Telling the Story of Healthcare Reform (Again)

The Affordable Care Act was passed a mere few months after Tropics of Meta started, in early 2010.  Our friends gathered around a TV in Queens, New York that showing C-SPAN and the fateful vote.  It felt like a solemn moment in history, even if many of us were sorely disappointed by what ended up in the Rube Goldberg-esque bill that resulted.

At the time, we tried to weigh in on what the whole thing meant.  The post, one of our first dozen or so pieces, shows the extreme risks of historians pontificating on fast moving events and uncertain, unpredictable outcomes yet to unfold.  We were preoccupied, understandably, by the lack of a public option that progressives had fought so hard for.  Like many on the Left, we were dismayed by the idea of government forcing people to buy private insurance, especially if there were not a separate, publicly run alternative that offered access to care.

Conservatives were, equally understandably, opposed to this idea, since they recognized that it would be the opening wedge to get to a single-payer system where government insurance ultimately crowded out the private corporations and “nonprofits” like Blue Cross Blue Shield. (That was, of course, the idea for most progressives, even if they didn’t explicitly say so.)  In any case, the Blanche Lincolns and Joe Liebermans of the world were never going to let government get in to the business of providing insurance beyond Medicaid, Medicare, S-CHIP, and the other grab bag of piecemeal solutions that make up the American way of governance.

We were also fixated on things that seemed big at the time but have receded into the distance since—another peril of historians trying to do their jobs in real time.  The so-called “Cadillac tax” is definitely one of them.  This component of the ACA was meant to control costs by penalizing employers that provided highly generous health plans to their workers, and many progressives opposed it, especially unions that had fought for relatively lavish benefits for their members as a major perk of their jobs in contract negotiations.  The wisdom of this policy is debatable, but it figured prominently in debates over the legislation at the time, and we definitely paid close attention to it in our analysis at the time.

One thing that I considered to be a huge issue was the “mandate,” the requirement that individuals had to have insurance and most large employers had to offer it.  I recall that this did not seem to get as much play as the issues over the public option, the exchanges, the Cadillac tax and so forth at the time, but it certainly became the centerpiece of conservative opposition in the years that followed.  Who is the government to make me buy a “product” I don’t want? They might as well make me buy a Yugo.

Hence, Paul Ryan’s smug and insincere assertion during the recent debate that freedom means people can just “choose” not to have health insurance. (Freedom is just another word for no kidneys left to lose.)  And the ingenious conservative stratagem, in court battles over the ACA, that the federal government could regulate economic “activity”—manufacturing, farming, retail—but not “inactivity”—the not-having of insurance.

It’s been a wild seven years.

Where are we today?  Again, we run the risk of being very embarrassed by the twists and turns to come, when our expert hot takes and sagacious projections prove to be badly wrong.  Yet we can try to take stock.  A few observations:

— What was viewed by most on the Left as a weak, perhaps even bad half-measure at the time has become the cornerstone of political hope for most liberals, if the wildly emotional reactions to ACA’s many brushes with death (my own included) are to be considered.  Back in 2009, I remember Nate Silver making the case that ACA may not be great, but it would still be the biggest expansion of social welfare in the United States since Medicaid and Medicare in the 1960s—that is, the biggest redistribution of wealth to the poor and working people in ages.  At the time, I don’t even remember the Medicaid expansion being the topic of a lot of discussion over the bill—perhaps I’m misremembering—but it has turned out to be probably the most consequential aspect of the policy from a social welfare spending point of view.

— If ACA survives—and that is still a very big “if,” despite GOP setbacks—then it will prove true the reasoning of Bill Kristol back in the 1990s.  He famously warned that Republicans must resist the temptation to work with Bill and Hillary Clinton on healthcare reform.  There must be no quarter given.  If a big entitlement gets passed, Democrats will get the credit for helping the middle class and the policy will be impossible to undo (like Social Security and Medicare, the bete noire of conservatives basically forever).  The GOP took the lesson, took to total, implacable opposition, and kneecapped Clinton politically.  They didn’t forget what they learned back then, as the Obama years showed.

I personally assumed Trump and the GOP would come in on day one and just write a bill that says “The ACA is repealed,” and let the chips fall where they may.  The interminable slog in Congress over “repealing and replacing” the ACA (a Stalinist shibboleth if there was one) suggests that taking away benefits from people actually is difficult—not impossible, but definitely unpleasant.  Consider the Republican governors who cautioned about the impact of throwing millions off the Medicaid rolls—eventually, ideology and rhetoric came into contact with actual reality.  Given the cartoonish surrealism of the Trump election and presidency, some of us were beginning to wonder if material reality mattered at all anymore.  (After all, the Bush people once bragged that they create their own reality. Trump definitely paid attention to that.)

Finally, the question remains: what does this mean for the ACA and healthcare more generally going forward?  Conservative apostate David Frum warned years ago that the ACA would be the Republicans’, not the Democrats’, Waterloo, and he has been taking some well-deserved victory laps on this.  (Let him have it.)  The Republicans’ failure to undo Obamacare could be as politically damaging as the Democrats’ inability to pass reform back in 1994—hence the crazed determination to pass something, anything, even something universally despised, to notch a win.

If the ACA remains in place—again, a huge if—then it becomes the new normal.  Maybe it already is.  If Trump throws another tantrum and bullies the House and Senate into taking up the issue yet again, then we could be right back on the crazy train again.  The GOP could easily hold the House and expand its margin in the Senate in 2018, and ACA would be right back on the chopping block without Senators Murkowski or Collins to save it.

But the survival of the ACA in the face of court challenges, Congressional brinksmanship, the recent push to repeal it and its own shortcomings suggest that it could become foundational in a way that few—certainly not I—understood back in 2010.  The principle that everyone should have insurance, indeed has to have coverage, and insurers are required to provide it, creates the premise of a universal system, if not the reality.

Once that principle is in place, it becomes not a question of should so and so have insurance, but what do we have to do make sure that people can access and afford it?  It becomes a question of not “if” but “how.”  And if the private insurance system fails to deliver the goods, as it so palpably is, then other thorny questions get raised. What more should government do? Should we expand Medicaid further? Should there be greater subsidies? Should we revisit a public option—or even, gasp, single-payer?

Those questions are all a ways off, but the (seeming) endurance of ACA is the fundamental, enabling premise that makes them all possible.  And Republicans who crowed and wailed and gnashed their teeth for seven years about the unspeakable horrors of Obamacare—they might have just acceded to a new reality.  From the point of view of those who care about the sick, the poor, the disabled, and the elderly—all of which we will all be at some point, if we’re lucky to live long enough—this would be a very good thing.

Stay tuned.  And hold onto your klonopin.