I set out to read The Ten Year War because I wanted to know about what I think must be the biggest political battle of my life. I think the first time I became really aware of politics was around the time when I was 14 or 15 and the Tea Party was emerging. A huge part of that was the opposition to Obamacare, and I remember the weeks and months when videos were constantly coming out of these town hall meetings going crazy over "death panels" and the like. So anyway, this book was just what I was looking for and more. In it, Cohn not only deals with the fight to pass Obamacare, but the decades-long prelude to it and the years of Republican attempts to "repeal and replace" the law after it was passed, which ended in defeat when John McCain gave a "thumbs-down" in July 2017. The book starts with one part about the prior attempts to pass universal healthcare, with extra focus on the Clinton years. Part two is about the legislative fight to pass Obamacare, and then part three is about Republican backlash to the law and attempts to change it.
There was longstanding feeling in both major parties that the healthcare system as it stood in the 1990's and 2000's was inadequate. Primarily, the issue was that large numbers of people, usually the young and healthy or the poor, did not get healthcare and were not purchasing healthcare through their employers. This led to high rates of uninsured, and the uninsured often went to emergency rooms to get care, causing delays for others. Additionally, high costs of healthcare plagued the system. Hospitals regularly charged exorbitant prices to insurers, who could haggle them down, but also charged them to the uninsured, who could not afford them.
Cohn identifies one of the critical difficulties with the cost of health insurance in a portion of the book I felt should have been much longer. I was interested to read that, "Back in the 1940s, the federal government had made a critical decision: if an employer provided an employee with insurance, the premiums wouldn't be subject to income taxes. The effect was to make a dollar of health insurance more valuable than a dollar in wages, and over the long run, it helped entrench job-based insurance as the primary source of coverage for working-age Americans. But the exception (or exclusion, as it was officially called) gave both workers and employers incentive to devote more money to healthcare--incentive that, most economists agreed, discouraged cost consciousness in healthcare, leading to more spending, eventually leading to higher costs for everybody." So there it is. That's why healthcare costs more in the United States than anywhere else on Earth. But that's not the problem Democrats tried to solve.
Republicans, on the other hand, were not really dedicating much serious intellectual effort towards fixing the healthcare system. You had some proposals, but by the 90's, Republicans were more focused on stopping Democrats' changes to healthcare. For example, in 1993, John Chaffee, a Republican Senator, authored a bill that was supported by other Republicans that would have expanded healthcare coverage through an individual mandate. Clinton’s, on the other hand, used payroll taxes on employers to fund increased coverage. There was plenty of room for compromise, but as the overall political environment became more polarized and toxic in the 1990's, neither side could compromise. In 1994, the Republican Revolution made Newt Gingrich the Speaker of the House, and he fought the Clinton plan until it was just a smaller expansion of government-run healthcare for children, CHIP.
After the failure of the Clinton effort, which the book details a lot more than I do, Democrats were not ready to give up. Trying to expand cheap health insurance had been a major goal of the party since the 1940s and 50s. The Service Employees International Union (SEIU) pushed candidates hard in 2004 to come up with plans to increase healthcare coverage and lower the cost of insurance. One great irony is that a Republican governor, Mitt Romney, achieved the biggest success in healthcare for the time. In Massachusetts, where he governed with Democratic legislators, Romney had passed a prototype for what would become Obamacare. While Romneycare didn't raise taxes on individuals, it was fundamentally similar to Obamacare. And the reason it didn't raise taxes on individuals is because it got extra money from the federal government to finance the expansion. Critically, the state used an individual mandate, which Romney had said would be a model for the nation, a line that he repudiated in 2011 to clarify that the states should try it on their own. I think that a big unanswered question is that if McCain won in 2008, could Obamacare still happen? It seems to me like Republicans were on their way to a version of Romneycare that would have been fundamentally similar to Obamacare. It is pretty tragic to think of how much time and energy was wasted fighting on Obamacare when in retrospect the disagreements on it are so slight.
By the 2008 race, healthcare was a top issue for Democrats. Hillary Clinton had been dedicated to the issue since the 1990s, and Obama adopted it as well. Something that surprised me is how popular in 2008 the individual mandate was as a plan among Democratic elites. It seems like most experts considered that to be the only way to sell the idea to insurance companies and to lower the overall cost of healthcare, because by forcing healthy people to buy healthcare, costs would be lower for everyone else. I guess my surprise is just at how little it was discussed how unpopular that would be, and it seems like Democrats weren't anticipating the level of pushback they would get on that mandate.
