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The promise and peril of Obamacare

🕐 11 min read

In the moments before Barack Obama prepared to sign the health-care reform law that would forever define his domestic legacy, Joe Biden famously whispered into his ear: “This is a big [expletive] deal.”

On that day, just 14 months into Obama’s presidency, Biden could not know just how profoundly correct he was in that assessment.

One word – “Obamacare” – would come to represent the promise and the pitfalls of Obama’s presidency. The March 2010 signing of the Patient Protection and Affordable Care Act stands as a pivot on which Obama’s legislative agenda turned, where the audacity of hope gave way to the reality and frustrations of divided government.

Obama would sign only one more blockbuster policy bill – the Dodd-Frank financial reform law – which, together with Obamacare and the fiscal stimulus package he signed shortly after taking office, will share top billing in the legislative history of the Obama administration.

Instead, Democrats lost the House and later the Senate, and Obama spent the final six years of his presidency mired in a series of high-stakes negotiations focused soley on keeping the federal government open for business and preventing the country from defaulting on its debts.

Other major pieces of his legislative agenda – on climate change, on immigration, on civil rights – stalled or died at different stages, and the administration turned to the exercise of executive power to achieve its goals.

“I’ve got a pen, and I’ve got a phone,” he said in 2014, describing his levers of power as his dealings with Congress continued to deteriorate.

Thus, Obama’s legislative legacy comes down to this question: What if?

Could health-care reform have been done in a different way? Could Democrats have kept control of Congress for another two years or more? Was Obamacare worth it?

The debate roiled Democrats, including some inside the administration, from the earliest days of the presidency. At the time, the nation remained beset by the economic turmoil sparked by the 2008 global financial meltdown, and many wondered whether health-care reform should be the top priority.

“I begged him not to do this,” former chief of staff Rahm Emanuel told a reporter in 2010, airing his preference for a hard focus on jobs and the economy even after the passage of the stimulus bill.

On Capitol Hill, many Democratic lawmakers, aides and consultants wondered – openly and not – about the political costs of the dogged pursuit of health-care reform. The costs were to be measured not only in congressional seats but in policy priorities.

What would this mean for other major items on the Democratic agenda, ones requiring major outlays of presidential political capital? What about cap-and-trade, union “card check,” the Dream Act or the Employment Non-Discrimination Act – each one a major priority for key parts of the Democratic base?

None of those bills would pass the 111th Congress, even though for the first time in more than 40 years one party held the presidency and dominant majorities in both houses of Congress.

‘Together in opposition’

The passage of the health-care law meant that, for the first time, Americans would be legally obligated to purchase insurance under the threat of tax penalties. In return, the law created new mechanisms to allow access to affordable insurance to millions who had been priced out of the market. New restrictions would keep employers and insurers from excluding the sick; a system of subsidized state exchanges would serve individuals without access to insurance through their jobs; and an expansion of Medicaid would cover a swath of Americans teetering above the poverty line.

Many of the ideas embedded in the law, including the individual mandate to buy insurance, had rattled around conservative think tank circles for decades as potential GOP alternatives to previous, more government-centric Democratic health-care plans.

But that history didn’t forestall a furious partisan backlash – one that gave Republicans a crucial rallying point just months after the 2008 electoral rout. In his recent memoir, Senate Republican leader Mitch McConnell recalled his advice to his GOP colleagues: “Don’t muddy this up.”

“I didn’t want a single Republican to vote for it,” McConnell (Ky.) wrote. “It had to be very obvious to the voters which party was responsible for this terrible policy, and I wanted a clear line of demarcation – they were for this, and we were against it. . . . So the strategy, simply stated, was to keep everybody together in opposition.”

The president craved the idea of a bipartisan bill, and Obama and congressional Democrats labored for months to get at least a few Republicans to buy in, soliciting input and suggestions from a few Republican senators, in particular. Ultimately, those talks went nowhere; every GOP senator agreed not to “muddy this up.”

Meanwhile, the shoots of a grass-roots uprising began to show. What would become the tea party movement had started to coalesce in opposition to the financial recovery bills passed in the earliest months of Obama’s presidency, and the health-care push gave it potent new fuel.

When the congressional summer recess came, protests erupted with chants of “kill the bill” in town hall meetings across the country.

“People are signaling that we ought to slow up and find out where we are and don’t spend so much money and don’t get us so far into debt,” Sen. Charles E. Grassley (R-Iowa), one of three key Senate GOP negotiators, said that August after a pummeling series of home-state meetings. Lawmakers never came any closer to compromise.

The surprise victory the following January of a Republican, Scott Brown, in the Massachusetts special election to fill the seat of the late Sen. Edward M. Kennedy cemented the peril for Democrats – and for the president’s agenda.

In a Washington Post op-ed days later, Obama political adviser David Plouffe acknowledged a “white-knuckled ride” ahead for his party’s candidates but warned against “bed-wetting.”

“I know that the short-term politics are bad,” he said. “But politically speaking, if we do not pass it, the GOP will continue attacking the plan as if we did anyway, and voters will have no ability to measure its upside.”

After a series of unusual legislative maneuvers and a flurry of intraparty deal-making, the Patient Protection and Affordable Care Act passed Congress without the support of a single Republican lawmaker, and Obama signed it into law March 23, 2010. But the political consequences extended well beyond any definition of the short term.

Vows to repeal

The Republican vows to “repeal and replace” Obamacare began that very day – one that then-House Minority Leader John A. Boehner (R-Ohio) called “a somber day for the American people.” Nine months later, he became the 53rd speaker of the House.

