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Granite Staters are paying too much for healthcare, have too few options, and don’t want to be stuck with government-run plans that are part of the Affordable Care Act.

That was the view of several panelists who participated in a radio roundtable on the Pulse of New Hampshire Friday, led by host Jack Heath. 

Heath said the politics of healthcare have become too fraught with Republicans and Democrats dug in. “Republicans would prefer private healthcare options, but they run away from the issue,” Heath said.

Americans for Prosperity New Hampshire head Greg Moore is also a former director at the N.H. Department of Health and Human Services. He said that in poll after poll, New Hampshire residents say they want better choices.

“People don’t like high costs, and they don’t like government-run healthcare,” Moore said. “There are other options, like giving everyone an HSA (health savings account).” 

There are ways to create more competition in the healthcare marketplace that will help drive down costs; he said. Moore favors options like changing the tax code to give individuals the same healthcare tax benefits that businesses currently enjoy.

The Main Street Freedom Alliance radio roundtable on health care hosted by Jack Heath on April 14, 2023.

And it’s not just individuals who are sick of the costs and regulations. Christie Elliot Peters, co-owner of Elliot Controls, an Amherst HVAC company that specializes in automated building controls, said her employees would love to be able to sign up for the company health plan rather than the Affordable Care Act Granite Advantage plan. But the plans her small business is able to secure can price out some workers. She said the costs have been going up almost every year for decades.

“When I trace back, the jumps we have had in rates result from legislation that was supposed to fix the problems or because of the Affordable Care Act,” Peters said.

State Sen. Keith Murphy (R-Bedford) owns Murphy’s Tap Room with locations in Manchester and Bedford. He told Heath he spends hundreds of hours every year trying to get the best plans to offer his 65 employees, But he said the plans are so expensive many of his younger workers opt out.

“When you’re 23, you’re immortal, you think,” Murphy said.

D.J. Bettencourt, deputy commissioner at New Hampshire’s Insurance Department, said Washington regulations that favor individual plans over small businesses are hurting the economy, especially in the Granite State. With New Hampshire companies struggling to hire workers, a good healthcare plan can be the difference between getting and keeping qualified employees.

“The government is trying to improve the individual market and not helping the small business market,” Bettencourt said.

He said New Hampshire’s economy relies on small business owners like Peters and Murphy. “We are a small business state; they are the engine of our economy,” he said.

Bettencourt noted between the aging New Hampshire population and the large swath of people signed up for Granite Advantage; insurance carriers see less reason to offer their plans in New Hampshire given the small pool of potential customers. 

“Layer on government regulations with that smaller pool, it’s even less attractive for (insurance) companies.”

That leaves people and businesses with fewer, more expensive options.

State Rep. Jess Edwards (R-Auburn) told the roundtable people want more choice in their healthcare options, but the government simply cannot get out of the way. Part of the problem is the unwillingness of Democrats to revisit the Affordable Care Act. 

“Democrats would not support plans to let people out of [the ACA] and get on plans offered by small businesses,” Edwards said.

Republicans also seem unable to address the problem in a meaningful way on their side of the aisle. Bettencourt noted the GOP had a trifecta in 2017 — control of the U.S. House, Senate, and White House — and could still not pass legislation to give people more choices.

“They were like the dog that caught the car,” Bettencourt said.

Moore said Democrats are bent on pushing for more government involvement in the healthcare market as part of the ultimate push for universal healthcare.

“Democrats want to increase the number of people on government insurance,” Moore said. “We need a third way.”

Listen to the entire discussion here.

The bipartisan effort to make New Hampshire’s Medicaid expansion permanent got a push Wednesday as the Senate Health and Human Services Committee heard from people like Manchester’s Michelle Lawrence, who said the law allows her to get vital cancer care. 

Lawrence, who is suffering from a rare form of cancer, told lawmakers she was finally able to focus on her health once she received care through New Hampshire’s Granite Advantage plan.

“For the first time in my cancer journey, the primary focus in my care has not been on insurance and insurance costs,” Lawrence said. “I’m not getting up in the middle of the night having to think about delaying care or paying rent.”

Senate President Jeb Bradley (R-Wolfeboro) joined Nashua Democrat Sen. Cindy Rosenwald in urging the committee to approve SB 263, the bipartisan bill that would make Medicaid expansion permanent.

“I think our law is a good common-sense law and should remain in place,” Bradley said.

