan (if any) emerges from the Republican Congress and declare it a ‘win.’”

Chief among the mayors’ concerns are potential cuts to Medicaid, which, under most of the proposed, but so far unsuccessful replacement plans circulating on Capitol Hill, would cut the deficit by $473 billion and leave more than 20 million people uninsured within a decade, according to the nonpartisan Congressional Budget Office. Sixty percent of mayors said Medicaid expansion under Obamacare has been “very important” to their cities. And mayors were nearly unanimous in their concern (95 percent said they were either “very or moderately concerned”) that any cuts to Medicaid would exacerbate the opioid crisis that plagues so much of America.

Fifty-seven mayors participated in the anonymous and non-scientific survey, the tenth in POLITICO Magazine’s award-winning What Works series. Just under 80 percent of mayors who responded to the survey in the 10 days after the July 4 holiday, were Democrats, a response that matches the generally liberal tilt of city halls across the country. Six of the 57 surveyed are Republican, while four identified as non-partisan or independent.

Though the outcome of the Congressional maneuvering remains in doubt, mayors aren’t sitting idle in their executive suites waiting for the hatchet to drop. Mayors on average estimated that between 75 and 80 percent of their residents have health insurance; they expect that a repeal of the ACA would cut that number by over 10 percentage points. That’s not a prospect they take lightly.

Most mayors are trying to stave off disaster by lobbying their congressional delegation. Many are mobilizing either constituents or local non-profits. A few are taking more creative approaches. One city has already created a small fund in case of federal cuts. Another city has proposed a $50 million reserve in its budget to soften the impact of more uninsured citizens.


A majority of mayors believe the real solution to the nation’s health care mess is one that Congress isn’t even contemplating: a single-payer system. Nearly two-thirds said a single-payer plan offered in their state “sounds better than the current system.” A handful would only support adopting single-payer if Congress repeals Obamacare. Eleven of the 57 mayors surveyed said they didn’t think an entirely government-funded plan “would work in my city.”

Single-payer is an issue that unites Democrats from the most progressive to the most conservative. In California, state lawmakers are pushing a $400-billion-per-year single-payer bill for the state’s 40 million residents that relies predominantly on state and federal funds currently dedicated to Medicare and Medicaid services. Trump said publicly Wednesday that a nationwide single-payer program would “bankrupt” the U.S. and force citizens to “wait in line for weeks to see a doctor.” On Sunday, Senate Minority Leader Chuck Schumer indicated that single-payer could be a centerpiece of a bolder economic fairness message from the Democrats.

Generally, the mayors surveyed were not placated by the Senate GOP’s attempt to compensate for Medicaid cuts by sending $45 billion to states especially plagued by the opioid epidemic. In fact, two-thirds of mayors also said the most helpful thing to tackle to opioid crisis would be more funding for treatment programs not less. A dozen mayors want more regulations to prevent over-prescription by doctors.

The Kaiser Foundation estimates that over 90 Americans die per day from overdosing on opioids such as heroin and prescription painkillers. The ubiquity of opioid use and dependency costs the U.S. an estimated $78.5 billion per year and has prompted action in cities across the country. For example, residents of Baltimore (whose mayor did not participate in the survey) were issued a blanket prescription for the overdose antidote by the city health department in 2015.

While mayors are predominantly worried about opioids, mayors also said obesity and gun violence (roughly a fifth of those surveyed for each) were the major health concerns in their cities. A few named viruses such as HIV and Zika as his or her city’s biggest health epidemic.

Approximately one-third of adults and one-sixth of children in the U.S. are obese, according to the Centers for Disease Control. Under Obamacare, insurers are banned from charging people more or denying coverage because of existing medical conditions, including obesity. Under the latest Senate GOP proposal, that would remain law. But the latest Senate bill would change the Obamacare mandate to now allow states to waive insurance rules, such as minimum contributions insurers must pay toward medical bills.

Six months ago, Trump’s Obamacare repeal rhetoric had mayors openly fearing catastrophe. Since then, the position of city bosses doesn’t seem to have shifted. The vast majority of mayors are skeptical of the president’s promise of a “great” Obamacare alternative that will “end in a beautiful picture.” Mayor Walter Campbell of Coral Springs, Florida believes the administration is dangerously “winging it.”

Trump promised Wednesday that any GOP healthcare replacement would give coverage to low-income citizens and maintain coverage for pre-existing conditions. He claimed the latest draft of the bill would allow insurance purchases across state lines. He also said that he wanted to let Obamacare fail and that he didn’t want to “own it” when it did.

“It appears that the current leadership did not expect to be in a situation where they would actually have to vote on a ‘repeal and replace’ bill,” said Democratic Mayor Helene Schneider of Santa Barbara, California. “Now they are acting like the dog who finally caught the bus and don't know what to do with it.”

