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The Real Reason Republicans Couldn’t Kill Obamacare

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Adapted from The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage, St. Martin’s Press 2021, and quoted from the Atlantic:

The affordable care act, the health-care law also known as Obamacare, turns 11 years old this week. Somehow, the program has not merely survived the GOP’s decade-long assault. It’s actually getting stronger, thanks to some major upgrades tucked in the COVID-19 relief package that President Joe Biden signed into law earlier this month.

The new provisions should enable millions of Americans to get insurance or save money on coverage they already purchase, bolstering the health-care law in precisely the way its architects had always hoped to do. And although the measures are temporary, Biden and his Democratic Party allies have pledged to pass more legislation making the changes permanent.

The expansion measures are a remarkable achievement, all the more so because Obamacare’s very survival seemed so improbable just a few years ago, when Donald Trump won the presidency. Wiping the law off the books had become the Republicans’ defining cause, and Trump had pledged to make repeal his first priority. As the reality of his victory set in, almost everybody outside the Obama White House thought the effort would succeed, and almost everybody inside did too.

One very curious exception was Jeanne Lambrew, the daughter of a doctor and a nurse from Maine who was serving as the deputy assistant to the president for health policy. As a longtime Obama adviser, going back to the 2008 transition, Lambrew was among a handful of administration officials who had been most responsible for shaping his health-care legislation and shepherding it through Congress—and then for overseeing its implementation. Almost every other top official working on the program had long since left government service for one reason or another. Lambrew had stayed, a policy sentry unwilling to leave her post.

On that glum November 2016 day following the election, Lambrew decided to gather some junior staffers in her office and pass out beers, eventually taking an informal survey to see who thought Obama’s signature domestic-policy achievement would still be on the books in a year. Nobody did—except Lambrew.

Yes, Republicans had already voted to repeal “Obamacare” several times. But, she knew, they had never done so with real-world consequences, because Obama’s veto had always stood in the way. They’d never had to think through what it would really mean to take insurance away from a hotel housekeeper or an office security guard on Medicaid—or to tell a working mom or dad that, yes, an insurance company could deny coverage for their son’s or daughter’s congenital heart defect.

A repeal bill would likely have all of those effects. And although Republicans could try to soften the impact, every adjustment to legislation would force them to sacrifice other priorities, creating angry constituents or interest groups and, eventually, anxious lawmakers. GOP leaders wouldn’t be able to hold the different camps within their caucuses together, Lambrew believed, and the effort would fail.

All of those predictions proved correct. And that wasn’t because Lambrew was lucky or just happened to be an optimist. It was because she knew firsthand what most of the Republicans didn’t: Passing big pieces of legislation is a lot harder than it looks.

It demands unglamorous, grinding work to figure out the precise contours of rules, spending, and revenue necessary to accomplish your goal. It requires methodical building of alliances, endless negotiations among hostile factions, and making painful compromises on cherished ideals. Most of all, it requires seriousness of purpose—a deep belief that you are working toward some kind of better world—in order to sustain those efforts when the task seems hopeless.

Democrats had that sense of mission and went through all of those exercises because they’d spent nearly a century crusading for universal coverage. It was a big reason they were able to pass their once-in-a-generation health-care legislation. Republicans didn’t undertake the same sorts of efforts. Nor did they develop a clear sense of what they were trying to achieve, except to hack away at the welfare state and destroy Obama’s legacy. Those are big reasons their legislation failed.

Obamacare’s survival says a lot about the differences between the two parties nowadays, and not just on health care. It’s a sign of how different they have become, in temperament as much as ideology, and why one has shown that it’s capable of governing and the other has nearly forgotten how.

Democrats were so serious about health care that they began planning what eventually became the Affordable Care Act more than a decade earlier, following the collapse of Bill Clinton’s reform attempt in the 1990s. The ensuing political backlash, which saw them lose control of both the House and Senate, had left top Democrats in no mood to revisit the issue. But reform’s champions knew that another opportunity would come, because America’s sick health-care system wouldn’t heal itself, and they were determined not to make the same mistakes again.

At conferences and private dinners, on chat boards and in academic journals, officials and policy advisers obsessively analyzed what had gone wrong and why—not just in 1993 and 1994 but in the many efforts at universal coverage that had come before. They met with representatives of the health-care industry as well as employers, labor unions, and consumer advocates. Industry lobbyists had helped kill reform since Harry Truman’s day. Now they were sitting down with the champions of reform, creating a group of “strange bedfellows” committed to crafting a reform proposal they could all accept.

