An eerie familiarity attends the stories of warnings to Obama administration officials that the enormously cumbersome Affordable Care Act was having significant implementation problems and that the website about to be launched was in danger of crashing. The disclosures are a metaphor for the history of this legislation, one that could be subtitled, “Damn the torpedoes, full speed ahead.”
Let me first digress. To hear the debate over the health care law, you’d think that all Americans either love it and fully believe that it is a terrific and long overdue program, or that they absolutely hate it and are convinced it will destroy most businesses and the U.S. economy. Those two views often tend to correspond with whether people consider themselves liberals or conservatives. Polls, however, suggest that public opinion is not that clear-cut, and that many Americans, about a quarter, have a much more nuanced view of Obamacare. Personally, I find myself in that middle group.
Think back to 2009, when health care costs were skyrocketing at an unsustainable level. Such costs were weighing heavily on businesses’ balance sheets and were a major driver of federal budget deficits and the national debt. The economy would have paid a terrible price if health care costs continued to grow at such an explosive pace. While most Americans had some kind of health insurance coverage (either through their employers, individual policies, Medicaid, or Medicare), the uninsured found themselves ignoring medical problems, often developing chronic illnesses and eventually seeking care in hospital emergency rooms, one of the most expensive and inefficient methods of health care anywhere. Sooner or later, something had to give; the issue had to be addressed.
But nothing happens in a vacuum, and as Barack Obama took office, in the immediate aftermath of the financial crisis, the economy was in horrible shape and getting worse. Obama and his large Democratic majorities in the House and Senate first focused on passing a stimulus package to jump-start an economy that seemed on life support. They attempted to do so with a proposal that Republicans insisted was too large and expensive, but one that to me (and I wrote this many times during that period) was not aggressive enough, a view that is now widely accepted by economists, including some who did not think so at the time. Obama’s defenders insist that it was the biggest package they could move through Congress; I would argue that a president with a better relationship with Congress could have gotten much more.
After checking the box with an inadequate stimulus package, with the economy still worsening and polls showing Americans wanting Washington to focus on job creation and stabilizing the economy, the administration and House Democrats tackled climate change, forcing a cap-and-trade bill through the House—at great political cost. All of this was done in spite of the fact that the bill had dim prospects at best in the Senate, where members from fossil-fuel states were almost certain to kill it.
Next, Congress turned to health care reform. House Democrats muscled through a bill in late 2009, in the face of polling data showing that Americans desperately wanted Washington to do something about the economy. Not surprisingly, the initiative immediately proved to be a very heavy lift in the Senate. It became clear that Republicans would oppose it and that the economy was worsening. Several books have since cited a key White House meeting in early August 2009 when the president’s congressional liaison staff delivered a negative assessment of the legislation’s outlook. Obama dismissed the advice, saying, “No, I feel lucky,” and opted to push ahead. That same week, the July unemployment report showed jobless rates at or above 9 percent for the third consecutive month. In retrospect, the decision to plow forward on health care reform probably cost Democrats their House majority.
The rest is history. Democrats pushed the Affordable Care Act through Congress on largely a party-line vote, although by any measure it was a bastardized version of Democratic and Republican principles. The ACA’s substance was not what any reformer had in mind, but what ended up being doable at the time. The public reaction to this enormous and complicated piece of legislation, which chewed up the better part of two years of Washington’s attention, was predictable. Democrats lost 63 House seats and control of the chamber; surrendered six Senate seats, cutting their margin over Republicans by two-thirds; and were beaten in gubernatorial and state legislative races that resulted in the worst redistricting map for Democrats in modern history. Quite a price.
At just about every step, Obama has pushed ahead on health care reform, even when it would have been more practical to put it aside, waiting perhaps until the economy stabilized or until the public was more accepting of the law. He most recently chose to plow ahead when the apparatus to implement the ACA had huge problems. Warnings inside the administration were ignored. If perseverance were the only virtue, the president and congressional Democrats would be the most virtuous people around and assured a place in heaven. But sometimes balance and reality should intervene. They certainly did not here.