Republican Mayor Acquanetta Warren of Fontana, California was one of the few surveyed who believe there is a plan. She said the president wants to move federal government “out of the way” and let states tackle health care based on their own needs—something Trump has explicitly pushed for. “If [you are] in California that's scary based on our legislative climate,” she said.

“The biggest mistake Trump made was promising to ‘repeal and replace’ Obamacare instead of simply ‘fixing’ it,” said Mayor Paul Dyster, a Democrat, of Niagara Falls. “If he had done that instead, there would still have been fierce debate on both philosophical and technical issues, but he would have found many Dems eager to help ‘make improvements.’”

While most mayors think Trump’s biggest healthcare priority should be either keeping Obamacare in place, further expanding Medicaid or making healthcare more accessible and affordable, a handful want him to prioritize the fight against the opioid crisis. Others suggested infrastructure spending to include parks and walking or biking paths. Some said the administration should allow insurance purchases across state lines, make Medicaid reimbursement rates competitive with neighboring states, or adopt universal or single-payer coverage. Some prioritized increasing preventative care, housing and behavioral health services. One mayor simply suggested the administration should prioritize bipartisanship. "All factions should have a voice in the creation of a comprehensive health care plan," he said.

Over a third of mayors think they should help their residents individually adopt healthier lifestyles, especially to combat obesity. Youth access to sports, smoking cessation, cleaner diets and expanding pedestrian forms of transportation were all repeatedly listed. More affordable and accessible healthcare was second on the list. Tackling gun violence and the opioid epidemic were each mentioned by several mayors as top priorities in their cities. So was combatting lead poisoning. One red-state mayor said shutting down their city’s coal plant would foremost improve residents’ health.

Anxiety over health care is tempered somewhat by a generally rosier outlook on the economy. Mayors said they feel better about their city’s economy now than they did six months ago: 88 percent feel either more or equally optimistic about their city compared to the time of Trump’s inauguration. Unemployment has dropped several tenths of a percent to 4.4 percent since late January – the lowest it’s been in a decade. This optimism is a notable increase from the most recent survey in April, when less than 70 percent of surveyed mayors reported equal or increased optimism. In January, that number was about three-quarters.

Most attribute their city’s economic state to either normal factors beyond presidential control or work by the previous administration. Only two believe measures enacted by the Trump administration account for the change.

Mayors who participated include: Denny Doyle, Beaverton, OR; John Marchione, Redmond, WA; Paul Soglin, Madison, WI; Mike T. Huether, Sioux Falls, SD; Nan Whaley, Dayton, OH; Steve Adler, Austin, TX; Barbara Halliday, Hayward, CA; William Capote, Palm Bay, FL;Jeri Muoio, West Palm Beach, FL; Madeline Rogero, Knoxville, TN; Acquanetta Warren, Fontana, CA; Ed Pawlowski, Allentown, PA; Noam Bramson, New Rochelle, NY; Andy Berke, Chattanooga, TN; Rick Kriseman, St. Petersburg, FL; Walter Campbell, Coral Springs, FL; Helene Schneider, Santa Barbara, CA; Chuck Bennett, Salem, OR; Tom Tait, Anaheim, CA; Kirk Caldwell, Honolulu, HI; Tom McNamara, Rockford, IL; John Cranley, Cincinnati, OH; Andrew Gillum, Tallahassee, FL; Bob Buckhorn, Tampa, FL; Joseph Petty, Worcester, MA; Carolyn Goodman, Las Vegas, NV; Larry Wolgast, Topeka, KS; Wayne Messam, Miramar, FL; Patrick Furey, Torrance, CA; Ed Lee, San Francisco, CA; Paula Hicks-Hudson, Toledo, OH; Jim Kenney, Philadelphia, PA; Bruce Whitaker, Fullerton, CA; Jon Mitchell, New Bedford, MA; Steve Hagerty, Evanston, IL; Jim Darling, McAllen, TX; Edward Murray, Seattle, WA; George Van Dusen, Skokie, IL; Adrian Mapp, Plainfield, NJ; Stephanie A. Miner, Syracuse, NY; Lyda Krewson, St. Louis, MO; Toni N. Harp, New Haven, CT; Karen Freeman-Wilson, Gary, IN; Allison Silberberg, Alexandria, VA; Steve Benjamin, Columbia, SC; Andrew J. Ginther, Columbus, OH; Debra March, Henderson, NV; Mark Stodola, Little Rock, AK; Pete Buttigieg, South Bend, IN; Suzanne Jones, Boulder, CO; Eric Garcetti, Los Angeles, CA; Paul Dyster, Niagara Falls, NY; Sly James, Kansas City, MO; Mitch Landrieu , New Orleans, LA; Mark Mitchell, Tempe, AZ; Betsy Price, Fort Worth, TX; Sean Wright, Antioch, CA.