'The Ten Year War' Over Obamacare (and the Battles Ahead)
January 21, 2021
Democrats are returning to the White House and the Senate majority with a long health policy to-do list. Reporter Jonathan Cohn says the battle over Obamacare offers lessons and clues as to where the party’s “unfinished crusade for universal coverage” may head next.
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President Biden: If I have the honor of being president I promise you I will lead. I will do everything I can to take responsibility and ease this burden on your families. I’ll put your family first…
Dan Gorenstein: President Joe Biden now has the chance to turn his campaign promises into reality.
Biden: That will begin with a dramatic expansion of health coverage and bold steps to lower health care costs.
DG: For the first time in a decade, Democrats control both chambers in Congress and the White House.
Between the pandemic, undoing certain Trump Administration actions, and threats to the Affordable Care Act, the to-do list is long. And Democrats’ razor thin majorities in Congress make that list an even tougher lift.
Today, the Democrats’ health care agenda in Washington and how the legacy of the ACA could shape the party’s policy plans for 2021 and beyond.
From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein, and this is Tradeoffs.
To help us get a handle on federal health reform over the next two years, we’ve invited Jonathan Cohn, senior national correspondent for HuffPost and author of a new book, “The 10 Year War: Obamacare and the Unfinished Crusade for Universal Coverage.”
Jonathan Cohn: Hi, thanks for having me on the show.
DG:So you’ve published this book about what you call the 10-year war over the Affordable Care Act and the policy goals it represents…did you expect this battle to last so damn long?
JC: No, no. I covered the Affordable Care Act debate in real time 2008, 2009, 2010. I remember very distinctly, I was in the House chamber when the main piece of legislation passed…
Speaker Pelosi: The yays are 220 the nays are 215, the bill is passed. [Applause]
JC: And it had been a massive crowd that night in the House chamber. Everyone who worked on the bill was there. Within an hour, it cleared out. I’d never been there before that late that the Capitol building was empty. Like it’s dead quiet. I remember having like one of those journalist epiphanies, like I’m going to use this at some point. This is a metaphor for the Affordable Care Act. We’ve had this huge fight. Now the law is passed. Finally, we can lower the temperature, we can move on. And a lot of people thought that. Obama thought that. He in his signing ceremony two days later makes a statement…
President Obama: It is fitting that Congress passed this historic legislation this week for as we mark the turning of spring, we also mark a new season in America. In a few moments, when I sign this bill, all of the overheated rhetoric over reform will finally confront the reality of reform.
JC: Finally, we’re going to move past this very contentious debate. And, of course, we didn’t. We were all wrong.
DG: I mean, it’s interesting, right, the Affordable Care Act only passed with Democratic votes, and just one Republican. And so in some way it foreshadows the reality that we’re living in today.
JC:I really think it does. I think this really was the case study in how our politics have changed. And not only do Republicans not vote for it, they spend the next 10 years fighting it and trying to rip it out.
Sfx: News montage of protests against the ACA
DG: Obviously your book largely looks at all of the fights and struggles of the past decade. But of course, the war is still being waged. The latest front is in the Supreme Court with the California v. Texas case pending. Jonathan, do you see ACA fixes near the top of Congress’s agenda?
JC: Yeah, I do think it is high on the list, you know, one thing to watch, obviously, you want to pay close attention to who’s in Congress. And so you look at who’s the new chairman of the Senate Finance Committee: It’s Ron Wyden, who is a real wonk. He’s a health care guy. Patty Murray, who is going to be chairwoman of the Health Committee in the Senate, also cares about health care. You know, the constraints are that they’ve got a pretty full agenda right now.
DG: If and when Democrats do get around to working on the ACA, what are a few major shortcomings you would expect them to revisit?
JC: So I think the first thing on everyone’s list is going to be making the financial assistance for people buying insurance more generous. I think when you look at the shortcomings of the Affordable Care Act, where it caused hardship, so many of them trace back to the fact that it’s underfunded. It just does not provide enough help to people who are buying insurance, given how much insurance costs in the United States. It’s an easy fix to do. It’s something people feel in their pockets. And by the way, it’s something you can do, and I don’t know if you want to get in the weeds of the congressional process, but you can do it through the budget reconciliation process where you only need 50 votes.
DG: In fact, the very same day we interviewed Jonathan, President Biden released a plan to do exactly this as part of his Emergency Relief Package.
