Adapted from The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage, St. Martin’s Press 2021.
The Affordable Care Act, the health-care law also known as Obamacare, turns 11 years old this week. 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 purchase, 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 longtime 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 legislation failed.
Obamacare’s survival says a lot about the differences between the two parties nowadays, and not just on health care. It’s a sign of how different they have become, in temperament as much as ideology, and why one has shown that it’s 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.
Out of these parallel efforts, a rough consensus on substance and strategy emerged. Democrats would put forward a plan that minimized disruption of existing insurance arrangements, in order to avoid scaring people with employer coverage, and they would seek to accommodate rather than overpower the health-care industry. The proposal would err on the side of less regulation, spending, and taxes—basically, anything that sounded like “big government”—and Democrats would work to win over at least a few Republicans, because that would probably be necessary in Congress.
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.
Kennedy was not alone in his belief that the champions of universal coverage would have to accept big concessions in order to pass legislation. The liberal House Democrats John Dingell, Pete Stark, and Henry Waxman, veteran crusaders for universal coverage who’d accrued vast power over their decades in Congress, were similarly willing to put up with what they considered second-, third-, and even fourth-best solutions—and they were masters of the legislative process, too. Waxman in particular was an expert at doing big things with small political openings, such as inserting seemingly minor adjustments to Medicaid into GOP legislation, expanding the program’s reach over time. “Fifty percent of the social safety net was created by Henry Waxman when no one was looking,” Tom Scully, who ran Medicare and Medicaid for the Bush administration in the early 2000s, once quipped.
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. He also was 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.
Obama could do this because the concept of universal coverage fit neatly within his conception of a just society as one in which people act through government to protect themselves from harm. It helped that he had surrounded himself with policy advisers widely recognized as thought leaders in the field of health policy. That included Lambrew and Nancy-Ann DeParle, who had been in charge of Medicare and Medicaid during the Clinton administration, as well as Zeke Emanuel, a physician, bioethicist, and prolific writer on health policy. Peter Orszag, an economist serving as Obama’s budget director, had spent so much time studying ways to reengineer the delivery of health-care services that the prestigious Institute of Medicine elected him as a member.
The key Democratic lawmakers had similarly deep benches of seasoned policy advisers. And as the legislative effort got under way in 2009, those advisers were in constant communication with one another and with the White House. There were daily (and sometimes twice-daily) conference calls led by DeParle or Lambrew, in order to coordinate messaging and keep the proposals from diverging too much. Those calls were not always fun, and Lambrew, during her frequent trips to Capitol Hill, usually drew the duty of listening to staff from each chamber vent about the other. But the back-and-forth meant that each committee and chamber understood the absolute limits of what the others could tolerate.
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 thing, 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.
“Obviously, it is the case that there were not enough conversations about ‘replace,’” Brian Blase, a conservative health-policy expert who was a top domestic-policy adviser in the Trump White House, told me. Dean Rosen, a GOP leadership aide from the early 2000s who went on to become one of Washington’s most influential health-care strategists, said, “There was an intellectual simplicity or an intellectual laziness that, for Republicans in health care, passed for policy development. That bit us in the ass when it came to repeal and replace.”
One reason for this laziness was a simple lack of interest. For decades, Republicans had seemed interested in health-care policy only when responding to Democratic policies required it. “Republicans do taxes and national security,” Brendan Buck, a former GOP leadership aide, quipped in an interview. “They don’t do health care.”
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 homework that hadn’t been successful was the work to coalesce around a single plan, a single set of specific legislative items that could be supported by most Republicans,” Price told me. “Clearly, looking at the history of this issue, this has always been difficult for us because there are so many different perspectives on what should be done and what ought to be the role of the federal government in health care.”
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. He had distinguished himself though 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. “He never talked policy,” Charlie Dent, a retired GOP congressman from Pennsylvania, told me later. “It was just, ‘Let’s get this thing done. Let’s get a deal here.’”
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. And although the same handful of conservative intellectuals are working diligently on policy papers, Republican officials haven’t shown interest in developing those plans into an actionable agenda.
Republicans remain focused on, and quite skilled at, delivering outrage to their supporters. They continue to show no enthusiasm for passing laws, on health care or anything else for that matter. Over the past few weeks, as Democrats passed that groundbreaking COVID-19 relief initiative, Republicans have put most of their energy into making arguments about “cancel culture.” And although Democrats are already moving on to other pieces of legislation, including plans for infrastructure, a minimum-wage increase, and immigration reform, the most concrete thing on the Republican agenda is talk of reviving a half-dozen Dr. Seuss books that the late children’s author’s estate stopped printing because they contained racist imagery.
Democrats are also talking about next steps on health care—and have been for a while, actually, although they are not all saying the same things. Some want to keep building on the Affordable Care Act incrementally, as the coronavirus-relief legislation did. Others seek much more ambitious changes, up to and including the idea of wiping out existing insurance arrangements so that the government can insure everybody directly through Medicare for All.
Some kind of reckoning between those two visions is inevitable. But in the meantime, policy experts and lawmakers are doing precisely what their counterparts were doing in the late 1990s and early 2000s—turning ideas into detailed proposals, with serious accounting estimates, and then writing legislation and attempting to build coalitions with outside groups. All of them remain as dedicated as ever to achieving their longtime goal of universal coverage.
Of course, some experts and officials in the Democratic Party are preoccupied with other matters, such as addressing the COVID-19 crisis. It remains the No. 1 priority for the Biden administration and for Jeanne Lambrew, who is back in her home state of Maine, serving as its commissioner of Health and Human Services.
Maine has fared relatively well during the pandemic, with one of the lowest per capita death rates in the country. There seems to be no single reason for Maine’s impressive performance, but a generally attentive attitude from leaders and a methodical, data-based approach to solving problems have likely helped. This work is rarely glamorous and gets little attention. But it’s essential to addressing the crisis and making sure the public sector functions properly, which is perhaps why the party that believes in government is so much better at it than the one that doesn’t.