USA: The Real Reason Republicans Could NOT Kill Obamacare – Jonathan Cohn | The Atlantic 

Democrats did the work, Republicans didn’t — and that says a lot about the two parties. 

Jonathan Cohn | The Atlantic 

The affordable care act, the health-care law also known as Obamacare, turns 11 years old this month. 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 purchased, 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 long-time 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 repeal legislation failed.

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

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.

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. Obama was also 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.

Despite all of these conversations and all the preparations that came before them, the journey of the Affordable Care Act through Congress was halting and difficult, and on several occasions the whole project seemed on the verge of failure. Over the course of several months, much of it in lengthy committee hearings, leaders had agreed to a whole new series of compromises, beyond the ones they had made initially — reducing the financial assistance available to insurance buyers, for example, and nixing a “public option” that was supposed to offer a cheaper, government-run alternative, all to keep a majority coalition barely together.

These compromises frustrated the champions of reform and would have serious consequences much later, because the deals limited the Affordable Care Act’s ability to make insurance affordable for everyone. But a bill got through Congress and, with the president’s signature, became law. 

THAT WAS NO SMALL FEAT, AS REPUBLICANS WERE ABOUT TO DISCOVER. 

The GOP assault on the affordable care act began officially on March 23, 2010, the same day Obama signed the law, and it took the form of a bill sponsored by Jim DeMint, a Republican senator from South Carolina. He was among the chamber’s most conservative members, once wrote a book warning that liberals were trying to turn America into a socialist country, and frequently attacked more moderate Republicans for supporting ideas that sounded to him like “Democrat lite.” In the summer of 2009, he had riled up Tea Party activists by proclaiming that defeating health-care reform would lead to Obama’s “Waterloo.”

That original DeMint bill had just 22 co-sponsors, which was still more than the total number of words in the legislation’s one-sentence text: “The Patient Protection and Affordable Care Act, and the amendments made by that Act, are repealed.” “Repeal and replace” was the party’s official motto, but this bill was all “repeal,” no “replace.”

Following the 2010 midterms, and big Republican gains in Congress, DeMint filed a new version of his legislation. This time, every single GOP senator signed on as a co-sponsor. This was an indicator of how much the caucus, and party as a whole, was signaling support for the ultraconservative, anti-government worldview of DeMint. It also revealed how de rigueur a commitment to full, uncompromising repeal had become.

But DeMint’s new legislation still had no replacement component. And this was a sign of things to come. Although a handful of conservative intellectuals worked on proposals and although a handful of GOP lawmakers, such as Senator Orrin Hatch of Utah and Representative Tom Price of Georgia, wrote legislation, these proposals never got sustained attention from either GOP leadership or members. Republicans had nothing like the detailed, ongoing discussions with outside advisers and interest groups that Democrats and their allies had undertaken in the years before 2009 — A FAILING THAT SEVERAL FORMER REPUBLICAN OFFICIALS LATER RECOGNIZED WITH REGRET. 

One reason for this laziness was a simple lack of interest. For decades, Republicans had seemed interested in health-care policy only when Democratic policies required it. “Republicans do taxes and national security – We don’t do health care.” Brendan Buck, a former GOP leadership aide, quipped in an interview. 

That ambivalence extended to the GOP’s networks of advisers and advocates. The cadre of Republican intellectuals who worked on health policy would frequently observe that they had very little company, talking about a “wonk gap” with their more liberal counterparts. “There are about 30 times more people on the left that do health policy than on the right,” Blase said. 

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 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.

The Republican effort involved nothing remotely like the daily conference calls that the Obama White House had convened with congressional staff. “Looking back, we should have had more coordination and communication,” Emily Murry, who in 2017 was a senior Republican health-care staffer on the Ways and Means Committee, told me. “We should have had weekly meetings, if not more, with the House, Senate, and administration.” And neither Ryan nor McConnell had much experience writing complex legislation — not even McConnell, despite his reputation as a strategic genius. McConnell had distinguished himself through his creative and brazen efforts at obstructionism. But passing bills requires a different skill set than blocking them. 

Upon releasing legislation, Ryan and McConnell each found himself in the predicament Jeanne Lambrew had foreseen: Whipsawed between more moderate Republicans who thought the legislation tore down too much of the Affordable Care Act and more conservative Republicans who thought it left too much in place. Members hadn’t expected devastating Congressional Budget Office reports projecting that more than 20 million would lose insurance. They hadn’t worked out how to justify those results after so many years of promising better, cheaper health care — something their policies quite plainly did not deliver — and they had no answers for the nearly unanimous condemnations by industry and patient-advocacy groups, with whom Republicans hadn’t negotiated in advance.