Right now, the people who qualify for help with Obamacare premiums earn 400 percent or less of the federal poverty level — that’s about $100,000 or less for a family of four. Biden’s plan would extend premium help to folks with higher incomes and make aid for lower income Americans more generous.
Jonathan also thinks Biden will use executive action to restore Obamacare outreach funding to help boost enrollment and rein in short-term insurance plans that are super cheap but offer skimpy coverage.
JC: And then you’ve got the public option. Progressives really want that. So I think there’s going to be some tension there. I don’t know where that comes out, but I don’t think the Biden administration can just walk away from that.
DG:And a public option is a health insurance plan run by the federal government that would, in fact, compete with private insurance plans. And so people who go to the exchanges and get their care through the Affordable Care Act right now, they buy a plan from United or Aetna or Blue Shield. A public option would offer consumers another choice with the hope that this new competition would drive prices down.
JC: Yes, there was one other item on the Biden agenda. It didn’t get a lot of attention. I actually think it’s probably among the most important things they could do. But that would be to open up the exchanges to people who have employer insurance available to them. I will be interested to see if that’s something they pursue.
DG: There’s a great line in the book from Senator Wyden who says employer based coverage is “melting like a popsicle in the summer sun.”
JC: Like we were saying earlier, you know, Ron Wyden is a very wonky guy. He knows a lot about health care. I think he can see down the road in the future that employer insurance probably isn’t going to last forever.
DG: When we come back, Jonathan tells a story…talks bipartisanship…and provides a much needed primer on budget reconciliation.
DG: Welcome back. We’re talking with HuffPost senior national correspondent Jonathan Cohn about the Democrats health policy agenda and how the legacy of the ACA may shape the party’s policy plans.
Jonathan, we were talking about the public option. And in your new book ‘The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage,’ you talk about one moment featuring former Connecticut Senator Joe Lieberman that seems to foreshadow what Democrats may face this year. Can you tell us that story?
JC: Sure. So Harry Reid, he’s the Senate majority leader. He’s trying to put together a bill and he’s looking at his votes. He’s like, “Huh, I got a problem. I got a bunch of conservative Democrats who don’t want the public option.” The biggest problem is Joe Lieberman. And when you talk to Democrats, Lieberman frustrates them more than anyone because Joe Lieberman’s from Connecticut. Come on. This is one of the most liberal states in the country. So Reid starts bargaining. And they do come up with another idea, which is to open up Medicare to people who are younger and letting not everybody, but fifty five and older, 50 and older, let them buy into it.
DG: It was an idea Lieberman had endorsed when he ran as VP alongside Al Gore.
JC: And then Lieberman on a Sunday morning goes on Face the Nation on TV…
Sfx: Face the Nation theme music
JC: And they ask him, would you support this new idea?
Lieberman: I will tell you that on one part of it, the so-called Medicare buy-in…from what I hear I would certainly have a hard time voting for it because it has some of the same infirmities that the public option did. It will add taxpayer cost. It will add to the deficit. It’s unnecessary.
JC: And he says, no I will not support this. If it’s in the bill, I will block it. Progressives were furious at that point. So at the end, that’s how the public option died.
DG:And really, this idea of beggars can’t be choosers is sort of what we end up with. That is the ACA. It is this series, as you point out, it is a series of compromises and it’s often the sort of true believers compromising with more conservative members.
JC:Yeah, I think over and over again, throughout the course of the ACA, you see that dynamic playing out. And we talked earlier, you know, saying what’s the most important things you can do to fix the ACA? We can fund it better because it was underfunded. Well, why was it underfunded? Well, there’s a variety of reasons, but a big one was that conservative Democrats were scared of a big price tag. And the bill at the end of the day was a lot less generous than the liberals wanted. They wanted to give people more help. And just the politics, they felt like they pushed the envelope as far as they could.
DG: It was really interesting to read President Obama’s account of getting the ACA passed and how much Democrats really sort of contoured around trying to curry favor with a handful of moderate Republicans. We’re in a new era 10 years later where the idea of bipartisanship sort of seems like a relic. How do you think that could shape policy action over even just the next two years?
JC: Yeah, yeah, that’s a really good question. So I think the new bipartisanship is getting the two wings of the Democratic Party to agree. I really do. The Republican Party does not look like it did 30 or 40 years ago. And you’re just not going to get much buy-in on anything. But one interesting question — this is my opinion — is that bipartisanship particularly during the Obama era…one reason to do bipartisanship was for the appearance of bipartisanship. But I think the lesson of the last 20, 30 years really is that whatever upside you get from appearing to be bipartisanship is going to be more than offset by the downside of not getting something done.
