The mover on health care loses, Democratic operative James Carville said in January. To do something is to lose. That cold-hearted political proverb has been repeatedly proven true, if the standard is short-term electoral gain. In terms of policy, its another story. Now that Obamacare repeal has fizzled, Democrats have officially won the eight-year health care war.
The victory was not by default. Trump might look silly blaming Democrats for the failure of repeal and replace when Republicans control all branches of government, but united Democratic resistance was critical to keeping the Affordable Care Act as law. Without a single Democrat in Congress breaking ranks, the ideologically divided Republican caucus found it impossible to stitch together a majority for a functional alternative to the status quo.
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But the euphoria of victory may quickly dissipate. Despite the fact that Obamacare was signed in this decade, many Democrats dont appreciate the bills history and have not internalized the lessons of its passage and durability. Without a clear-eyed understanding of their own triumph, Democrats may hastily launch another health care war, repeat many of the Republican Partys clumsy mistakes and prove Carville right all over again.
Many analysts will attribute the repeal bills demise to raw politics: be it Trumps unpopularity, poor salesmanship by Republican leaders, incorrigible Republican backbenchers or Democrats cynically betting on gridlock. But the biggest reason why Democrats were able to unify was the substance of the Patient Protection and Affordable Care Act. However imperfect, however unpopular, the law was built to last.
The popular provisions were intertwined with the unpopular provisions. The program was designed with input from insurers, hospitals and pharmaceutical companies; critics say they got off light (for example, POLITICO just investigated how much hospitals have been able to profit off of the ACA while cutting back on charity care), but all had a stake in Obamacares success. The bill was worked and re-worked until Democrats secured the blessing of the Congressional Budget Office. Finally, the law implicitly enshrined the principle that the government is responsible for making the health insurance system work for all Americans.
Plus, while theres plenty of room for improvement, the simple truth is the ACA has helped many people, covering more than 20 million additional people and contributing to an approximately 50 percent decline in bankruptcies.
Facing off against these strong foundations, the Republicans were outmatched. Playing Jenga with Obamacares complementary elements was doomed to crash at the steps of the CBO. Leaving people to the mercy of the free market was a political non-starter. The insurance industry, long the bte noir of the left, plunged a stake in the final version of the Republican replacement plan, warning the last-minute addition of the Cruz Amendment made the bill unworkable in any form.
And where the Republicans collapsed, the Democrats stood firm. Some Democrats on the left never liked the Affordable Care Acts compromises with the private health industry. Some red state Democrats were sensitive to complaints about rising premiums and little to no choices in some state insurance marketplaces. But all Democrats put those differences asideas they did in 2010to unite behind thwarting repeal. Yes, the amateurish nature of Republican lawmaking, at the presidential and congressional level, no doubt aided that unity. But if the current law was a complete bust, several Democrats would have broken ranks out of political necessity. They didnt.
And so, after eight exasperating years of playing defense on health care, Democrats finally have some wind at their back. But where they take that momentum is far from clear, as Democratic factions with competing goals are bound to draw different lessons from their win.
Health care wars never truly end; they just enter new phases. The core elements of Obamacaremost critically, the individual mandateare now entrenched. But there are still debates to be had about maintaining insurer subsidies, attracting insurers to uncompetitive marketplaces, reducing consumer costs and achieving 100 percent universal coverage.
In this next phase, unity will be much more difficult for Democrats. Opposing is always easier than proposing, and Democrats are already offering vastly different proposals in response to these issues. Fundamentally, Democrats have to ask themselves: Is it time to go big, or to largely quit while theyre ahead?
Some Democrats view Obamacares resilience as proof they should stick to fine-tuning within the structure of the current law. For example, Sen. Joe Manchin, the West Virginia Democrat who represents the largest percentage of Trump voters, is organizing a bipartisan group of senators to discuss how do you fix the private markets?
