Something important happened at the end of September — or, rather, didn’t happen. On September 30, the “reconciliation” deadline passed in the US Senate — the date by which legislation can be classed as a budget measure, and thus be passed with a simple majority of 51 votes.
September 30 went by, with the vote-of-all-votes unpassed: the Obamacare repeal, which Republicans had been promising since it became law in 2010, a cause that President Donald Trump took up as a centrepiece of his campaign. Two major attempts to craft a repeal-and-replace bill were put to the Senate and failed, due to the refusal of Republican senators John McCain, Susan Collins, Lisa Murkowski and Rand Paul. A final attempt, known as the Graham-Cassidy plan, looked more threatening, as it was put forward by John McCain’s Senate bromance Lindsey Graham. But McCain would not consent, and it was never even taken to the Senate floor.
Now, a Politico story suggests that many Republicans have given up on a full repeal-and-replace at all. “Most of it will probably be there in ten years,’”one Republican Senator remarked, off the record. Should that prove to be the case, that will serve as a major vindication of Obama’s presidency, and of those on the left who, amid fraught battles, argued that this comparatively limited system change should be supported, planted in US society and defended.
Doubtless, Trump will want to return to repeal-and-replace, when the reconciliation process returns next year. Or his advisers will. Or some of them. Some Senate Republicans will want to as well — those up for re-election and facing primary challenges from the right, organised by Breitbart, run by Steve Bannon, now exiled from the White House. But the majority will want to move on, knowing that another failed attempt would have wasted the first two years of a nominally Republican presidency. Obamacare was what Obama got done in the first two years, so there would be a pretty telling symmetry.
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Given that the Republicans spent most of Obama’s second term passing “Obamacare repeal” bills through the House, and then the Senate, this is a pretty pass. But not an unexpected one. The dozens and dozens of Obamacare repeal bills that went through, never had any chance of getting past a presidential veto, and only a government shutdown — the refusal to pass a budget bill that funded Obamacare — would have nobbled it. Under the leadership of Ted Cruz, they tried that, but only once.
The “repeal” bills were a luxury, of course. With no chance of success, there was no need for a “replace” option. Nor, in the first year or so, was there much demand for one, among the party’s supporters, and right-leaning independents. But that luxury did not last. Despite a few false starts — a computer sign-up program that was atrociously engineered, and malfunctioned for months — the system began to enrol millions of people in healthcare they’d previously been denied. Many of these were families with pre-existing conditions, many of them Republicans and wary independents. By the time the 2016 election came round, a “replace” option was essential. Trump made a feature of it, drawing on his populist image to promise the “best healthcare scheme” ever. Polling of Trump supporters found that some believed that — and others believed he was bluffing about repealing it at all, and they were happy about that.
The “repeal-and-replace” schemes varied, but they all focused on answering the demands of Big Insurance: removal of a ban on pre-existing exclusions, business levies to pay the mandate, and a loosening of the standards for new plans, i.e. bad plans, that the companies could offer. That would have thrown millions back off the rolls, and removed many who’d become eligible for the low-income service Medicaid. The gap immediately opened between the Senate and the general public, with support for the proposed new systems gaining only around 30% public support.
The final try, Graham-Cassidy, tried to take an end-run around these difficulties by turning the funding into a block-grant system, in which all 50 states were left to determine their own rules. But it was the dilatory approach of many states to healthcare that Obamacare had been designed to avoid in the first place.
By the end of the Graham-Cassidy process, even the health insurers were coming out against it, fearful of the chaos and uncertainty it would create. Every other medical peak body was against it from the start. Essentially, Obamacare had become laced into the deep structure of the health system; removal of it was meeting resistance from both producers and consumers. The elegance of the system’s design had been starting to pay off: as more and more healthy uninsured were signed up — instead of paying the fine for being uninsured — the “risk pool” widened, and the premiums of the early adopters — the ill and hitherto uninsured — could come down.
But that was the core of Obamacare. At the surface, it was not without problems. To pass the bill, a herculean effort, far beyond the stamina or skill of Trump and Republicans, the Democrats had had to renounce some control on “co-pays” — the amount you have to pay, before your insurance kicks in, often as much as $5000-$10,000 — and control of pharmaceutical pricing, among others. But their major political error — recounted in Steven Brill’s America’s Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System, one of the most page-turning accounts of public policy implementation ever written — was to cancel a whole series of policy plans when Obamacare was implemented.
“If you like your plan, you can keep it,” Obama had said. But, as Brill notes, he was often absent from the micromanagement of the implementation, and mid-level wonks — who had favoured a further-left “public option” — had immediately removed so-called “dogmeat” plans. These were manifest ripoffs, with low premiums that many people liked — simply because they never had to rely on them for sustained illnesses. Those who did, suddenly found that their plans were near worthless, and they were on the hook for up to a million dollars in healthcare costs. Persuading many of the healthy of this was impossible; many such plans were sold to “low information” consumers, to put it politely. Many saw no relation between the disasters befalling a neighbour or friend, and their own situation.
But cancelling their plans — at the same time as establishing an online new enrolment system which didn’t work — was a disastrous double-move, which created genuine enemies, and was a propaganda gift to the Republicans. It has taken the subsequent years of rising enrolment to countermand that bad start.
Yet for all that — for the lack of complete coverage, the diversion through the private sector, the inflated costs from Big Pharma — the implementation of Obamacare was the right move, politically and policy-wise. Obama was right to make it a priority, to not divert so much energy into a war around the 2008 crash, to not try for a full public option that could never have got past centrist Democrats, to create a system that integrated itself into healthcare practice in a manner difficult to remove, and which then began to generate a class of people — in their millions — with something concrete to lose from its removal.
Indeed, Obamacare may have made possible its repeal-and-replacement, from the left. A decade ago, any sort of “public option” or “single-payer”, comparable to the UK’s NHS or Australia’s Medicare, was out of the question. Now, it is the limitations of Obamacare, together with the rise of Bernie Sanders, that has made “single-payer” a mainstream possibility, as a solution to the problems Obamacare raises, with 17 Democrat senators now signing on for a proposal.
Hitherto, Sanders couldn’t get a seconder/co-sponsor. It shows how the implementation of a particular policy will make concrete and real, a general right, something that must be achieved. This was something that presidents from Theodore Roosevelt onward have tried to achieve. If it can be held and consolidated, and improved, then Obama, and the vast movement to create the bill, has indeed changed America. It is not only a triumph for him, for them, but a powerful lesson in the sort of choices one needs to make in advancing progressive policies. Something happened.