DG: With odds of bipartisan compromise so slim, Jonathan, this means that ultimately, the Democrats are going to have to rely on the super wonky process called budget reconciliation. Before we go any farther, can you just give us a budget reconciliation 101?
JC: Yeah. So basically, you know, once upon a time, most legislation passed through the House and Senate with a simple majority. Senate adopted some rules that allowed senators to hold up debate and it evolved over time. But it means that if senators want to hold up debate indefinitely, and effectively block a bill that way, it takes 60 senators to overrule that. One of the exceptions is bills that are part of the budget process. There was a sense that, gee, at the end of the year when Congress is trying to make the numbers add up, we should be able to do that without having to get 60 votes. It’s just too hard. It’s too cumbersome. Let’s have a kind of special protected process where there’s a set time for debate, you can’t filibuster, and 50 votes will pass. So that has become a vehicle for passing legislation. But the trick is you’ve got to fit the legislation into those rules, and that’s not easy.
DG: The rules of budget reconciliation are pretty arcane. And very technical. Here are the two most important: 1) Any legislation MUST be related to the budget in a meaningful way. 2) Bills cannot increase the deficit after a decade. The takeaway: reconciliation could definitely work to increase ACA subsidies, but a public option is harder — even if all the Dems end up on board.
Budget reconciliation and tight majorities pose two very real challenges to advancing Democrats’ more ambitious goals over the next two years. But if there’s reason for optimism it stems from the legacy of Obamacare.
At one point you write, “Universal coverage does not yet exist. Some of its principles now have wide acceptance. The boundaries of acceptable political conversation have changed, quite possibly forever.” What are you actually saying there, particularly as it pertains to this sort of shift in how we think about health care?
JC: Yeah, so the clearest sign that the political conversation has changed is the posture of Republicans in the 2018 and 2020 elections. Having spent so much time bashing Obamacare, Republicans were falling all over themselves to say we are absolutely committed to protecting people with pre-existing conditions. Now, that’s not true. That case in the Supreme Court is trying to take those protections away. But the fact that they are so desperate to say that, those rhetorical shifts are really important.
DG: It’s seemed to me that when people talk about the importance of protecting people with pre-existing conditions, that part of the legacy of Obamacare, is that health care is a right now. I don’t think a lot of people thought that in 2010.
JC: I think that’s correct. And I think ironically, the rhetorical victory, right, outpaces the reality on the ground, which is why we’re in this debate now about Medicare for all. We’ve established that ideal. Now, again, there’s dissenters and it could come apart in the Supreme Court, could do whatever, who knows? But rhetorically, that’s where we are. And then you look around like, OK, well, we’re supposed to be making sure people can get health care and lots of people can’t get health care, right? So, I mean, this stuff takes time, but the rhetorical commitments matter partly because I think they set a standard, a mirror, that you then hold up to reality and you say, alright, where are we? What do we need to keep doing?
DG: Jonathan Cohn, thank you for taking the time to talk to us on Tradeoffs.
JC: Thank you for having me. Tradeoffs is the heart of all policy, and it’s great to get a chance to kind of think about them and what they really mean.
DG: Jonathan Cohn’s book, “The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage,” comes out February 23.
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Select Reporting on the Democrats’ Health Policy Agenda in 2021 and Beyond:
Here’s The Way Joe Biden And The Democrats Can Pass Their Agenda — Maybe (Jonathan Cohn, HuffPost, 1/10/2021)
Biden’s First Order of Business May Be to Undo Trump’s Policies, but It Won’t Be Easy (Julie Rovner, Kaiser Health News, 1/8/2021)
With New Majority, Here’s What Democrats Can (and Can’t) Do on Health Care (Sarah Kliff and Margot Sanger-Katz, New York Times, 1/7/2021)
What Happens When the Senate Is Split 50-50? (Natalie Andrews, Wall Street Journal, 1/6/2021)
A President Looks Back on His Toughest Fight (Barack Obama, New Yorker, 10/26/2020)
Jonathan Cohn, HuffPost senior national correspondent and author of “The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage”
The Tradeoffs theme song was composed by Ty Citerman. Additional music provided by Blue Dot Sessions.
This episode was reported and produced by Andrew Parrella, Leslie Walker and Christine Fennessy.
Additional thanks to:
Kathryn Hough Boutross, the Tradeoffs Advisory Board…
…and our stellar staff!