“Don’t touch my Medicare!”
-Sign held by Tea Party protester
The Republicans’ efforts to rid the country of Obamacare are currently stalled by internal policy differences. The House version was reportedly dead on arrival in the Senate, but then the Senate bill emerged looking not all that different, and it hasn’t been warmly embraced by the members of Senator McConnell’s caucus either. Casual observers of the process may be wondering what is holding things up. After all, the Republicans have clear majorities in both houses of Congress; they don’t need any Democratic votes (which, admittedly, they aren’t getting). But, as the president has acknowledged, laughably and unwittingly, health care is complicated, and getting a majority of Senators to agree on a replacement for the Affordable Care Act is going to take a bit more work.
Still, at the end of the day (as the expression goes), I expect that the Republican senators will find a way to 50, meaning the Senate will, ultimately, pass a bill that will appear to replace Obamacare with something else. That bill will then go to the House where it will face more difficulty, because as dysfunctional as the Senate’s Republican caucus is, the House’s version is even more so.
But the elected Republicans need to pass something (because they have been claiming that they would for seven years and because Trump promised they would when he was a candidate), and at some point they will probably do so (albeit the final bill might be a totally unworkable mess with all the compromises it will include). And so, we can assume that Obamacare will, ultimately, be repealed, and that it will be replaced by something different, something that will be less universal in its coverage and less affordable for those most in need. (Both the House and Senate versions that are currently in play would have those effects.) What, in that event, would Obamacare have done to and for the country? What would its final report card look like?
From a purely political perspective, Obamacare was a disaster for the Democrats. Let’s remember where the country was politically in 2010 when the Affordable Care Act was signed into law. The Democrats were firmly in control of Congress with sizeable majorities in both the House and Senate. They also were doing well in state legislatures and governor’s offices, with majority control of 60 of the 98 state houses in the country and of 26 of 50 state gubernatorial offices. But the Democrats lost heavily in the November 2010 elections. In Congress, the Republicans gained 63 seats in the House, flipping it to Republican control, and six seats in the Senate. And in state races, the Democrats only retained control of 39 legislative houses and 20 governor’s offices.
The loss of Congressional dominance made Obama’s remaining six years far more difficult, especially when the Democrats ultimately lost control of the Senate in 2014. But the result of the shift in power in state legislatures in 2010 allowed the Republicans to control much of the critical redistricting that happens after the national census that is taken at the start of every decade. With the redistricting that took place after the 2010 census, Republicans had control of legislatures that set the district lines for 195 Congressional districts, while Democrats could control only 49. (Neither party controlled the redistricting of the remaining districts.)
The resulting gerrymandering created the Republican majority in the House that has been unbroken since 2010. And if you don’t think gerrymandering affects control of Congress, just consider that in 2016 Republican candidates for the House received 49% of the votes cast compared to 48% for Democratic candidates, yet they retained majority control of the House by a far wider margin (currently 240-193 with two vacancies) than that narrow advantage would indicate.
Now it may well be that the Democrats would have lost control of the House in 2010 even without the albatross that the passage of Obamacare created for Congressional candidates. Likewise, Republicans may have made gains at the state legislative and gubernatorial level as well. But let’s remember that Obama was still a popular president in 2010 and that he won re-election in 2012 by a fairly wide margin (five million votes; 51% to 47%). So the 2010 mid-term results were not a rejection of him. Obamacare was the major domestic issue in that year, and it cut against the Democrats and has haunted them ever since. Even Hillary Clinton’s loss can at least in part be attributed to continuing antagonism to Obamacare, as Trump continuously slammed it in a chorus with Republicans and the right-wing media (Fox News, Limbaugh, Breitbart, et al.).
But even as it was disastrous politically for Obama’s party, his health care bill at least became the law of the land, creating a new pathway to health care insurance for millions of Americans who had previously been shut out of the existing system. He may well have considered the new law as the principal legacy of his presidency, at least in terms of domestic policy achievements.
So what would be left of it if the Republicans succeed in repealing and replacing it? Can Obamacare still get a passing grade if it no longer exists as envisioned and if it was a political disaster for the Democratic Party? And the answer to that question is that it probably can because its existence, short-lived though it may end up having been, has changed the expectations of the American people.
Think about Social Security or Medicare and how engrained they are in America’s national mindset. No politician dares to speak of ending either program. Even the suggestion that benefits might be reduced is dangerous territory to any candidate of either party. Obamacare hasn’t achieved that level of acceptance or expectancy, but the provision of a method by which health care access is guaranteed probably has. Obamacare has implanted that thought in the American political calculus. (Even Trump acknowledges it, to the extent he understands what he is saying.) And the ongoing Republican struggle with the “replace” part of the repeal-and-replace commitment will prove that point.
Americans (like the rest of the industrialized world, by the way) now expect that they will have a way to provide for their healthcare needs, even if they have a pre-existing condition. Insurance companies, no matter how the Republican alternative ends up looking, are going to be writing policies with that provision mandated for those who need it. We are never going back to the days when hospital emergency rooms were the only recourse for millions of Americans who desperately needed medical care.
Obamacare may not continue to exist as a national law, but its spirit will always be with us. Health care in America, if not a right, is no longer a privilege. It has become, like much of the “deep state” that Steve Bannon so detests, an entitlement. And, as Bannon, and presumably his boss, well knows, Americans do not give up their entitlements.
Let’s start with the fact that ACA is not functioning as planned. At the time it was enacted, roughly 10%-12% of the US population wanted to buy health insurance but couldn’t for multiple reasons. Today that figure is around 9% (various sources). A good portion of that improvement simply came from young people staying on their parent’s insurance until age 26.
So the ACA turned the entire system upside down for very little gain on that measurement.
Meanwhile, ACA premiums have gone up substantially, employer provided plan premiums, and private plan premiums have skyrocketed, and many large insurers had to leave the ACA because they were losing so much money. My former employer’s cost had gone up so much, they had to cut the premium subsidy to employees from 50% to 25%.
Doctors and other medical providers are awash in additional paperwork. My doctor had to hire an additional clerk. You can bet he raised his fees because of it.
Everybody’s paying more, the insurers are exiting, the medical providers are burdened, and for very little progress on the goal of getting more people covered.
The ACA had to be revised no matter what party ended up being in power. After creating the mess in the first place, do you think the Democrats would have put aside all their factions and put Humpty Dumpty back together again into an efficient system to everyone’s satisfaction?
Obama left this “Cleveland Steamer” on his desk for the people that followed.
I agree with you, Ed. But having said that, I suspect that some important parts of “Obamacare” will remain as the “replace” part of the GOP’s equation. Especially, if they are going to get the votes they need in the Senate it is very likely that any successful bill will have to drop the drastic Medicaid cuts. The really sad thing about the “repeal” part of the Republican bill is the loss of the requirement that people become insured or pay a penalty. It is obvious that unless the more healthy youthful part of the population is insured, insurance rates will soar for the older, sicker portion of the population. Ultimately, Medicare for all seems to me to be the answer.