On the Compromises of Obamacare

January 5th, 2014

Richard Kirsch, the campaign manager and chief executive of Healthcare for American Now (HCAN) has a wide-ranging interview in the Post, discussing the origin of the Affordable Care Act. Now that the ACA is settled, in his words, HCAN is closing shop.

These comments about the compromises of the passage of the ACA are helpful to remember.

The reality was that they were relying on 60 Democrats and not relying on Republicans. It became pretty clear by the summer of 2009 that Baucus was being led down the primrose path by Chuck Grassley. Grassley was making all sorts of public statements that he wasn’t really going to reach a deal on this. Yet Baucus kept trying and trying.

You have to look at Baucus and Obama together on this. Jim Messina, who was one of the top people working for Obama and his deputy chief of staff, had been Baucus’s chief of staff. They kept making concessions when it was clear the Republicans weren’t going to support it. Even when it was crystal clear — and they gave up on getting Republican support – -they didn’t go back and present a better bill. They might have said, “Well, we’re going to write the bill that we want and then we’ll make compromises to get 60 Democrats.” Instead, they kept all the things they added to appeal to Republicans that hadn’t worked. So they were unnecessarily negotiating with themselves. Then, at the end in December, when they had to get it through the Senate, they had to negotiate with the Joe Liebermans and the Ben Nelsons and had to make concessions. Had they not made all these concessions earlier, they would’ve started it with a stronger bill … .  The conservative Democrats could only ask for so much. The final bill would have been stronger.

By making these preemptive concessions to appease Republicans, Baucus and Obama put themselves in a much weaker position from a policy point of view and eventually from a political popularity point of view, as well.  That’s the thing I want to emphasize: It’s not just a political game.  At HCAN we kept asking: how is it going to affect real people’s lives? We were looking for legislation that people would find the most affordable and giving them the best opportunity to gain access to good health care.  That’s what our mission was.

Also, he makes a point I made before. Obamacare is HIllarycare 2.0.

HP: So much of your story might be called the prehistory of health reform, which did so much to shape what became the Affordable Care Act. People like to use terms such as ObamaCare. Yet if we had had President Hillary Clinton instead, I wonder how different the final product would actually have been.

RK: There’s no reason to think it would be fundamentally different.  A lot of work was done before the 2008 election really got into gear to get the major Democratic candidates aligned in support of the same health policy solutions. As a result,  the three leading Democratic candidates — John Edwards as well as Hillary Clinton and Barack Obama — were all supporting almost the same proposal, which was in effect the Massachusetts law, with a public option added to it.

I think President Hillary Clinton would’ve come in with a similar proposal and faced a similar political climate, with a very hostile opposition. After all, we saw the tremendous opposition to her husband from the right. Many of the same people who hate Obama have lots of reasons to hate the Clintons, too. So I don’t think we would have seen a very different contour to the political fight. She may not have made some of the concessions that Obama made preemptively, which made it harder to win good policy, but it’s hard to know.  It wouldn’t have been that different.

And on the demise of the public option:

HP: That $900 billion figure also encouraged another original sin of ACA: back-loading of so many key provisions. One floated proposal would have allowed states to start Medicaid and the new exchanges whenever they wanted. So the blue states could have started when they were ready.  Especially as we’re in the middle of a devastating recession, front-loading would have added some economic stimulus, too. Had a couple of states started early, we might also have received greater forewarning about some of the implementation and software issues …

Then there was the public option. From a progressive perspective, what happened was doubly sad. The public option didn’t make it into the final bill. And it wasn’t bargained away to get anything in return. It seems like it was just left on the table. Part of the political challenge for Democrats was that people on the left were very excited about the public option. Other things such as the affordability issues didn’t quite have the same handles to grab onto. So it wasn’t as if the one could say, “Well, we’ll give up the public option if you provide subsidies to 500 percent of poverty or whatever.” I don’t know whether there was a way that might have been handled differently. As things played out, there was no way the left could’ve got anything back for giving up the public option that wouldn’t have demoralized people. 

Kirsch: Part of the problem — this was a huge problem for us that I talk about in my book — was that to do a big public campaign around issues of affordability would have been very tricky. Affordability was people’s biggest fear about the legislation. The right was attacking ACA as not being affordable.  For us to make a big public campaign about ACA’s affordable would have been risky, particularly after the tea party gains of August 2009.  We did organize grass-roots lobbying to seek improvements to affordability and won some small improvements in the final bill. But these were much more subdued than a big public campaign.

In addition to which, the reality is that a lot of the excitement about the public option was that this was something bold and different. Progressive base activists could get a hold of that and get excited about it.  There’s nothing about affordability that’s that sexy and clear. If you say, “We want to be sure instead of 200 percent of poverty paying no more than 2.5 percent, we want to get that down to 1.5 percent,” that’s a huge thing in people’s lives, but it’s really hard to get people excited about it.

On Obama being “conciliatory.”

HP: At one point in your book, you asked someone in the White House, “What’s the inside/outside game?” This person basically responded, “There is no outside game.” Watching from a distance in 2009 and early 2010, I always got the feeling that the White House didn’t quite know how to strike the right balance here. They faced practical challenges of negotiating inside deals to get this done. By the way, I think the president’s progressive base understood that. People had watched the Clinton effort fail. They knew that some deals needed to be cut. President Obama had a tremendous amount of good will from liberals and the left coming on his historic election. For all this, there was tremendous uneasiness in Washington about what would happen to ACA if all of these somewhat uncontrollable outside groups who were operating alongside a delicate set of negotiations. 

How would it work if grass-roots activists — including many who had been quite active in the Obama campaign — pursued a populist campaign against the insurance companies at the very moment politicians were in the room with the insurers  negotiating the myriad practicalities of health reform. One end result was a de factodemobilization of outside voices out of a fear these might have complicated the inside game.

RK: This was a huge misunderstanding by the Obama folks about power and political dynamics, just a fundamental miscalculation and blindness that was really destructive.  The president’s personality is to be conciliatory. Until the summer of 2011 and the grand bargain collapsed, he always wanted to be conciliatory. He also had people like Rahm Emanuel and Jim Messina in the White House who wanted to totally control everything and did not want any on the left pushing them. But power works differently. They would have been in a much stronger position if they could say, “We’re being pushed really, really, really hard from the left, and so this is the best we can do.”  And then cut final deals when they had to.

Look at the difference in approach between Ronald Reagan and Barack Obama.  Reagan did not compromise publicly. He staunchly stood up for his conservative ideals publicly.  But finally he made a lot of deals. He made a lot of concessions. People now point out that a lot of what Reagan agreed to was further left than where Republicans are now on taxes and other things.  But when Reagan made those deals, his base ultimately forgave him. They saw he was out there as a champion and said, “Well, this must be the best he can do.” But because Obama was constantly undercutting his own rhetoric, he lost credibility with his base.