The following is adapted from Jonathan Cohn’s “The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage,” to be published by St. Martin’s Press on February 23.
Everybody is talking about how Democrats need to avoid the traps that ensnared them during former President Barack Obama’s first term, when they repeatedly got bogged down in bipartisan negotiations, made all sorts of substantive concessions on policy, and still got virtually no GOP support for their initiatives.
Not so long ago, I got to interview an expert on the matter: President Obama himself.
Our conversation took place in early March 2020, well before anyone knew Joe Biden would win the nomination and become president this year, or that Democrats would also have full control of Congress, or that the overwhelming political priority would be dealing with COVID-19. And strictly speaking, the interview with Obama wasn’t about how Democrats should govern. The subject was the Affordable Care Act, for a new book about the law’s history that is coming out on Tuesday.
But the conversation covered a lot more than health care policy, because it’s impossible to talk about the 2010 law without talking about the ways politics have been changing in the past decade, and how those changes affected what Democrats were and weren’t able to do. In many ways, the saga of the Affordable Care Act is a case study in the challenges that progressives must overcome if they want to pass ambitious legislation ― challenges facing Democrats now just as surely as they did during Obama’s tenure.
The Democrats today have one advantage, though. They can learn from the past. And when I asked Obama to reflect on what he and the Affordable Care Act’s architects got wrong, he cited a failure to grasp the depth and duration of GOP opposition.
“I think what we got wrong was underestimating the degree to which political polarization had ― the degree to which political polarization meant that the issue was never settled,” the former president said, adding later, “I think any progressive president, on any issue for the next several years, is going to have to confront the problem that the GOP has shifted into a perpetual campaign mode.”
Obama’s focus on Republican opposition and its effects may sound self-serving to some people ― whether it’s conservatives who blame Obama for polarizing the country, or progressives who think Obama is trying to avoid blame for compromises he should never have made. Reasonable people can certainly question individual decisions that Obama, along with other Democratic leaders, made at various points in the Affordable Care Act’s history.
But the transformation of the Republicans into a more ideologically and temperamentally extreme party really has changed American politics in profound ways, and Democrats really do need to adapt to that transformation if they want to succeed. That means paying attention to what went wrong with the Affordable Care Act ― although, to be clear, it also means recognizing what went right. And Obama has some ideas about that too.
A Blueprint For Compromise
The conversation with Obama, inside an office building not far from the White House, lasted for nearly an hour. He looked more relaxed than I’d ever seen him. He was wearing a black, open-collar shirt, casual dark gray pants and loafers ― and, as he gleefully pointed out, no socks. “The best part of not being president anymore,” he said of his attire. But he talked like he always did, with that deliberate, professorial cadence and sentences full of dependent clauses in order to capture every last nuance.
The timing seemed fortuitous because it was right before the 10-year anniversary of the Affordable Care Act’s signing, a milestone he planned to mark by attending a conference and celebration at American University nearby. Then the pandemic hit, forcing it to be canceled, which felt somehow appropriate given that the law continues to inspire mixed feelings. Approval of the program is higher than in the past, according to polls, but it’s still lower than cherished programs like Medicare and Social Security.
Some of that is due to polarization, with Obamacare popular among Democratic voters and unpopular among Republicans for reasons that probably have little to do with anything but partisan loyalty. But performance is still an issue. Many millions still can’t pay their medical bills, because they don’t have insurance or their insurance covers too little. The U.S. still has the world’s most confusing and expensive system, with little evidence that the extra money buys better quality.
Not that the Affordable Care Act’s architects thought they were fixing all of the health care system’s problems. After nearly a century of failed attempts at passing universal coverage, most recently during Bill Clinton’s presidency, Democrats were determined to find a more politically viable path. By around 2006 or so, a consensus had taken shape around a plan that leaned heavily on private insurance and minimized disruption of existing arrangements, and a strategy that stressed negotiating with the health care industry rather than fighting it.
It was a far cry from the government-run insurance plan that Harry Truman once championed, but Democratic leaders embraced it as the best they could get ― and so did Obama, who repeated in our interview his belief that something like a government-run, “single-payer” system would probably work best, but creating one right away would be too difficult.
“We have a legacy system that is one-sixth of the economy,” Obama said. “The idea that you could, in some way, dismantle that entire system ― or even transition it entirely ― to a single payer system looked politically impractical and probably really disruptive. … The best chance to actually get people healthier was going to be to design a system that acknowledged 85% of the American people have health insurance and that plugged the gap for those 15% who don’t.”
The concept was notional until April 2006, when a state-level reform fitting those criteria became law in Massachusetts, with the signature of a Republican governor (Mitt Romney) and support of some conservative intellectuals (at the Heritage Foundation). It was proof of concept for the Democrats ― including Obama, who, while putting together his campaign health plan, was already thinking about what might get GOP votes.
“I was never under an illusion that we would get majority Republican support,” Obama said. “But it was my belief that a law signed by Mitt Romney, and that could be traced back to ideas that had appeared in the Heritage Foundation literature, would give some political cover to those Republicans who were so inclined to vote for it.”