The GOP leveraged Obamacare into massive political gains, and they didn’t end with the profound Democratic losses in the 2010 midterms. By the last year of the Obama administration, his party had lost 14 Senate seats, 68 House seats, 12 governorships and hundreds of state legislative seats.

One academic paper suggested that the Obamacare vote alone cost the Democrats roughly 25 House seats – the difference between a historic landslide and two more years in the majority.

The Senate remained under Democratic control until 2015, but a Republican House majority, with an ascendant cadre of hard-line tea party conservatives unwilling to compromise, meant that Obama’s progressive agenda was a dead letter two years into his presidency.

Card check and cap-and-trade were out. A series of high-stakes fiscal cliffhangers were in, starting with a showdown over a potential U.S. credit default that ended in a deal forcing years of spending cuts that reined in Obama’s domestic ambitions.

Fifteen years earlier, President Bill Clinton took his own midterm lumps and proceeded to make a centrist peace with new GOP House Speaker Newt Gingrich (Ga.), cutting deals on welfare reform, crime and other bills. With the exception of a brief and unsuccessful attempt at a fiscal “grand bargain” in 2011, Obama did not seek compromise at a Clintonian scale – the gulf between his progressive agenda and a hard-right House majority was too wide, and seemingly unbridgeable.

When he did seek to push a controversial priority though Congress – notably, seeking to expand firearm background checks – he lost. Instead, he shifted his efforts away from a branch of government he did not control to the one he did. His domestic legacy would be written in policy memos and the obscure pages of federal agency rulemakings.

The Keystone XL pipeline would not be built; power plants would emit less carbon dioxide; investment advisers would adhere to higher standards; and environmental regulators would have new authority over U.S. waterways. The Obama administration did those things by itself over the loud objections of the Republican Congress.

Meanwhile, what Obama could accomplish by legislation lay in a few scant areas where he had significant agreement with Republican congressional leaders. And those have, by and large, failed to come to pass.

An attempt at the most ambitious immigration reform effort in decades had some early momentum in Obama’s second term. Then an unknown college professor with an anti-immigration platform and tea-party support deposed the sitting House majority leader, Eric Cantor (Va.), in a little-noticed 2014 primary. Republicans were spooked, unwilling to move ahead. Obama responded with a new set of executive actions, further alienating Congress.

And his bid to ratify the Trans-Pacific Partnership trade agreement, the centerpiece of a foreign-policy “pivot to Asia,” now appears dead on arrival thanks to grass-roots revolts in both parties. If the TPP moves forward, it will probably not be during Obama’s presidency.

Mixed reviews

Any reasonable analysis must conclude that the political opportunity costs of Obamacare have been considerable. The other side of the legacy ledger – the human benefits – are only beginning to be measured.

More Americans are insured than ever before, with federal data showing the uninsured rate dropping from 15 percent to 9 percent in the first three years of the law’s implementation. Upwards of 20 million more Americans now have insurance, and the rise in health-care prices has slowed – although it is not clear how much can be directly attributed to the reform law.

Meanwhile, the long-term political benefits that Plouffe predicted have not materialized – far from it. Polls show a country sharply and continually divided on the law, largely along partisan lines.

A June 2016 survey from the Kaiser Family Foundation found that 29 percent of Americans say that Obamacare has hurt their family, compared to 18 percent who say it has helped. Most cited increased costs; others pointed to new difficulties in accessing care.

But Republicans faced political difficulties of their own. The party was consumed with attempts to repeal the law, even though another Kaiser poll found that only about a third of Americans favor a full repeal and about a third want to expand it. Polls also show voters still trust Democrats over Republicans to handle health care, although the margin has narrowed somewhat since Obamacare became law.

What congressional leaders never did, until way late in the game, was put forth a coherent alternative that attempts to address at least some of the gaps in the pre-Obamacare health system. And the sketch of an alternative released by House Republicans in summer 2015 presented no estimates of the plan’s costs, nor did it lay out how many fewer Americans might be insured if their changes were implemented.

But the political calculus has been clear: Hard-line opposition has been awfully good for GOP candidates, even if the arguments don’t always add up. McConnell, after describing how he forestalled any attempts at compromise, wrote in his memoir that the “chaos this law has visited on our country isn’t just deeply tragic, it was entirely predictable.”

He added: “That will always be the case if you approach legislation without regard for the views of the other side. Without some meaningful buy-in, you guarantee a food fight.”

Even as Donald Trump’s candidacy scrambled the GOP policy agenda, opposition to Obamacare remained near the top. “We are going to replace Obamacare with something so much better,” said Trump, who has offered the barest outline of such a plan, in a February primary debate.

For Obama, the law has entered a mythic adolescence. The exhilaration of its passage and the frustration at its botched rollout have given way to a heroic narrative.

In a video aired before Obama’s address to the Democratic National Convention this year, the passage of Obamacare took its place alongside his handling of the financial crisis and the killing of Osama bin Laden in a story about an embattled president’s resolve to serve the American people. And Emanuel, the doubter, is the foil.

“He’s thinking to himself, if I decide not to push forward, what do I say to all those people who came up to me with tears in their eyes telling me they need this to save themselves,” former speechwriter Jon Favreau intones in a voice-over. “And if that means that I’m a one-term president, then I’m a one-term president.”

He was not, in the end, a one-term president. But his decision carries a more complicated accounting. Given all the chaos, Obamacare may or may not have been the smart play at the time, but it was most certainly a “big [expletive] deal.”

Has Obama delivered on his promise of hope and change for Americans?

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