When Obama became president, then-vice president Joe Biden urged him not to tackle healthcare. The gist of his argument was that it would tank his presidency and be a waste of time for very little gain, and in retrospect it seems like he wasn't entirely wrong. But Obama decided to go for it anyway. Obama also decided not to try to pass the bill through budget reconciliation, which would have gotten around the filibuster and passed the bill with 51 votes rather than the 60 that had become necessary in the modern Senate. The belief at the time was that bipartisan reform would be easier to sustain politically and that reconciliation would alienate more moderate Democrats, who wanted bipartisan cover. I would say that in retrospect this was an enormous mistake for the Democrats. They probably couldn't have known the extent of it then, but there was no way this was going to be bipartisan.
One critical aspect of Obamacare was the Medicaid expansion, which provides health insurance to those with low incomes. In June 2009, the House Democrats proposed that everyone with an income of 133% of the poverty line would qualify for Medicaid, and that those with higher incomes could buy insurance policies through exchanges. The exchanges idea was based on the plan that Mitt Romney had backed as Governor of Massachusetts, that created an exchange called the Massachusetts Connector. To finance the Medicaid expansion, House leaders proposed increasing taxes on the wealthy and cutting Medicare payments for some industry sectors. The proposal also included an individual mandate, an idea that Obama had rejected during the primaries but had signaled that he would support it in April. Moderate Democrats negotiated to weaken the public option, which would have allowed all Americans to buy into Medicare. Now, those who bought into Medicare would still be able to do so through the public option, but Medicare would have to negotiate prices for reimbursements just like a private insurance plan, making it a more expensive choice.
The Democrats knew that they couldn't just craft a good bill. That was only half the work. They needed to draft something that would garner institutional support. In the 1990s, the American Medical Association and health insurance lobbying groups had fought the Clinton administration hard and killed their legislation. But this time, Democrats got pharmaceutical companies to lobby for the bill.
However, Democrats faced unprecedented opposition from Republicans that was greater than anything they imagined. Republican leaders called the plan a government takeover and suggested that the Democrats' plan would centralize healthcare like in Canada and Europe. Republicans then went on to make false claims that those countries were rationing care. In June, the first conservative invented the ideal of "death panels," when analyst Elizabeth McCaughey alleged that the legislation would make it mandatory for people in Medicare to have a required counseling session to tell them how to end their life sooner. In actuality, the bill only provided for reimbursement to doctors for time spent advising patients who wanted to write advance directives for their end-of-life care. Then, a few weeks later, Sarah Palin coined the actual term "death panel" in a Facebook post.
Then, conservative groups formed the Healthcare Freedom Coalition, which financed advertisements against Obamacare and bussed people to events. They distributed scripts to individuals that trained them how to succeed at a town hall meeting by spreading out in the front half of the room, and to challenge the speaker's arguments early. Their lobbying and activism were extremely effective, and convinced moderate Pennsylvania Senator Arlen Specter to announce that he would switch parties, taking the Democratic majority from 60 to 59 in the Senate. The Democrats then seated Al Franken in Minnesota, but this left them with a bare 60 vote majority to pass the bill with every Democrat vote. In April 2009, 51% approved Obama's handling of healthcare with 26% disapproving, but by July, only 42% approved while 46% disapproved.
At this point, Obama decided to assert more control over the process to pressure Senator Max Baucus, who had led the effort so far, to move his bill forward. Meanwhile, in the House, Democrats passed their bill with 220 votes, gaining just one Republican. In the Senate, Majority Leader Harry Reid tried to include a public option in the bill, but was forced to compromise with moderates on creating the public option to buy into Medicare only for those 55 and over. But then, when agreement was allegedly reached on the issue in the Senate, Senator Joe Lieberman claimed that there was no agreement the day after Reid had announced it. Reid decided to go ahead without the public option, because he really had no other choice, but progressives were furious. 2004 presidential candidate Howard Dean advocated for passing the bill through budget reconciliation, but Obama and the Democratic leadership disagreed. I would say in retrospect that this was the next big mistake. After seeing how the next 13 years of American politics played out, it is clear that the Democrats missed a huge opportunity at this junction by trying to pass a bipartisan bill. In reality, the bill would not be bipartisan, and there would be no major bipartisan legislation for years to come, at least through the time I am writing this.