“Obviously,” Obama said, “that did not prove to be the case.”
Opposition As The Republican Brand
No, it did not — although, contrary to what some Republicans say now, it was not for Democrats’ lack of effort. In addition to believing in bipartisanship as a virtue, Obama could count votes, especially in the Senate, where a small-state bias gave conservative states disproportionate power ― and where the filibuster was becoming a de facto, 60-vote requirement for all legislation.
Among the many political realities of 2009 frequently forgotten today are that Democrats had only 58 Senate seats for the first few months, because of litigation over Minnesota’s close Senate race (eventually Democrat Al Franken won the seat) and because Pennsylvania Sen. Alan Specter was still a Republican (eventually he switched parties).
Ending the filibuster wasn’t on the political agenda in the way it is now. And Democratic leaders rejected the idea of using the budget reconciliation process, where they wouldn’t have to worry about the filibuster, in part because they thought its complex parliamentary rules would prohibit essential parts of the proposal, turning legislation into “Swiss cheese.”
Behind a belief in the necessity of bipartisanship was a faith that it was possible ― a notion that didn’t seem as preposterous then as it does now.
Lawmakers from both parties had collaborated in the late 1990s to create a new program for insuring children. The senators who led that effort were Orrin Hatch, the conservative Republican from Utah, and Ted Kennedy, the liberal Democrat from Massachusetts. At one point in 2008, a former Kennedy aide told me, Hatch dispatched his advisers to see if the two could work together on a universal coverage bill.
Another possible GOP partner was Iowa Sen. Charles Grassley, who had worked closely with the top ranking Democrat on the Finance Committee, Montana’s Max Baucus, on the Medicare drug program under President George W. Bush. They had a close relationship and, at a private meeting of several senators that Baucus convened just after the election in 2008, Grassley said, “I haven’t heard anything here I don’t like … I can’t think of an issue that isn’t compromise-able,” according to the notes one participant took.
But even if Hatch and Grassley were truly interested in bipartisanship, they did not speak for their party or for leadership, which from the beginning urged members to oppose Obama’s agenda fully ― as Mitch McConnell, who was (and is again) the Senate minority leader, later admitted. All of this happened at a time when the GOP was also becoming more ideologically extreme, with conservatives displacing the remaining moderates.
By the middle of 2009, Jim DeMint, the arch-conservative South Carolina Republican who had riled up Tea Party activists by promising that defeating reform would be Obama’s “Waterloo,” was setting the tone on health care. Grassley, facing the threat of a conservative primary challenge, started talking about “death panels” at events back home. And in a meeting Obama later described in his memoir, the Iowa senator told the former president there was no concession that would win his vote.
The Leverage Of Conservative Democrats
The ultimate futility of courting Republicans — so memorable today — is one of many grievances more progressive Democrats still hold over Obama’s handling of the health care law. And in the popular imagination, it is the main reason Obama made so many key compromises, like dropping a “public option” — the idea of a government-run insurance plan that would offer a more efficient, more patient-friendly alternative to private insurance.
But here too it is easy to forget another reality of 2009 politics, one still very relevant today: The big pressure to compromise came from conservative Democrats who had leverage to kill legislation if they wanted. In the Senate, this was a function of the same small-state bias that gave Republicans outsized power, and as a practical matter, it meant that Democratic leaders were constantly trying to satisfy senators from places like Arkansas and Nebraska where voters were especially suspicious of big new federal programs and prone to believing conservative propaganda about what proposed legislation would do.
Those conservative Democrats were the ones who were dead set against the public option. They were the ones who kept pushing to give state officials more power over the program. They were the ones most anxious over new spending. And those decisions had consequences later, when the law took effect. Among other things, it meant less financial assistance for some middle-class Americans buying insurance.
Whether Obama could have pushed conservative Democrats harder, or picked different places to give ground, remains a source of disagreement between him and some of his liberal allies even today. What’s not in dispute is that Obama always realized the law would need more work. That’s why he talked about it as a “starter home,” with the expectation that it would be possible to bolster and expand the program over time, through a series of legislative and administrative fixes.
But that chance never came, because Republicans focused on repeal and, at times, trying to sabotage the program outright. “Think about Medicare,” Obama said. “That was a big political fight, but once it got passed, everybody moved on and tried to make it work. Bush’s drug benefit program, right? It was a contentious issue. But once it got passed, even those Democrats who had opposed it tried to make it work.”
In our interview, Obama still seemed taken aback that Republican state officials were refusing to expand Medicaid eligibility, as the Affordable Care Act envisioned, even though the federal government had committed to covering most of the cost and literally millions of low-income Americans scattered across states like Florida, Georgia and Texas stood to get insurance.
“What I did not see, for example, was Republican governors refusing [federal] Medicaid dollars that would provide health insurance to millions of their people,” Obama said. “We’ve never seen in American history a situation in which state governments reject benefits for their people purely on ideological grounds.”