At the same time, the populist left wants to do what Republicans tried: repeal and replace. But instead of repealing Obamacare to give the wealthy a tax cut, hard-core progressives want to supplant the current system in favor of their long-time health care holy grail: single-payer, or Medicare for All. In the words of one progressive activist, single-payer is becoming a litmus test, not just for progressives, but for Democrats writ large. Sen. Bernie Sanders championed the Canadian-style plan in his 2016 presidential bid, and now 2020 possibilities such as Sens. Elizabeth Warren and Kristin Gillibrand have joined the club.
Both camps are taking big risks. Manchin and his fellow red state Senate Dems10 of whom are up for re-election next yearneed to be careful not to sacrifice the political leverage their party has earned from united resistance when they work to forge a bipartisan fix for the bill. Any deal that involves gratuitous concessions to Republicans will enrage the Democratic rank-and-file and cause a debilitating rift. But so far, the right-leaning Dems havent bound themselves to a specific set of proposals.
Not so on the left. The rigidity and intensity of the single-payer movement could well put Democrats in the same untenable box Republicans find themselves. Republicans just humiliated themselves by juicing their base with a grandiose yet simplistic promise, then learning the hard way they couldnt deliver. Now the GOP has to worry about turning out a deflated base for the midterms. A single-payer strategy could put Democrats in a similar predicament if and when they regain power.
The House Medicare for All bill (which, as of this spring, a majority of the Democratic caucus has co-sponsored for the first time ever) is a light 30 pages, hardly enough detail to engender confidence for a successful transition of one-sixth of the American economy. The Atlantic reports that Sen. Sanders will soon unveil a significantly more detailed single-payer plan. But there are fundamental obstacles that await any such bill.
Recall why the Affordable Care Act won the war: Because a nuanced policy was crafted with the input of the insurance, drug and hospital industries. All of these forces either fought for Obamacares passage (the pharmaceutical lobby spent a whopping $100 million in support of the bill in 2009 and 2010) or helped defend it against repeal, as the hospital lobby did fervently and the insurance lobby did in its late strike against the Cruz amendment.
For single-payer to succeed, a grassroots army would need to overwhelm the powerful health industry lobbies. No deals could be cut with an insurance industry literally fighting for its life. Meanwhile, the hospital and drug lobbies would fear getting squeezed hard by a government looking to consolidate all bargaining power. Recent single-payer fights on the favorable deep blue turf of Vermont and California did not provide much hope these obstacles can be overcome. Legislators in both states flinched because the taxes required to cover the upfront cost are so politically daunting.
Advocates of single-payer also dont have answers for voters who still want to hear whether they can keep their current plans if they like them. Some progressives see the public option, which would give customers the choice to buy into Medicare but wouldnt require it, as a way out of that jam. Except too many on the left, including Sanders, have already given away the game: Theyve said out loud they want public option to undermine private plans and be a stepping stone to single-payer. Therefore, insurers and their allies will have the political ammo needed to malign public option as a Trojan Horse.
Health industry lobbies would invest millions upon millions to stoke such consumer concerns. And winning a health care war without some health industry support is extraordinarily difficult, if not impossible. That was the lesson President Barack Obama took from the 1994 failure of Hillarycare.
Of course, a battle royal with the health care special interests is exactly what the populist left wants. Not only do many progressives believe they can win the legislative battle in Congress, they believe its the way Democrats can win control of Congress. MoveOns Ben Wikler recently told McClatchy that the decision whether or not to back Medicare for All is a choice between a broken past or a future that gives people a reason to knock on doors and get involved in campaigns. It may be true that single-payer would motivate the Democratic base. But MoveOn and Wikler managed to successfully rally their troops for weeks in order to save the broken past known as the Affordable Care Act, so we know single-payer is not the only way to generate enthusiasm.
Its one thing to believe in your heart of hearts that, despite the political challenges, single-payer is the best health care policy. Its quite another to make it a litmus test that questions the sincerity of Democrats who disagree, either on substantive or politically pragmatic grounds. That would shatter Democratic unity, the very unity that Democrats needed to win the eight-year Obamacare war.
Bill Scher is a contributing editor to Politico Magazine, and co-host of the Bloggingheads.tv show The DMZ.
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How Democrats Won the Healthcare War - POLITICO Magazine