Soon after she assumed office to represent Arizona’s Tucson-based district in the House of Representatives, Martha McSally voted for a Republican-backed measure to repeal the Affordable Care Act.

McSally’s “aye” vote for H.R. 596 was recorded on the evening of Feb. 3, 2015, and came as her party was intent on undoing, tweaking or rolling back the controversial 2010 health care law implemented by President Barack Obama and Democrats.

A year later, McSally voted again to repeal the law.

And in May 2017, McSally voted for the GOP's American Health Care Act, which revived their hopes of repealing central portions of the Affordable Care Act, often referred to as "Obamacare." That legislation, if passed, would have reduced the federal deficit but resulted in 23 million more uninsured Americans through 2026, a Congressional Budget Office analysis found, though McSally's campaign says that estimate was based on "bad projections" about the Affordable Care Act that never materialized.

Arizona's Medicaid program last year estimated that same legislation would have cost the state an extra $3.3 billion through 2026. And a federal funding change could have jeopardized childless adults enrolled in the government health insurance program for low-income people.

McSally urged her colleagues, gathered on the day of that 2017 vote in a private meeting, that it was time to get this “f---ing thing” done, according to the Associated Press.

Ads target McSally votes

Now locked in a competitive statewide Senate race against Democrat Kyrsten Sinema, McSally finds herself blistered by campaign attack ads and having to explain her past votes and current views on health care and the Affordable Care Act, which has grown in popularity in recent years. About 20 million more Americans gained health insurance after the act passed.

McSally told The Arizona Republic on Saturday that she's being "character assassinated" by her critics on health care.

McSally said the fact that 20 million more Americans are insured post-Obamacare does not mean they can all afford their health care. Many Americans are struggling to afford high deductibles and prescriptions, she said.

What's more, there are still millions of uninsured Americans (about 28 million), she said. Many Americans are opting not to purchase coverage because it is "crappy insurance" and doesn't meet the needs of their families, she said. She meets such people every day, she said.

"Now what we have is people right now, under Obamacare, with pre-existing conditions who have no health insurance," she said.

Still, McSally said she agrees with "the intentions of Obamacare," such as "to increase coverage, increase support and lower cost.” But she also believes in a different approach on how to achieve those goals.

McSally remains critical of 'Obamacare'

Though she says the model of Obamacare hasn't worked, McSally says we can't go back to the way things were before the federal law passed in 2010.

"Before the Affordable Care Act, we know many, many people could not get health insurance because they had some sort of condition like diabetes, asthma, heart disease," she said. "Someone very close to me filed for bankruptcy over medical bills because of this issue."

Americans need a system that moves away from Obamacare and creates a healthier individual health insurance market, she said.

McSally was asked if she would vote again to repeal the health-care law on conservative commentator Sean Hannity's radio show.

"Well, Sean, I did vote to repeal and replace Obamacare on that House bill — I’m getting my ass kicked for it right now because it’s being misconstrued by the Democrats," she said. "They’re trying to, you know, invoke fear in people who have family members or loved ones with pre-existing conditions."

McSally said the law has failed in Arizona in part because 14 of the state's 15 counties have only one choice for individuals buying insurance on the Affordable Care Act marketplace. In 2019, that number will change to 13 of Arizona's 15 counties, as more companies are entering Pima and Maricopa counties.

She said on the show that she wants people to have "more flexibility at the state level, more free-market" to ensure access to insurance, and reiterated that when she spoke Saturday with The Republic.

"I voted to protect people with pre-existing conditions," she said.

Sinema sharpens criticism

Sinema has aggressively run on her health care record, making it the centerpiece of her TV ads, mailers, and meet-and-greets with everyday Arizonans, donors and business leaders. Sinema in recent days has taken a sharper stance against McSally's self-characterization as a warrior for people with pre-existing medical conditions.

"Martha is willing to lie about anything to get elected," Sinema told The Republic on Thursday. "We've seen that throughout this campaign. But the facts are really clear."

Everywhere she goes, Sinema said, people "are concerned about Martha's attempts to roll back protections for people with pre-existing health conditions, which she has done several times."