Making Medicaid permanent is part of Gov. Chris Sununu’s budget plan. Ben Vihstadt, Sununu’s communications director, said Sununu is ready to make sure the bill gets to his desk.

“Gov. Sununu worked with legislators in 2018 to deliver a five-year reauthorization of Medicaid Expansion in a fiscally responsible manner and supports this permanent step. He looks forward to working with the legislature this session to get this bill across the finish line,” Vihstadt said.

Granite Advantage, which currently provides health care to 94,000 residents, was last reauthorized in 2018 and is set to expire at the end of June. The current proposal will make the program permanent, meaning it will not have to come back for reauthorization if approved.

New Hampshire first expanded Medicaid in 2014 under President Barack Obama’s Affordable Care Act. Henry Lippman, New Hampshire’s Medicaid director, said the program is expected to decrease to about 64,000 enrollees by the end of the year as the COVID-19 emergency authorization is expected to be phased out.

Extending Medicaid to low-income Granite Staters has been economically beneficial to the state’s hospital system, according to Steve Ahnen, president of the New Hampshire Hospital Association. Uncompensated care for hospitals dropped to $69 million in 2021, down from $173 million in 2014.

Uncompensated care costs all Granite Staters, Ahnen argued, and the bills are generally passed on through higher premiums to those with insurance. Bradley said the program has cut this hidden tax while also bringing down the cost of insurance for everyone else. 

Business & Industry Association President and CEO Michael Skelton said keeping Medicaid expansion in place is good for businesses and people. Access to healthcare means employees won’t lose time to serious medical problems, and businesses that are already short-staffed will be able to4 remain open.

“A healthy population contributes to worker availability,” Skelton said.

And without Granite Advantage, New Hampshire could lose up to $500 million a year in federal funding while having to shoulder the costs of uncompensated care alone.

“We benefit from an overall healthier population,” Skelton said. “Hospitals and other caregivers avoid catastrophic loss of revenue and employers and employees across the state will benefit from individuals being healthy enough to work.”

Robert Dunn, director of public policy for the Roman Catholic Diocese of Manchester, made a moral argument for Medicaid expansion, saying the expanded coverage has likely saved lives. Speaking on behalf of Bishop Peter Libasci he urged the committee to support the permanent expansion.

“I think we can say it’s a pro-life measure,” Dunn said. 

Though the bill had bipartisan support in the Senate committee, there is resistance in the House of Representatives, sources say. And the influential Americans for Prosperity – NH opposes the move. State Director Greg Moore said the plan incentivizes people to earn less income in order to qualify for health care.

“This regressive policy works to keep people in poverty instead of lifting them out of – it is the opposite of the Live Free or Die way of life,” Moore said. 

But Moore’s position did not carry the day. The committee voted unanimously to approve the bill, sending it to the full Senate for a vote.

People with anxiety and depression are disproportionately prescribed painkillers. That’s what new research from the Dartmouth-Hitchcock Medical Center suggests, adding a complex layer to the opioid epidemic ravaging the United States and encouraging calls from New Hampshire’s congressional delegation to not move forward with the repeal of the Affordable Care Act.

The findings, which appear in the July issue of the Journal of the American Board of Family Medicine, show that nearly 19 percent of the 38.6 million American adults with mental health disorders use prescription opioids compared to only 5 percent of those without a disorder. Adults with depression and anxiety receive 51 percent of the 115 million opioid prescriptions distributed each year in the U.S., the study found.

“Because of the vulnerable nature of patients with mental illness, such as their susceptibility for opioid dependency and abuse, this finding warrants urgent attention to determine if the risks associated with such prescribing are balanced with therapeutic benefits,” said Brian Sites, an anesthesiologist at Dartmouth-Hitchcock and one of the co-authors of the study.

Image Credit: Dartmouth-Hitchcock

Opioid prescribing in the U.S. quadrupled between 1999 and 2015, and during that time more than 183,000 people died from overdoses related to prescription opioids, according to the Centers for Disease Control and Prevention.

Sites also notes that because pain is subjective, “the presence of mental illness may influence the complex dynamic between patient, provider, and health system that results in the decision to write an opioid prescription.”

The study does not give a specific reason why people with mental disorders are more frequently prescribed opiates. The study encourages more research on this population to understand opiate addiction.