Out of these parallel efforts, a rough consensus on substance and strategy emerged. Democrats would put forward a plan that minimized disruption of existing insurance arrangements, in order to avoid scaring people with employer coverage, and they would seek to accommodate rather than overpower the health-care industry. The proposal would err on the side of less regulation, spending, and taxes—basically, anything that sounded like “big government”—and Democrats would work to win over at least a few Republicans, because that would probably be necessary in Congress.

Proof of concept came in 2006, in Massachusetts, when its Republican governor, Mitt Romney, teamed up with the Democratic state legislature to pass a plan that fit neatly into the new vision. It had the backing from a broad coalition, including insurers and progressive religious organizations. Ted Kennedy, the liberal icon and U.S. senator, played a key role, by helping secure changes in funding from Washington that made the plan possible. “My son said something … ‘When Kennedy and Romney support a piece of legislation, usually one of them hasn’t read it,’” Kennedy joked at the signing ceremony, standing at Romney’s side.

Kennedy’s endorsement said a lot about the psychology of Democrats at the time. No figure in American politics was more closely associated with the cause of universal health care and, over the years, he had tried repeatedly to promote plans that looked more like the universal-coverage regimes abroad, with the government providing insurance directly in “single-payer” systems that resembled what today we call “Medicare for All.” But those proposals failed to advance in Congress, and Kennedy frequently expressed regret that, in the early 1970s, negotiations over a more private sector-oriented coverage plan with then-President Richard Nixon had broken down, in part because liberals were holding out for a better deal that never materialized.

Kennedy was not alone in his belief that the champions of universal coverage would have to accept big concessions in order to pass legislation. The liberal House Democrats John Dingell, Pete Stark, and Henry Waxman, veteran crusaders for universal coverage who’d accrued vast power over their decades in Congress, were similarly willing to put up with what they considered second-, third-, and even fourth-best solutions—and they were masters of the legislative process, too. Waxman in particular was an expert at doing big things with small political openings, such as inserting seemingly minor adjustments to Medicaid into GOP legislation, expanding the program’s reach over time. “Fifty percent of the social safety net was created by Henry Waxman when no one was looking,” Tom Scully, who ran Medicare and Medicaid for the Bush administration in the early 2000s, once quipped.

Obama had a similar experience putting together health-care legislation in the Illinois state legislature—where, despite proclaiming his support for the idea of a single-payer system, he led the fight for coverage expansions and universal coverage by working with Republicans and courting downstate, more conservative voters. He also was a master of policy detail, and as president, when it was time to stitch together legislation from different House and Senate versions, he presided over meetings directly (highly unusual for a president) and got deep into the weeds of particular programs.

Obama could do this because the concept of universal coverage fit neatly within . . .

Continue reading. There’s much more.

Later in the column:

Another problem was a recognition that forging a GOP consensus on replacement would have been difficult because of internal divisions. Some Republicans wanted mainly to downsize the Affordable Care Act, others to undertake a radical transformation in ways they said would create more of an open, competitive market. Still others just wanted to get rid of Obama’s law and didn’t especially care what, if anything, took its place.

“The homework that hadn’t been successful was the work to coalesce around a single plan, a single set of specific legislative items that could be supported by most Republicans,” Price told me. “Clearly, looking at the history of this issue, this has always been difficult for us because there are so many different perspectives on what should be done and what ought to be the role of the federal government in health care.”

The incentive structure in conservative politics didn’t help, because it rewarded the ability to generate outrage rather than the ability to deliver changes in policy. Power had been shifting more and more to the party’s most extreme and incendiary voices, whose great skill was in landing appearances on Hannity, not providing for their constituents. Never was that more apparent than in 2013, when DeMint, Senator Ted Cruz of Texas, and some House conservatives pushed Republicans into shutting down the government in an attempt to “defund” the Affordable Care Act that even many conservative Republicans understood had no chance of succeeding.

The failure to grapple with the complexities of American health care and the difficult politics of enacting any kind of change didn’t really hurt Republicans until they finally got power in 2017 and, for the first time, had to back up their promises of a superior Obamacare alternative with actual policy. Their solution was to minimize public scrutiny, bypassing normal committee hearings so they could hastily write bills in the leadership offices of House Speaker Paul Ryan and, after that, Senate Majority Leader Mitch McConnell.

Written by LeisureGuy

28 March 2021 at 4:52 pm

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