Bill Clinton on Monday referred to Obamacare as “a crazy system” and “the craziest thing in the world” for people who earn too much money to receive federal insurance subsidies but not enough to afford rising premiums.
Republicans gleefully accepted the comments as a political gift. “See, everyone? Bill Clinton thinks it’s crazy too!” It was, in their view, a Kinsley gaffe from President Obama’s “explainer-in-chief” validating criticisms they’ve been leveling at the law since its inception.
Yet when read in full, Clinton’s comments are not that far off the message that Obama and Hillary Clinton have been sending about the law for several months. No, Obama surely wouldn’t want anyone, let alone a former president, to call his signature domestic policy achievement “crazy.” But in an interview with New York Magazine’s Jonathan Chait, the president said that while he believed the law had been “a huge success,” it also had “real problems.”
Both Obama and Clinton are referring to the same central challenge the Affordable Care Act now faces. Not enough young, healthy people have signed up for insurance under the law’s exchanges, leading to higher premiums for those who are enrolled and prompting insurers to withdraw from the exchanges in many states.
“The current system,” the former president said while campaigning in Flint, Michigan, “works fine if you're eligible for Medicaid, if you're a lower income working person, if you're already on Medicare, or if you get enough subsidies on a modest income that you can afford your healthcare.”
But the people that are getting killed in this deal are small businesspeople and individuals who make just a little too much to get any of these subsidies. Why? Because they're not organized, they don't have any bargaining power with insurance companies, and they're getting whacked. So you've got this crazy system where all of a sudden, 25 million more people have healthcare and then the people that are out there busting it—sometimes 60 hours a week—wind up with their premiums doubled and their coverage cut in half. It's the craziest thing in the world.
Speaking a day earlier in Pontiac, Michigan, Clinton offered a similar analysis, only it sounded more favorable to the law because he prefaced his critique by saying Obamacare had been “a remarkable success” for the 25 million who have gained health insurance.
And in both appearances, Clinton immediately followed his diagnosis of what ails Obamacare with a description of Hillary Clinton’s plan to fix it. “Hillary believes we should simply let people who are above the line for getting these subsidies have access to affordable entry into the Medicare and Medicaid programs,” Bill Clinton said. “They’ll all be covered, it will not hurt the program, we will not lose a lot of money. And we ought to do it.”
In truth, the explainer-in-chief could have explained this better. He appears to be merging separate elements of Hillary’s plan into one. She has called for expanding Medicare so that anyone age 55 and older can buy in. She has proposed incentives to cajole states that didn’t expand Medicaid to do so now. And joining President Obama and more than two dozen Senate Democrats, she wants to revive the “public option” that was left out of the Affordable Care Act in 2010 because it didn’t have the votes to pass.
“President Clinton spoke about the importance of the Affordable Care Act and the good it has done to expand coverage for millions of Americans,” Clinton campaign spokesman Angel Urena said by way of cleaning up his remarks. “And while he was slightly short-handed, it’s clear to everyone, including President Obama, that improvements are needed.”
Clinton’s proposed “improvements” are all proposals that are popular with Democrats who are increasingly concerned that if left untouched, the problems with the Obamacare exchanges may only grow, thus feeding into the Republican charge that the system will collapse under its own weight. “There are definitely red flags out there,” said Larry Levitt, a senior vice president at the Kaiser Family Foundation. Like other healthcare experts, Levitt is watching closely the outcome of the open enrollment period that begins next month.
“The future of the law hinges critically on how the next enrollment period goes,” he told me. If the numbers increase, especially among younger, healthier people, then the concerns about the stability of the exchanges “could begin to fade away.” But that’s unlikely.
“There’s a chance of that,” Levitt said. “It’s less than 50-50, but there’s a chance.”
Absent a boost in enrollment, however, the clamor for congressional action next year to fix, or at least “tweak,” the law will increase, and the crescendo will likely come just about the time the next president takes office in January. And that’s why if Clinton wins, the big question will not be what she proposes but whether Republicans are willing to negotiate any changes to the law that would put it on more solid footing.
So far, of course, the answer has largely been no. Republicans have actually supported changes to the ACA short of repeal, but those fixes have been done either without much public debate or when the GOP could argue they had succeeded in undercutting the law rather than bolstering it. Yet all of Clinton’s proposals would expand the scope of Obamacare, either by offering more generous subsidies or support for states enlarging Medicaid, or by creating new publicly-run insurance options to compete with private companies.
Democrats could hope that Republicans would give up their repeal-or-bust attitude toward Obamacare once its namesake is out of office and after losing consecutive presidential elections following its passage. But it’s hard to see the GOP coming to the law’s rescue if the market seems to be achieving what their efforts to legislate or litigate it out of existence could not.
“They’re eminently fixable problems in terms of strengthening the marketplace, improving the subsidies so more folks can get it, making sure everybody has Medicaid who was qualified under the original legislation, doing more on the cost containment,” Obama said in his interview with Chait. “But you hit a point where if Congress just is not willing to make any constructive modifications and it’s all political football, then you’re getting a suboptimal solution.”
That’s not what Bill Clinton said about Obamacare in Michigan on Monday. But when you get beyond the word “crazy,” it’s not that far off, either.