Over 7 years the Affordable Care Act took its hits. Its passage cost the Democrats their majorities in 2010. It’s been dinged and sabotaged by the likes of Marco Rubio. The GOP voted countless times to repeal it. And even Bernie Sanders — to be sure, a good guy who always voted to increase coverage — says to keep our sights on single-payer instead of getting too wrapped up in defending Obamacare.
I’d like to offer some support for those beleaguered politicians, staffers, activists and other “stakeholders” who made the ACA happen in the first place. It was hard work. I don’t think anyone — certainly not those of us on the left — ever thought it was going to make everything perfect. It included, as even its proponents acknowledged, some pretty bitter pills: The continuation of the private insurance system. The personal mandate. This wasn’t the kind of cradle-to-grave health care that one would envision from scratch.
It was, expressly, a kluge that could get through a very big-tent, very fractious Democratic Congress in 2010; made politically palatable (supposedly) by being minimally disruptive to the health insurance people already had. It was based on the Massachusetts plan, which was designed to appeal to a moderate-conservative Republican governor. When it went national, even this accommodation was politically perilous: The bill barely survived passage, and many Democrats did not survive the subsequent elections.
But for all its shortcomings, have we noticed that the Overton window changed drastically? That for all their criticisms, people really don’t want to go back to what was the norm, pre-ACA? And that Republicans were prepared only to smash the whole thing, not to actually improve upon it.
Watch the Republicans flounder, with their catastrophic CBO score of 24 million losing coverage. You knew this was going to happen, because every criticism they ever offered was shallow, opportunistic and unrealistic. Led by Trump — no outlier among Republicans on health care — they promised their plan would somehow cost less and cover more, but be more … free-market-ish. Trump upped the ante at every opportunity.
- Free market solution! Yeah, thought of that. They’re called exchanges.
- Mandated coverage is bad! Insurance needs to insure. It has to be worth something. We didn’t know we needed seat belts in cars either, but I’d be dead a couple times over without them.
- Personal mandate: The Dems, and Romney, considered the problem of adverse selection — that you don’t “need” insurance until you need it. So they included the mandate.
- With Thursday’s PowerPoint, Paul Ryan seemed to attack the very idea of cross-subsidization – in other words, insurance: The young shouldn’t have to pay for the old! Welp, ask the old how they like jacked-up, unaffordable premiums. Thought of that. (Cf. Men shouldn’t have to pay for lady-stuff like pre-natal care — as if women got pregnant on their own.)
- Screw the poor! Always, always in GOP-land, the underserving poor should be abased and reviled. Well, they end up in ERs when they get sick, and cost a lot more that way. [It's also really cruel and mean -- ed.] This is one reason why states and hospitals really like the Medicaid expansion. Thought of that, thanks so much.
The Democrats had an understanding of the issue and its inherent tensions, and had staff expertise to hash through it. The GOP apparently has little of either, and is driven by a propaganda culture actively hostile to knowing about such things.
In other words, the Republicans are screwed. They’re screwed if they don’t pass their hideous bill; they’re triple-screwed if they do. And as with everything, so are we. So are we.
So for a brief moment I’d like to salute the 2009-2010 lawmakers, wonks, and advocates who actually understood that there would be really hard trade-offs; that the policy of health care is really complicated, and always politically dangerous — and has been for over a century. I’d like to salute those lawmakers who were good Democratic Party soldiers, and got shellacked due partly to unfair and deceitful attacks (“death panels”, etc) — but also simply because of those difficult trade-offs: Even as it did a great public service, there was something for everyone not to like. C’est la vie.
What we’re seeing now is that the poor unloved ACA was basically doing its job: Providing a modicum of justice and convenience in the health care market; a little bit of breathing room from those who have suffered illness; helping people see doctors when they’re sick; and curbing the worst, greediest and most misanthropic abuses of the insurance industry.
It is not enough — no health care advocate, no compassionate person would claim that. We are still at the mercy of an industry — one-sixth of our economy — that ruthlessly leverages human need and inelastic demand for its own profit. In a sane world, we’d regulate that and find ways to reduce costs. We’d probably have to introduce price controls; and if you thought the ACA was a political donnybrook, you can imagine what instituting price controls would be like. Currently that’s impossible, when one party is dead set on sabotaging and killing the bill, as well as allergic to any kind of heavy-handed market regulation.
The ACA was not the Make Everything Perfect For All Time bill. But it was in many respects a courageous (QED) and extremely thoughtful piece of legislation. In other words, a real step forward. And the public is not going to consent to go back to what we had before.
Update: John McDonough, formerly of Health Care For All in MA and Ted Kennedy’s point man on the ACA, on the Republicans exchanging working-class lives for more money for rich people. “All for a little bit of money” …