Fixing The Senate ― And Democracy
Near the end of the conversation, I thought back to something Obama said at the March 2010 signing ceremony: “We are a nation that faces its challenges and accepts its responsibilities. We are a nation that does what is hard. What is necessary.” Had the difficulty passing and implementing Obamacare shaken that faith?
“No,” he said quickly, “because it passed, and 20 million people got health insurance, and it’s still there.“ Then he paused, opened his eyes a bit wider, and started up again: “But I think what it does reveal is some major structural problems in our current political system that make it much harder to do big things than it used to be.”
One of those structural problems, he said, is that “the conservative media universe operates in an entirely different universe,” less tethered to reality. Another, he said, is the makeup U.S. Senate, where the small-state bias gives lawmakers representing a small portion of the population the ability to block legislation ― and to escape accountability for doing so.
“You can have something that 70% of the country wants and it can’t pass,” Obama said. “And that can’t be how any democracy functions over time. If you ask me what has contributed to the cynicism ― of government, and to some degree what contributed to the cynicism around the health care initiative ― it’s the fact that a small minority of people can put a halt to everything.”
Eliminating the filibuster would mitigate, although not eliminate, the small-state bias ― and Obama said that “may” be necessary. When I pressed to see if he’d endorse the idea more clearly, he said, “That’s a longer argument and discussion to have.” (Several months later, at the funeral of Democratic Rep. John Lewis of Georgia, Obama offered a stronger endorsement for ending the 60-vote requirement, though he was specifically speaking about voting rights legislation.)
Obama also said future Democrats need to make different policy design decisions. Specifically, he said, they should expect no more cooperation for implementing their reforms than he got for the Affordable Care Act ― although, he warned, without such cooperation, making government programs work is bound to be a lot more difficult:
“You get the program started, you figure out what the kinks are, what works, what doesn’t. You amend, build, improve, refine ― that kind of iterative process, where you’ve set a goal and gotten the foundations laid, and then Congress in a cooperative fashion works to keep making it better. That process, which is very beneficial because you’re getting real data and feedback about what’s working and what’s not ― that’s less available to you now. The process that built Social Security, built Medicaid, Medicare, that only works if you got both parties working in good faith.”
Hard Things Are Hard; Better Is Good
The awareness of structural problems in American politics, starting with the Senate, already feels stronger than it did a year ago, when Obama said all of these things to me. And the approach Democrats are taking to their COVID-19 relief bill suggests they are learning to adapt. Party leaders decided early on to use budget reconciliation, so they can pass something with 50 votes in the Senate; Republican support would be nice, they said, but they’re not going to hold up legislation for it.
But reconciliation isn’t a cure-all for the Senate’s structural problems, especially given the strict, quirky rules about what provisions can even pass through that process. And at least for the moment, ending or even reforming the filibuster seems to be off the table.
A big reason for that is the same one that checked liberal ambitions in 2009: the resistance of more conservative Democrats. Already two of them, West Virginia’s Joe Manchin and Arizona’s Kyrsten Sinema, have said they would oppose eliminating the filibuster. They’ve also expressed skepticism about ideas high on the progressive agenda, like raising the minimum wage to $15 an hour.
They could change their minds of course. And the pressure to enact these policies could build, thanks to a progressive movement that is already louder and more organized around goals than it was during Obama’s presidency. But even if Democrats succeed at reducing structural barriers to change, and even if a progressive movement succeeds in demanding more action, legislation is likely to be full of compromises and fall short of Democrats’ loftiest goals, just like the Affordable Care Act did.
Those kinds of compromises are frequently deflating. That doesn’t mean they should be, and the Affordable Care Act is an example of why. It still achieved a lot ― more, in fact, than even many liberals seem to grasp. It’s already transformed the political conversation on health care, so that the principles of universal coverage now have wide acceptance.
The proof is in the rhetoric of Republicans, who claim to support these goals as much as Democrats do, while promising supposedly better alternatives they’ve never been able to pass as legislation.
“The fact that they haven’t been able to come up with something,” Obama said, “indicates either bad faith on their part or the fact that we were pretty thorough and looking at all the options and we arrived at what was the most realistic way to deliver universal health coverage.”
The Affordable Care Act’s other impact is the human one ― the people who got insurance and are better off, financially and medically, according to a substantial and growing pile of research. The number of Americans without insurance remains near historic lows. It’s no exaggeration to say that the Affordable Care Act, for all of its inadequacies, is still the most far-reaching and significant domestic policy achievement in half a century.
Talking about his “starter home,” Obama told me, “It’s been vandalized. And people at times tried to undermine its foundations. But it’s held up.” He’s right, and now the Biden administration may even have a chance to do some of the repair work Obama never could, starting with extra funding for subsidies that is already in the Democratic COVID-19 relief bill.
Two of Obama’s favorite sayings are “hard things are hard” and “better is good.” Both apply in this case, and today’s Democrats would do well to keep them both in mind.
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