In late 2009, Democrats ran into another issue with a moderate in the party, and this time it was Ben Nelson, Senator from Nebraska. Nelson said he opposed Medicaid expansion because it would force states to spend more money on the program. This was true, but the program had the federal government paying the vast majority of the costs. Nelson preferred to make the Medicaid expansion optional, and that in states that did not expand, the federal government would subsidize private insurance for the poor. The problem is that this would cost much more money, because subsidizing individuals did not have the economy of scale that Medicaid expansion would offer. In the end, Reid was able to make a deal with Nelson known as the "Cornhusker Kickback," covering all the expenses of Nebraska's Medicaid expansion. In the end, expansion would be optional anyway, so Nebraska got to have its cake and eat it too. However, the Cornhusker Kickback was an obvious source of major controversy, and wasn't even popular in Nebraska. That absolutely blows my mind that Nebraskans weren't celebrating the guy who got them a ton of free money from the federal government.
In the end, the Democrats succeeded with a 60-39 vote in the Senate in December, with the bill being endorsed by the AARP and the American Medical Association. However, in January, Ted Kennedy, who had died in August 2009, was replaced by a Republican, meaning that Democrats would lose filibuster-proof supermajority before they could reconcile the House and Senate bills. The Democrats were forced to pass the Senate bill as it was in the House, and then passed a second bill through reconciliation that featured smaller changes that the House wanted. In retrospect, and I know I keep saying this, it probably would've been smarter for the Democrats to have just used reconciliation to start with.
The bill was implemented, but Republicans pledged to repeal it. After efforts to repeal it in the Supreme Court failed (except for making Medicaid expansion optional), Republicans led by Jim DeMint (who had left the Senate to lead the Heritage Foundation) attempted to pass an appropriations bill with zero funding for Medicaid expansion. They were aided by struggles in implementation of Obamacare, the crashing of the exchange website on its first day, and the revelation that not veryone could keep their healthcare plans. I still do not understand what exactly happened with the "if you like your plan, you can keep it" failing. Like, what forced people off plans they liked and why? On the other hand, healthcare was improving. Cohn writes that, "nationwide, clinic visits increased by 26 percent in the six years following the Affordable Care Act's enactment, with dental visits (another service many clinics provided) up 43 percent and behavioral health visits up 57 percent."
Republicans they could only repeal if they won the presidency, which they did in 2016, inaugurating Donald Trump the next January. Unfortunately for the Republican establishment, Trump was not very interested in Obamacare repeal, and in fact, in the past he had supported universal healthcare, which would mean taking Obamacare further. But eventually he came around. Paul Ryan was now Speaker of the House, and he and Trump pledged to repeal Obamacare within the first hundred days of the administration, smartly using reconciliation. Although I will note that by this point, everyone understood where we were at in terms of polarization, and the Republicans didn't have 60 seats in the Senate, so reconciliation was the only serious option. They also planned for the repeal law to be delayed by two years to give them time to come up with a replacement.
At this point, Republicans faced a huge problem: they were finding out that their voters opposed the "Obama" part of Obamacare, and not the substance of the law. I remember this was a huge part of the discourse at the time. If you polled people on Obamacare, they disapproved. But if you polled people on the individual provisions of Obamacare, they supported them all except for maybe the individual mandate. Now, the House was in the hands of Paul Ryan, who was zealously trying to reduce the size of government, but he faced a political base that didn't want to lose the benefits Obamacare had given them.
The Republican plan for replacement of Obamacare called for ending protection of those with preexisting conditions and replacing it with "continuous coverage," meaning a continuation of the Obama policy (basically grandfathering it in) unless it lapsed. It also called for creating high-risk pools, so basically separating sick and healthy in health insurance and then subsidizing the sick. This sems ironically more socialistic to me than the Democratic plan. Finally, the Republicans called for transforming Medicaid into a block grant, which would likely reduce overall spending for reasons I didn't fully understand. Cohn writes that the disputes Republicans were having sounded much like the problems Democrats had eight years earlier, except that the Democrats had already spent decades studying these issues. Republicans split into factions and were floundering.