Those patients may have some form of physical pain, but their mental condition may cause them to feel that pain more acutely or be less able to cope with it, leading to increased requests for something to dull the pain. As a result, doctors trying to be empathetic to their patients’ complaints may tend to overprescribe opioid painkillers, Stiles said.

Research also shows that patients are more likely to take opioids when there aren’t specialists nearby. A study published earlier this year found that the number of seniors in rural America who take at least three prescribed psychotropic drugs ― including opioids and antidepressants ― tripled over a nine-year period. The study found that many of these prescriptions were given without a proper diagnosis.

Being able to identify a subset of the population that could be more likely to use opioids could help providers and policymakers address opioid use. It “suggests that there may be additional patient- and provider-related factors specific to those with mental illness that increase the likelihood of receiving prescription opioids,” the authors wrote.

U.S. Rep. Annie Kuster, D-N.H., was present for a press conference about the study on Monday. She said repealing Obamacare could be disastrous for New Hampshire’s opioid epidemic.

“This is critically important in New Hampshire, as we have gone from second in the nation in deaths from the opioid crisis and heroin to first for fentanyl,” she said. “That’s not what we want to be known as first in the nation for.”

The U.S. Congress is currently in a heated healthcare battle. The Senate is working on legislation to repeal the healthcare law, but a vote on the bill has been delayed due to opposition from Republicans. New Hampshire Democratic Sens. Jeanne Shaheen and Maggie Hassan have both stated their opposition to the healthcare overhaul and have sent many press releases condemning “Trumpcare.”

“This new study is yet another reminder that, to combat the devastating opioid crisis, we must make mental health treatment affordable and accessible,” Shaheen said in a statement.

Hassan said she opposes proposed cuts to Medicaid that would affect coverage of mental health and substance abuse services.

“As we work to combat the horrific substance misuse crisis that is devastating our communities and taking a major toll on our economy in New Hampshire, this study highlights how dangerous Trumpcare, which includes massive cuts to Medicaid, would be for our state,” Hassan said in a statement. “We need a comprehensive, holistic approach to combating this epidemic that addresses the underlying causes of addiction, including mental health issues.”

To address the overprescription problem within the mental health community, Sites has suggested physicians need more access to alternative medicine besides opioids, including acupuncture, massage therapy, physical therapy, and non-opioid pharmaceuticals.

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For 2018, the company was seeking to increase premiums by about 30 percent but is working to organize as a new insurance provider, Minuteman Insurance. It would remain in the ACA exchange but would not be subject to the co-op rules.

“Offering our members a quality, more affordable coverage option has been Minuteman’s mission from day one,” said Minuteman Health CEO Tom Policelli. “We want to continue that mission in 2018 and beyond through the new company we are currently working to organize. Forming Minuteman Insurance Company will allow us to address numerous federal restrictions and work to make our coverage available to more people.”

Nationally, insurers are pulling out of some markets or are seeking to charge higher premiums. Republicans are hoping to repeal President Barack Obama’s health care law, and the Senate is pushing a bill that would leave 22 million more Americans uninsured over the next decade, according to a Monday analysis from the Congressional Budget Office. It would also cut the federal deficit by $321 billion, driven by reductions in Medicaid and smaller subsidies to help people buy insurance.

Minuteman Health is the second co-op to drop out of the New Hampshire market. Community Health Options pulled out for 2017 to focus on Maine, and recently announced it made a surplus after two years of losses. With Minuteman Health exiting, individual and small group customers in New Hampshire will have three options in next year’s exchange: Anthem, Harvard Pilgrim, and Ambetter.

The American Health Care Act (AHCA) was pulled Friday minutes before a vote was to take place on the bill in the U.S. House of Representatives, which essentially means Obamacare is here to stay.

House Republicans were shy of the votes needed to get the legislation passed, and defections from the conservative House Freedom Caucus, whose members didn’t think the “repeal and replace” bill went far enough, put it out of reach for President Donald Trump and House Speaker Paul Ryan.

After pulling the vote, Trump said that the “best thing we can do, politically speaking, is let Obamacare explode. It’s exploding right now. Almost all states have big problems.”

With no new health care plan in the foreseeable future, there are a couple of bills that New Hampshire lawmakers are expected to revisit that would make changes to Granite Staters’ health care.

Under AHCA, the Congressional Budget Office estimated that 14 million fewer people would be insured in the first year if it passed. Although it was unknown how many New Hampshire residents could have lost coverage under the plan, about 91,000 people had individual plans on the health exchanges as of February, according to state estimates. Also, 52,000 low-income people in New Hampshire who have insurance through Medicaid expansion were at risk.