Health care is a top issue for voters across the nation, and Democrats and their allies are hammering Republicans such as McSally with millions of dollars worth of political ads about their records on the Affordable Care Act.

"Regardless of what happens with the Affordable Care Act, one of its major impacts is we have a real cultural shift in this country on the concept of pre-existing conditions," said Swapna Reddy, a clinical assistant professor at Arizona State University's College of Health Solutions. "It's to the point now where you have both parties, who in their own way, want to protect people with pre-existing conditions"

Once Americans understood they were being discriminated against for conditions they often had no control over, they decided it was unjust and they are now unwilling to go back, Reddy said.

Health care resonates with everyone it seems, from parents to grandparents to young adults who rely on their parents’ insurance plans.

Democrats have jumped on the relevance that health care has for their base and are using it to energize votes and "bludgeon" Republicans, Drew Altman, president of the non-profit, nonpartisan Kaiser Family Foundation, wrote in a column published on the non-profit organization's website Thursday.

"Health issues matter most right now to Democrats and women," he wrote. "In a midterm (election), mostly the bases for each party and seniors come out to vote. The greater the turnout on the Democratic side, and among women voters, the more health will matter in this election "

Focus on pre-existing conditions, positions

Meanwhile, a GOP-aligned outside group known as Defend Arizona, is working to reinforce McSally’s message with its own advertising.

“Republicans nationally are now trying to say they’re there to protect pre-existing conditions, which is contrary to their record, said Bruce Oppenheimer, a Vanderbilt University political science professor. "(President Donald) Trump is making it the argument now. But it just doesn't pass the smell test."

Trump promised during his "Make America Great Again" rally in Mesa this month that Republicans would protect Americans' health coverage. He appeared alongside McSally to bolster Republic enthusiasm and warned the crowd that it was Democrats — not Republicans — who want to undermine their health care protections.

"They’re trying to put a false narrative out there," Trump said of Democrats. "And if there is a Republican out there that doesn't, let me know. Believe me — him or her, we'll talk him into it. We’re going to protect pre-existing conditions."

McSally said during the only debate with Sinema on Oct. 15 that “the Obamacare model has failed,” and accused Democrats of using “classic fear tactics” to misconstrue her positions on the issue.

“If you turn on a TV all over the country right now, the Democrats have nothing to run on and so they’re choosing to run on fear,” she said.

McSally added that she voted to protect people with pre-existing conditions, a reference to the AHCA, which did prohibit insurance companies from denying people coverage for having a pre-existing condition.

However, the AHCA also allowed insurers to charge people with pre-existing conditions higher premiums, which the Affordable Care Act prohibited, Reddy said.

"The Affordable Care Act not only protected consumers from being denied coverage due to pre-existing conditions, but also from being charged more for pre-existing conditions," she said. "It's a two-part protection. The AHCA would have only preserved one part of that."

Reddy said McSally's assertion that she voted to protect people with pre-existing conditions does not fully reflect her vote.

"I think it's important for consumers and voters to know that entire picture if they really want to understand her voting history on pre-existing conditions and make a decision based on that," she said.

A May 2017 Kaiser Family Foundation analysis estimated that 6.3 million people could have faced higher premiums under the AHCA because of pre-existing health conditions.

The analysis said that's because the bill allowed states to apply for waivers for insurers to vary premiums for a year based on the health status of certain enrollees in the individual market who had a gap in insurance.

Another way people with pre-existing conditions could have been hurt under the AHCA is that it allowed states to apply for waivers allowing them to alter the Affordable Care Act's mandate that insurers cover "10 essential benefits," including maternity and newborn care, prescription drugs and preventive services in the individual and small group market, said Karen Pollitz, a senior fellow at the Kaiser Family Foundation.

By allowing insurers to sell more bare-bones types of plans, people facing an unexpected illness like cancer or an unanticipated injury could be hit with expenses that their plans don't cover, and that they cannot afford, Pollitz said.

Also, the AHCA would have reduced subsidies to help people in the individual market pay for health insurance, which could have prevented some people from buying it at all, she said.

McSally: 'The model has failed'

McSally argued to The Republic that the idea that Obamacare is covering and supporting everyone with pre-existing conditions is untrue.