In contrast to the Democratic efforts to pass the bill, Republican efforts to repeal it were highly centralized. Pelosi and Reid had allowed committees to write the ACA, but Ryan and McConnell managed the process much more closely in 2017. When the bill was unveiled, Senators and Representatives didn't know enough about it to answer criticisms. Additionally, since the bill hadn't been workshopped with the industry, the AMA, AARP, and major hospital groups opposed it publicly. Even worse was the score from the Congressional Budget Office (CBO) announcing that it estimated twenty-four million people would lose health coverage under the Republican bill. It also shifted subsidies so that some elderly would pay much more while some younger people would pay much less. Despite those obstacles, the bill passed the House by a narrow vote of 217-213. But in the Senate, the bill failed, with McCain famously giving a thumbs down and ending the Republican effort to repeal Obamacare.
Looking back, Obama said that he would have pushed single-payer if he could do it all over. He has expressed how the level of resistance from Republicans surprised him. And in retrospect I think that makes a lot of sense. The Democrats went in having already negotiated themselves to a position they thought Republicans would accept, not realizing that there was no position that Republicans would accept. The Democrats went in on hard mode, needing 60 votes in the Senate instead of 50 through reconciliation. And now, no Republicans even care about Obamacare anymore. As soon as the repeal effort ended, the issue disappeared. It is so weird to read about it now, because Obamacare really was the biggest legislative fight of the last twenty years and today you would hardly know it ever happened. I think this is primarily because of changes in the Republican party. By the time Obama was elected, Republicans were losing substance and now they are just running on vibes. Democrats are heading down this path too. It feels like politically the nation is less interested in policy and more interested in condemnations and posting. So, when Republicans tried to repeal Obamacare, the purpose wasn't to actually repeal it, but just to express a position.
This leads me to believe that it's no longer worth it in American politics to pursue big plans like this that play out over years. If the Democrats had chosen a more instant policy, they would have been able to at least face the consequences in the 2010 midterms. But in 2010, the law hadn't gone into effect yet. So the system wasn't really working because Democrats were rejected in 2010 because of Obamacare when nobody knew what its impact would be. It feels like a political system where we vote every two years requires us to have short attention spans and pass laws that are impactful in that time. Because we really needed at least five years to evaluate Obamacare. If that had been possible, then people probably wouldn't have been so worked up about it.
This book made me want to read something about the debate on the stimulus package used to fight the Great Recession. It loomed in the background here that maybe the real opposition was not to the healthcare law, but to Obama himself (plausible) or to the stimulus law, seen as wasteful government spending. It seems like that's another area where we got the worst of both worlds. In Obamacare, we got acrimonious public debate without a strong policy, only a transitionary, stopgap measure. And in the stimulus bill, we also got the horrible debate and polarization without a stimulus big enough to revive the economy. I read about that in Adam Tooze's book, Crashed, but I would be interested to learn more. I have a feeling that the big trigger for our partisanship may have been more the stimulus than Obamacare's content, because the more I learn about Obamacare, the more I feel like it was a Republican-friendly plan. Or maybe it just seems like that because of how far left the debate on healthcare has shifted in the Democratic party as a result of the failings of Obamacare.
- Harris Wofford is running for Senate in Pennsylvania when he meets an ophthalmologist who says “Americans have a right to a lawyer when they are charged with a crime, so why don’t they have a right to a doctor when they are sick?”
- Between 2006 and 2008, uninsurance in working-age adults in Massachusetts fell by from between 10 and11 percent to just 4 percent, the lowest in the United States thanks to the Romney health insurance plan, which was a model for Obamacare.
- In the 2008 campaign, then-Democrat Joe Lieberman, who had been the Democrats' Vice-Presidential nominee eight years earlier, endorsed Republican John McCain. He even spoke at the Republican convention. Democrats had thought of stripping him of his party membership but decided not to at the time.
- In 2010, Marco Rubio beat Charlie Crist and Kendrick Meek to become Florida's Senator. In summer 2009, Crist had led Rubio by more than two to one, but then Rubio reversed this in ten months. Crist dropped out and ran as an independent and split the vote with Kendrick Meek, the Democrat, and Rubio won. What I want to know is how the heck did a Republican running as an independent split the vote with a Democrat? Wouldn't you expect him to split with the other Republican?