It didn’t take long for the Granite State’s all-Democratic congressional delegation to praise the withdrawal of the AHCA, citing how much harm it would do to the state’s residents.

“It’s time for them to admit that while the Affordable Care Act is not perfect, it has made New Hampshire and the country healthier and is worth improving, rather than repealing,” U.S. Sen. Jeanne Shaheen said to WMUR.

U.S. Sen. Maggie Hassan also applauded the defeat of the bill.

“The failure of Trumpcare is good news for people across New Hampshire and America who would have faced higher costs for less care,” she said.

They also all said that Republicans and Democrats should work together to make improvements to former President Barack Obama’s Affordable Care Act (ACA).

“It’s time to have a serious discussion about improvements that can help our health care system work better for everyone,” U.S. Rep. Carol Shea-Porter said. “There’s so much more work to do if we can put partisanship aside and work for the good of our constituents. Let’s get to work.”

Since it appears Congress isn’t going to change health care, it’s now up to the states to make changes within the scope of the ACA, and that’s what the New Hampshire Legislature will do. Leaders of each state party also seem ready to tackle Medicaid expansion with bipartisanship, yet there appears to be some disagreement over when it should get done.

Gov. Chris Sununu said he had issues with the AHCA and he wanted flexibility under the law to allow states the power to implement the policy in ways that made sense to each state. He previously supported a block grant system for Medicaid, which would have capped the federal share, letting the states decide how to spend the dollars on care.

“The bill that’s been proposed in Congress gives us concerns on a lot of different levels,” Sununu said last week. “Expanded Medicaid is part of that discussion. There’s no doubt expanded Medicaid has provided [drug] recovery, treatment options for a lot of folks that otherwise may not have had that option available.”

New Hampshire was one of 31 states that expanded Medicaid under Obamacare. Former Democratic Gov. Maggie Hassan signed the plan into law in 2014 after working with Republican legislators to approve it in two-year increments. She signed the latest expansion bill in 2016. New Hampshire has more than 187,000 individuals enrolled in either traditional or expanded Medicaid, according to state health officials.

Now that block grants aren’t on the table anymore, New Hampshire lawmakers will figure out if they want to extend the program past 2018. The Senate tabled a bill last week, without debate, that would make Medicaid expansion permanent. Senate leadership said they wanted to see what happened with the AHCA before they debated Medicaid expansion in the state.

Senate Minority Leader Jeff Woodburn told NH1 News that “what we designed in a bipartisan fashion clearly has worked. Democrats are ready to move immediately.”

Senate Majority Leader Jeb Bradley said lawmakers shouldn’t rush into anything, especially since the New Hampshire Protection Health Program doesn’t expire until the end of next year.

“Even though the legislation in Washington was pulled and there’s no changes right now to federal guidelines for Medicaid Expansion, I think before we think about reauthorizing the current program, we need to make sure that’s exactly what’s going to happen in Washington that three or four or five months from now, they’re not coming back with a new health care bill,” Bradley told NH1 News. “If December comes and there are no changes to the ACA, that will guide us in what we’re going to do in terms of Medicaid Expansion next year. To me that’s the prudent way to do it. It’s what we did in 2016. We waited for the implementation to go forward in [2015]…So I continue to think doing it now is premature.”

Sununu has also previously indicated that he doesn’t want to continue kicking the can down the road with Medicaid expansion by renewing it every two years. He said he wants to find a long-term solution.

The right-leaning public policy group, Federalism in Action, released a 2016 study discussing the issue of long term care in New Hampshire and the challenges it will face in the future.

“New Hampshire is an apt harbinger of the country’s long-term care challenges. The state’s age 85 plus population will nearly quadruple in the next three and a half decades,” the report stated. “If its Medicaid long-term care expenditures for the elderly keep pace they’ll increase from $282 million per year to $1,047 million, more than one billion dollars every year. Sustainability at that level is highly dubious.”

It’s not immediately clear if New Hampshire lawmakers plan on taking the Medicaid expansion bill off the table in 2017 or will debate in 2018.

The N.H. Senate also tabled Senate Bill 149 last week that would allow out-of-state health insurance companies to operate in the Granite State without providing the benefits required under state law. It was tabled most likely to see what the federal government was going to do.