Trump, who thought of himself as a master negotiator, tried to play the role that Obama had. But Trump’s success in business was mostly at branding, and legislating required workmanship, NOT showmanship. Trump couldn’t be bothered with legislative details and betrayed no clear sense of mission, except to get a big win and erase Obama’s signature accomplishment from the history books. 

Telling legislators to “get a deal here” wasn’t an especially effective tactic, and although a bill got through the House, it collapsed in the Senate when John McCain gave a dramatic thumbs-down to a scaled-back, last-gasp piece of “skinny” legislation designed simply to keep the process moving forward. The legislative debate had exposed the GOP, finally, as a party that didn’t have a plan to get more people medical care — and wasn’t especially concerned with trying to find one.

The Affordable Care Act now looks as though it’s here to stay, unless the Supreme Court surprises everybody and rules in favor of a far-fetched challenge it heard back in November; while Republicans remain focused on, and quite skilled at, delivering outrage to their supporters.

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Comments

  • brandli62  On 03/29/2021 at 12:16 pm

    The Biden administration needs to expand and secure Obama care for future generations. Access to affordable health care is standard in all advanced economies, with the exception of the US.

  • wally n  On 03/29/2021 at 12:31 pm

    The health care providers and Big Pharmacy have their knees on America’s neck. It was badly/hastily created, filled with flaws. It has to be repaired if possible, but the goons that gain the most already bought out the politicians.
    It is sad that a country that can change this in very little time, and having the resources, show little interest. (Quoting my sister now, EX obama supporter.)

  • Clyde Duncan  On 03/30/2021 at 1:17 am

    The author wrote:

    Obama was also 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.

    “Republicans do taxes and national security – We don’t do health care.” Brendan Buck, a former GOP leadership aide, quipped in an interview.

    Power had been shifting more and more to the Republican party’s most extreme and incendiary voices, whose great skill was in landing appearances on Hannity, NOT providing for their constituents.

    McConnell had distinguished himself through his creative and brazen efforts at obstructionism. But passing bills requires a different skill set than blocking them.

    The Affordable Care Act now looks as though it’s here to stay, …… while [the good fo’ nuthun] Republicans remain focused on, and quite skilled at, delivering outrage to their supporters.

    And, I agree wid duh!!

  • brandli62  On 03/31/2021 at 9:39 am

    Good analysis, Clyde!

  • Jo  On 04/01/2021 at 8:30 pm

    Also in the mix but not mentioned in this detailed review is the fact that the constituents in many Republican ridings, turned up to be vocal in support of Obamacare. No they weren’t Democrats, but hell..they’d never had such economic relief in dealing with health bills and weren’t about to give them up. So many of the poor who had worked in coal and had the ill health to prove it appreciated getting treatments for their chronic conditions caused by their years of labor. They won the day for Obamacare.

  • Clyde Duncan  On 04/02/2021 at 7:45 am

    Jo: I hear ya!! EXCEPT, Here is the thing:

    The Republican LEADERSHIP is vowing to vote AGAINST the Biden-Harris Infrastructure Plan; while we know the Republican VOTERS are for it.

    Therefore, there is an obvious disconnect between the Republican VOTERS and the Republican LEADERSHIP.

    No point in me re-inventing the wheel – the author said it:

    THE INCENTIVE STRUCTURE IN CONSERVATIVE POLITICS DOESN’T HELP, BECAUSE IT REWARDS 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, Rafael Cruz and other Republicans shut-down the government in an attempt to “defund” the Affordable Care Act that many conservative Republicans understood had no chance of succeeding.

    The Republican LEADERSHIP do NOT represent the Republican VOTERS.

  • wally n  On 04/02/2021 at 11:19 am

    All the discussions of obamacare centre around politicians, maybe a little bit of light should be directed to, people who constructed, and are still raking in billions from this mess. Everyone is being misled, they should go after, Big Pharma and the Insurance Companies. Recent history has shown politicians on both side are weak and vulnerable, chances of them cutting off an out side (large) income not gonna happen, so remember under $200,000 per year, but live in a $14 million mansion, maybe there, is your problem.

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