By Jonathan Cohn
There’s little enthusiasm for going back to the way things were.
The Affordable Care Act overcame the tea party protests of 2009 and the Democrats losing their filibuster-proof Senate majority in 2010. It survived two challenges in front of the Supreme Court and the calamitous rollout of healthcare.gov.
Now it has withstood the attempt to replace it with the American Health Care Act, better known as Trumpcare.
Somehow, despite the intense political forces arrayed against it, and the mind-boggling policy problems it tries to solve, the 2010 health care law keeps defying efforts to wipe it out. That says something about the people who wrote it ― and what they have achieved.
Obamacare has never been hugely popular, and it has never worked as well as its architects hoped. Millions of Americans don’t like it and, even now, there are parts of the country where the markets are struggling to survive.
But the program has provided security and access to care for millions of others. More importantly, it has shifted the expectations of what government should do ― and of what a decent society looks like.
This week’s defeat of the Republican repeal effort shows just how hard it is to undo those changes. And it won’t get any easier.
What Obama And Pelosi Did (And Trump And Ryan Didn’t)
On Friday, hours before President Donald Trump and House Speaker Paul Ryan (R-Wis.) formally conceded their bill lacked the votes to pass, White House press secretary Sean Spicer signaled what was coming. Trump, he said, had “left everything on the field.”
The statement was preposterous.
Trump and the Republicans in Congress had spent all of 63 days trying to pass their Obamacare repeal ― less than three weeks of which were spent actually debating the text of the AHCA. They held votes before Congressional Budget Office evaluations were ready, and were about to ask the full House to decide on the proposal just hours after making major changes to it.
Over in the Senate, Majority Leader Mitch McConnell (R-Ky.) had already indicated he intended to bypass his committees altogether and take legislation directly to the floor ― perhaps with a quick House-Senate negotiation, a fast vote and a signature from the president.
By contrast, it took former President Barack Obama, former House Speaker Nancy Pelosi and former Senate Majority Leader Harry Reid (D-Nev.) more than a year to pass Obamacare ― a politically tortuous period that many people later blamed for Democrats losing their House majority in 2010.
At the time, every apparent error loomed large ― from taking on health care at all, to letting the process drag out for more than a year, to slavishly crafting a proposal as CBO specified, to cutting unpleasant deals with health care’s special interests.
Lost amid the recriminations was the talent each player brought to his or her task ― and the Democrats’ single-minded focus on avoiding mistakes of the past in order to achieve something their party had been trying to do since the days when Franklin Roosevelt was in the White House.
I am not saying we needed 14 months to do this. But I think a more careful and deliberate approach ... would have gotten us further down the path to a solution. Sen. Tom Cotton (R-Ark.)The work had begun long before Obama even ran for president. In the aftermath of the defeat for Bill Clinton’s 1994 health care plan, activists, advocates and intellectuals regrouped ― and then spent literally years hashing out their ideas for achieving universal coverage in a politically viable way. When Obama did run, he borrowed their work for his own plan. When he was elected, the most pivotal committee chairman of the process, Senate Finance Chairman Max Baucus (D-Mont.), was ready with his own blueprint that looked nearly identical.
Baucus had done something else: Working with then-Sen. Ted Kennedy (D-Mass.), he had convened meetings with virtually every health care stakeholder, from hospitals to unions to insurers to patient advocacy groups, exchanging ideas and negotiating over principles. It meant that when the actual legislating started, the channels of communication were already open and the groundwork for a common vision was already in place.
And still it was a nearly impossible task. Like the Republicans this year, Democrats found consensus difficult to achieve ― among the outside groups, and within their own ranks as well. Liberals wanted a more generous program, and a public option. Moderates wanted to avoid too much government spending and too much meddling with the way independent businesses operate.
But unlike the Republicans, the Democrats’ reaction was to work with the different groups and slowly bring them along ― most vividly, by negotiating with a handful of moderate Republicans, in the hopes that one or two (or maybe more) would sign onto the plan. It never happened, but the effort to woo those members helped secure moderate Democrats who needed to tell their constituents that, yes, they had tried to be bipartisan.
One reason Democratic leaders were able to preserve legislative momentum was that they understood, at all times, where they were trying to go ― and they were fluent enough in the policy to handle direct negotiations on their own. One of the enduring images of Obama during the Affordable Care Act fight was his visit to a Republican Party policy retreat in Baltimore, where he fielded questions and parried criticisms from the assembled members for roughly 90 minutes.
The work that led to Obamacare had begun before Obama even ran for president.
Trump, by contrast, seemed to lack anything beyond a superficial understanding of the bill, to the point where allies worried about letting him negotiate details. “Either doesn’t know, doesn’t care or both,” a Capitol Hill aide told CNN about the president.
As for Pelosi, her job was easier than Ryan’s in one important sense. Nobody in her caucus was as extremist or nihilist as the Freedom Caucus, partly because Democrats had done so much prep work and hammered out a rough consensus before the hard legislating work began. But Pelosi didn’t try to jam through “slapdash” legislation, as Harold Pollack, writing in Politico, recently called the AHCA. And she didn’t flinch when her political task looked utterly hopeless.
When Kennedy’s seat went to Scott Brown, depriving Democrats of a filibuster-proof majority to approve a final compromise, she told Obama she would get the votes for the Senate’s bill ― and she did, taking charge of the whip count personally ― and working her caucus, one member at a time, until she had a majority. On Sunday, during an appearance on CBS’s “Face The Nation,” Sen. Tom Cotton (R-Ark.), conceded that maybe the Democrats knew what they were doing.
“When the Democrats came to power in 2009, for 60 years at least, they had been pursuing a national health care system, yet they didn’t introduce legislation for eight months, and they didn’t pass it for over a year of Barack Obama’s first term,” Cotton said. “I am not saying we needed 14 months to do this,” he added, “but I think a more careful and deliberate approach, which we now have time to do because we are going to have to revisit health care anyway, would have gotten us further down the path to a solution.”