Significant questions still remain over what Obamacare would have in store for people with health insurance on the exchanges. Health experts are also curious about how the insurance industry will react in 2018. Will they stay or leave? What will rates be like? Minuteman Health in New Hampshire said it plans to be on the exchange in 2018, but no other health insurer has yet to say it would remain in the state.

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When it comes to Medicaid expansion in New Hampshire, Gov. Chris Sununu is in a tight spot. It’s not just him, actually. A lot of Republican governors across the country are having a difficult time figuring out how to balance the “repeal and replace” rhetoric on Obamacare within their party, while also seeking to protect certain provisions of the health care law, like Medicaid, that help the residents of their states.

It’s a balancing act that Sununu, the first GOP governor in the Granite State in 12 years, waded into last week. He said in its current form, he’s not “signing on” to the House Republicans’ American Health Care Act due to his concerns over Medicaid funding and coverage.

“The bill that’s been proposed in Congress gives us concerns on a lot of different levels,” Sununu said on Tuesday. “Expanded Medicaid is part of that discussion. There’s no doubt expanded Medicaid has provided [drug] recovery, treatment options for a lot of folks that otherwise may not have had that option available.”

The Congressional Budget Office estimates that $880 million less in federal money would be spent on Medicaid over the next decade. The Republican plan phases out the program by 2020 with states receiving funding for existing expansion recipients as long as they maintain continuous Medicaid coverage.

The Medicaid provisions in the Republican’s bill are reigniting a longstanding debate between conservatives and moderates of the party. Conservatives are critical of the program’s cost and performance, while moderates are worried that cuts to the program will result in a loss of funds in their state’s budget, leaving patients without help.

Sununu falls into the latter category. He has previously indicated his support for Medicaid expansion, yet doesn’t want to make the program permanent. He’s waiting to see how the Medicaid battle plays out in Congress before taking any action in the state.

New Hampshire was one of 31 states that expanded Medicaid under former President Barack Obama’s Affordable Care Act. Former Democratic Gov. Maggie Hassan, now a U.S. senator for the state, signed the plan into law in 2014 after working with Republican legislators to approve it in two-year increments. She signed the latest expansion bill in 2016, with the program scheduled to expire at the end of 2018. New Hampshire has more than 187,000 individuals enrolled in either traditional or expanded Medicaid, according to state health officials.

During Sununu’s 2016 gubernatorial bid, he said extending the state’s Medicaid program until 2018 was “probably a good step forward,” but lawmakers shouldn’t keep doing it every two years.

“I like the idea that we’re moving forward without any tax payer burden, any tax burden on the taxpayers back,” he told NH1 News in February 2016. “We have essentially a public-private partnership helping to fund it as we move forward, and those are very positive steps. What I would like to see is a long term strategy for this state, not simply taking it in two- or four- year chunks.”

Democrats attempted to paint him as opposing Medicaid expansion because of his 2014 Executive Council vote against a $292 million state contract to implement Medicaid expansion. However, the item was added to the agenda at the last minute and he tried unsuccessfully for a two-week delay to fully understand the contract. He said the council shouldn’t vote on something that hasn’t been read thoroughly.

Yet, throughout the campaign, he was ambiguous about his plans for the future of Medicaid in New Hampshire. He didn’t indicate if he was supportive of extending past 2018 or would support an outright repeal of the program.

Those in New Hampshire who were concerned about Medicaid’s future were also not consoled by a letter Sununu sent to Congressional GOP leadership in January. With Republican President Donald Trump in the White House and GOP majorities in the U.S. House and Senate, it appeared that the repeal of Obamacare was imminent.

As a result, Sununu sent a letter to U.S. House Majority Leader Kevin McCarthy, urging Congress to give states as much flexibility as possible to design their own health care systems.

“We urge Congress to untie the hands of the States,” he wrote in the letter. “Let us have the flexibility to design a New Hampshire system for New Hampshire citizens.”

However, his letter left out any mention or comment on Medicaid expansion.

It wasn’t until February that Sununu became more clear on what he thinks about the program. He said “there’s no doubt that it’s [Medicaid expansion] been helpful.”

“It was a price tag of somewhere between $400 and $500 million,” he told NHPR. “We’ve been able to do it to date without a single New Hampshire taxpayer dollar. No state taxes go into it.”

Later that month, he expanded on what he wanted to see from Medicaid in the GOP’s health care plan.