"The model has failed, OK?" she said. "We're trying to move toward another model. We're trying to take a different approach."

McSally has said she successfully negotiated $8 billion in additional funding to bring down insurance costs for people with pre-existing conditions. She is referring to an amendment that would have added money for states for six years to provide government-subsidized assistance to high-risk people with expensive medical conditions.

It was funding that some critics viewed as a corrective move to try to make up for adverse AHCA impacts. High-risk pools have been tried in several states and proved to be prohibitively expensive.

In May 2017, the AARP said that amendment would "do little to reduce the massive premium increases for those with pre-existing conditions."

McSally's campaign literature on her health-care record says that she negotiated $165 billion in additional funding in the AHCA bill to help people struggling to afford health insurance.

She cites a $90 billion increase in the health care tax credits for Americans in the 50-64 age group, $15 billion to help young mothers and those struggling with mental and substance abuse disorders, and $60 billion in Medicaid to help the elderly and disabled.

Dr. Daniel Derksen, a health policy expert and vice president of health equity at the University of Arizona who helped draft part of the Affordable Care Act, said she is misleading in two ways.

"First, the AHCA bill did not pass (become law), so it’s misleading to claim that, 'Martha secured $165 billion in additional funding in the bill.' Nothing was secured — just proposed," he said.

"Second — and this is the more important point — the AHCA would have cut almost a trillion dollars over 10 years of federal Medicaid funding to states. Eight hundred and eighty billion is a much larger cut that the small increments proposed.

"Draconian federal cuts to state Medicaid programs would disproportionately harm states like Arizona."

Torunn Sinclair, McSally's campaign spokeswoman, pushed back on Derksen's charge that McSally is misleading.

"Martha fought for billions of dollars to protect Arizonans, ensuring they would have access to affordable health care," Sinclair said. "Any comments to the contrary are just plain false. Obamacare is failing Arizonans, this university professor helped create Obamacare, (and) Martha is trying to fix it.”

Medicaid also plays a big role in covering people with pre-existing conditions who have incomes below the poverty level, particularly in states such as Arizona that opted to expand Medicaid, Larry Levitt with the Kaiser Family Foundation wrote in a recent column.

McSally responds with TV ad

On Wednesday, McSally launched a new TV ad that says she is “leading the fight to force insurance companies to cover pre-existing conditions.".

By "leading the fight," McSally said told The Republic she is referring to her own, continuing actions to fight for people with pre-existing conditions in the transition from Obamacare to a new health care model.

McSally described herself as "in the middle of a boxing ring" and saying "no way" when cuts that would have hurt vulnerable populations were proposed within her own party during repeal and replace negotiations.

"I was in a lot of meetings where I was dropping some swear words and making sure that those who were talking about this as if it was just a campaign slogan understood," she said. "I'm trying to help. I'm actually trying to fix it."

McSally said that the House's AHCA was the "first step" in a legislative process. It wasn't perfect but that it was a way to go forward from the "failure" of Obamacare, she said.

"What we were trying to do was move toward more innovation at the state level that was still using some taxpayer resources," she said. "I think we can all agree some taxpayer resources need to be used in order to help people who have fallen through the cracks and who have the most complex conditions."

Texas v. Azar

Besides changes that could happen on a legislative level in the future, a pending lawsuit — Texas v. Azar — is a current, looming threat to the Affordable Care Act.

A group of Republican state attorneys general, including Arizona's Mark Brnovich, are arguing that because the Affordable Care Act's tax penalties for not having health insurance are no longer enforceable in 2019, the individual mandate to have health insurance is unconstitutional. The lawsuit argues that the entire Affordable Care Act is therefore unconstitutional.

"Usually when you say a piece of federal legislation is unconstitutional the federal government defends it," ASU's Reddy said.

"In an unprecedented move, our own federal government has said they are not going to defend the legislation, and they are siding with the plaintiff. They are not saying the entire legislation is unconstitutional but that parts are. ... It could be incredibly dangerous for the Affordable Care Act as a whole."

If the court agrees with the Justice Department's arguments, it could eliminate the Affordable Care Act's core pre-existing condition protections, Pollitz said.

Sinema opposes Texas v. Azar. McSally told The Republic she is not weighing in.

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