“When we hear the term block grants coming out of Washington, especially with healthcare, the opportunities are tremendous for us,” he said at a meeting of the Concord Chamber of Commerce. “We spend tens of millions of dollars on the state level on things we simply don’t need. So give us a block grant.”

When Republicans initially rolled out their health care plan, block grants weren’t included. The House plan focused on paying states a fixed per-capita amount to cover their population based on their average expenses, but a Republican amendment to the bill allowed the option for states to choose a Medicaid block grant in lieu of the capped reimbursement model.

Under current health care laws, when an eligible person enrolls in Medicaid there are matching federal funds to ensure that they get care. The block grant proposal caps that federal share, letting states decide how to spend the dollars on care. However, many health care professionals say capping Medicaid funding in block grants could hurt access to quality health care for the poor, children, and elderly by cutting the amount of federal dollars available.

It’s not immediately clear if Sununu approves of the most recent, updated version of the American Health Care Act, but Sununu said he would work with Trump to to ensure that the bill gives states the opportunity to create “flexible” and “nimble” health care program.

Democrats in the state, including Hassan, believe block grants would fail to sustain the expanded Medicaid program. It’s a position that’s shared with many advocacy groups, including AARP, which released a “fact sheet” last week about how changing Medicaid to a block grant or per capita cap could hurt New Hampshire residents.

“The House bill will impact health care seriously, but what it would do to Medicaid expansion … it would in fact repeal it,” Hassan said at a press conference last week. “That [block grants] will make health insurance out of reach for thousands of Granite Staters, and it hurts the ability of those on the front lines to save lives and fight this [opioid] epidemic.”

New Hampshire has one of the highest drug overdose death rates in the country. Nearly 500 people died from drug overdoses in 2016 and approximately 6,000 Medicaid expansion recipients have accessed treatment, state health officials said.

Sununu, and other state Republican leaders, believe block grants will allow them to allocate the money to places that need it most, such as towns hardest hit by the opioid crisis. Yet, some policy experts argue that block grants will severely strain state budgets and leave states vulnerable when they have to deal with unexpected issues, like drug outbreaks that raise the average cost of treating individual patients.

Sununu said he has spoken with Trump and Vice President Mike Pence about the importance of Medicaid with treatment and recovery for the opioid crisis, and how that requirement should continue under the GOP plan.

The N.H. Senate tabled a bill Thursday, without debate, that would make Medicaid expansion permanent. The senators said they wanted to wait to see what will happen at the national level before they tackle it in the state.

As conservatives and moderates battle it out on Medicaid provisions in the GOP health care bill, it appears New Hampshire, and Sununu, will wait for the dust to settle.

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There are 19 groups in New Hampshire that have signed on to completely resist President Donald Trump, and they’re trying to take a page out of the Tea Party’s playbook.

A new national organization called “Indivisible” is going back to the basics: push back against Trump from the grassroots level. The group published a manifesto, essentially a manual on how to resist the Trump agenda, written by former Democratic congressional staffers.

“We examine lessons from the Tea Party’s rise and recommend two key strategic components: A local strategy targeting individual members of Congress; a defensive approach purely focused on stopping Trump from implementing an agenda built on racism, authoritarianism, and corruption,” they wrote.

Indivisible, which has more than 2,400 local groups registered with them, is advising voters to assemble at the local level and have members focus on their respective elected senators and representatives by speaking out at town hall meetings, asking their elected officials questions at local photo-ops and ceremonies, showing up at their district offices for meetings, and overwhelming their phone lines with coordinated calls.

“We can all learn from their [the Tea Party] success in influencing the national debate and the behavior of national policymakers,” the group wrote. “To their credit, they thought thoroughly about advocacy tactics.”

Many progressives are trying to recreate the circumstances that led to a wave of Republican victories in Congress and state legislatures in the 2010 midterm elections. Republicans gained control of the House of Representatives, gained more seats in the Senate, and flipped several state legislative seats, mostly campaigning on conservative ideals and anti-President Barack Obama rhetoric. But liberals could find it difficult to implement a similar strategy and might find more success if they work with Trump when possible.

The Democratic Party enters the Trump presidency completely shut out of power, with Republicans in control of the White House, House, Senate, and even most state governments. And they’re already divided amongst themselves with progressives versus moderates, and whether they should oppose Trump or work with him on common interests.

Just after his first week in office, it looks like many Democrats and progressive activists want to resist him at every step. The American Civil Liberties Union already filed a lawsuit challenging Trump’s executive order that temporarily bars entry to refugees from Iraq, Syria, Iran, Sudan, Libya, Somalia, and Yemen due to terrorism concerns. A federal judge granted an emergency stay Saturday to stop deportation of people with valid visas who landed in the United States.

But if they continue that mentality, they might run into some trouble in the 2018 midterm elections and even the 2020 presidential election. Even though the party in charge usually doesn’t do well in midterm elections, many House seats will still favor Republican control due to gerrymandering. And Democrats have to defend 10 Senate seats in Republican-controlled states. The political terrain isn’t favorable for them right now.

By refusing to compromise, Democrats may be unable to influence policy even when the president’s agenda aligns with traditional Democratic interests. It’s true that rejecting compromise can reveal internal differences and struggles within the president’s own party, such as with the ongoing Republican debate on repealing Obamacare. More damage could be done by working with Trump and exposing the internal divide in the Republican Party that’s been there since the rise of the Tea Party movement in 2009.

An area some Democrats and Trump could work on together is infrastructure spending, albeit with some disagreements on how to fund it. Trump will almost need Senate Democrats to help get it through Congress. Some of his ideas resemble the “big-government conservatism” of George W. Bush that upset many Tea Partiers. Working out a few deals with Trump could anger some Republicans, and it might do more damage to the president than being vehemently opposed to everything he does.

If the Democrats could unify around that message, they could be in much better shape to retake Congress and the presidency, and ultimately be able to govern themselves and the country better than before.

Uncompromising Democratic opposition is essentially saying the party wants to be more like the Republican Party, by trying to emulate what the Republicans did in 2009. But while the Republicans were “unified” by being anti-Obama anything, they didn’t take the time to rebuild as a party and create a clear message for the base. That was evident by the loss of Mitt Romney in 2012. And now, look at them. They ended up nominating a candidate who barely aligns with their platform. They have full control over the federal government, but they still are struggling to be unified over how to run it, as exhibited by disagreement over many of Trump’s policies.

While it’s understandable that Democrats and progressive activists would want to go about rebuilding their party the same way the Republicans did in 2009, it’s better for their party to engage with Trump in policy debates because those issues are ones they can build a campaign on, and not just on partisan rhetoric.

The Democrats have a prime opportunity to genuinely build their party from the grassroots level up. If the loss of Hillary Clinton in the 2016 election taught them anything, it’s that they need to listen to the working class in Middle America again and create a message that appeals not only to their base, but also to disenfranchised voters who feel left out of the system.

It’ll prove to be difficult for them to do that though, especially with some major players on the national stage that see the party going in a different, more radical direction.

Just look at the confirmation hearing battles. Several Democratic senators who are looking to run for president in 2020 won’t vote for anything put forward by Trump out of fear from attacks to their left. John Kelly was confirmed as secretary for homeland security by a vote of 88-11. Some of those “no” votes came from Sens. Elizabeth Warren (D-Mass.), Cory Booker (D-N.J.), and Kirsten Gillibrand (D-N.Y.). The more moderate Democrats might feel pressure to vote a certain way in order to follow suit, and especially when the media reports that former Democratic presidential candidate Bernie Sanders, Warren, and Booker voted one way, it could make it seem like the Democrats who don’t fall in line aren’t supportive of the party.

An unpopular Trump could win another four years if the next Democratic presidential leader is too far outside of the political spectrum.

And speaking of leaders, the race for the next chair of the Democratic National Committee is revealing to show how anti-Trump and against compromise the Democratic Party could be. While members of their party were participating in the Women’s March earlier this month, most of the 10 candidates for DNC chair were at a private fundraising conference held by liberal political operative David Brock. The message that could send to grassroots leaders is that the Democratic Party hasn’t learned its lesson from its recent defeat and instead, continues to listen to big money rather than voters.

The latest forums between the candidates have also shown that there aren’t many disagreements between them; they don’t have many new ideas to jumpstart the party, and they all have zero desire to work with Trump.

“That’s a question that’s absolutely ridiculous,” said New Hampshire Democratic Party chairman Ray Buckley at one of the forums, when he was asked about working with Trump.

If the Democrats try to imitate the Tea Party movement, don’t create a unifying message for its voters, and resist Trump at every turn, then they’re in for a long eight years.

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