“Let Obamacare Fail”

That every major piece of seminal social legislation in modern American history – from Social Security to Medicare – has been amended and updated by Congress multiple times is simply a realistic reflection of what needs to happen when complex legislation is enacted. There is no possible way to get it right the first time. Additionally, the first pass of a law that reflects these seismic shifts almost always relies on catering to special interests fearful of the change.

When the Affordable Care Act (ACA or Obamacare) passed in 2010 through a Democratic Congress and was signed by a Democratic President, there was no exception. The “just expand Medicare and offer it to the people” faction was shot down by the big insurance carriers who did not want to face additional competition from a government-provided alternative. That universal insurance “mandate” was both (i) a necessary part of creating a sufficiently large risk pool and (ii) to placate insurance carriers that they would grow their business as a result. The big pharmaceutical special interests were terrified that large new health insurance exchanges would have the effective bargaining power to force those behemoths to drop their prescription drug prices. So the ACA exchanges were barred from challenging those hyper-expensive drug prices; they had to pay full price.

To make matters worse, with a strong undercurrent of racism, anti-government-healthcare-system conservatives only needed to call the program Obamacare – calling up the same anti-Obama vitriol that gave rise to the “birther” challenge, to extract waves of right wing rage at the program. Videographers were having a field day interviewing constituents who stood the most to gain from the ACA. Biased interviewees seemed to approve of the provisions of the ACA when described without a title. But once the system was called “Obamacare,” they turned and trashed the statutory schema with extreme anger. But they still wanted the “benefits” of that “other” healthcare program. You probably will never hear a Republican candidate call the ACA anything but “Obamacare” for obvious reasons.

During the waning years of the Obama administration, the newly-installed GOP-dominated Congress has voted well over 60 times to repeal or defund the ACA but never to fix its obvious short-comings, some stemming from the very compromises made in favor of special interests to get the law passed in the first place. It was easy to sit in the peanut gallery, cast aspersions and issue threats against the ACA, and point out clear failings of the program that that GOP majority never lifted a finger to fix. They could criticize without having to provide a program that would work. While Democrats were committed to patch these ACA holes, the GOP simply wanted that program to fail so that they could point out how it was never a well-structured healthcare alternative.

The extreme right wing of the GOP joined with libertarians to demand that the government simply abandon any notion of a statutory program to cover more Americans with healthcare coverage. Let the marketplace determine who gets covered and how, they screamed. Meanwhile, moderate Republican governors, supported by their legislatures, actually took advantage of the ACA’s “expand Medicaid” option to cover more of their constituents, almost always a locally-popular choice.

And then it happened. A Republican candidate – with a basic platform of “repeal and replace” the ACA with a program that would provide better coverage at a lower price – became president. Conservatives in Congress “wink-winked” each other with the belief that they could either get rid of the ACA entirely or replace it with a deeply eviscerated alternative that would allow them to shift the savings into a tax reform package aimed at cutting tax rates for their richest constituents, their mainstay contributors. And hey, the GOP now controlled every facet of the federal government they needed to pass that “eviscerating” legislation. Woohoo. This should be easy.

Donald Trump could not be truly committed to his workingman pledge – effectively to phase in universal healthcare – and still be the leader of the Republican Party, they reasoned. They were obviously correct as the President championed House and Senate versions of a “repeal and replace Obamacare” bill that would throw millions of currently-insured people out without any healthcare and effective toss those with preexisting conditions onto rocky shoals that threatened their very survival. A reality repeatedly that was made clear by the non-partisan Congressional Budget Office with devastating projections on “repeal and replace.” “Repeal only”? Worse. The CBO tells us 32 million folks will lose coverage and premiums will soar by 25% within a year should that occur!

Insurance companies, doctors, hospitals, and healthcare organizations at every level joined millions of constituents to decry the each of these GOP proposals. Town hall meetings became intolerable venues for Republican member of Congress visiting their home base. Many GOP governors raised their voices in protest, literally making it impossible to pass the GOP “repeal and replace” or even a naked “repeal” bills; the necessary GOP Senate majority would never materialize.

But the Donald Trump administration has been anything but subtle in their commitment to make sure that the ACA fails. The President’s sabotaging tools include refusing to reimburse insurance companies for reducing low-income customers’ out-of-pocket costs to making sure that the Department of Health and Human Services fails to enforce the mandate that most Americans have health coverage, thus decimating the basis for insurance companies to remain in the system. By constantly trashing the ACA and threatening its extinction, Mr. Trump creates an atmosphere where insurance companies can no longer plan their own futures, an intolerable situation for them. Trump believes that no matter why the ACA might fail (even if it is through his overt sabotage), (a) he can blame the Democrats and (b) therefore, Americans will eventually beg for the inferior healthcare package that was so soundly rejected by the Senate in recent days. So he is simply going to make sure it fails.

Even with the ACA, a dramatic improvement from what preceded passage of that statute, here’s what we still face today, even with more people covered under the ACA: “In 2015, the United States spent almost three times on healthcare as the average of other countries with comparable incomes, according to data from the Organization for Economic Cooperation and Development, also known as OECD, a group of 35 countries, the majority of which have advanced economies, that works to promote economic development.

“And despite spending more, the U.S. results don’t necessarily yield better health. Both Italy and Britain, for example, spent at least $5,000 less per person than the United States on healthcare, and yet the population of each of those countries has a higher life expectancy at birth than the United States…

“[The] the United States spends more on healthcare than any other country, including those belonging to the OECD… ‘[But] we definitely have worse health outcomes,’ said David Squires, president of the Commonwealth Fund, a private foundation based in New York that carries out independent research on healthcare issues.

“‘It doesn’t appear that people in the U.S. use more healthcare in general. We go to the doctor less often than people in other countries and get hospitalized less, so it’s not like we are making greater use, but we are paying more for the things we do use,’ he said…. Despite investing heavily in healthcare, Americans live shorter lives than people in 30 other countries, data from the World Health Organization showed.” Los Angeles Times, July 19^th. We spend a whole lots more for the same treatments and prescriptions. Without greater access to controlled healthcare, we will continue to fall in those comparisons. Let the ACA fail and those negative statistics will overwhelm us. But that Trump’s plan: make sure the ACA fails, with more than a push and a shove from his administration.

However, there are a series of political realities that are going to stick that failure to those who pushed it over the edge. Sure, Trump’s base will probably believe whatever he tells them to believe, but most Americans are not that easy to convince. Generally, the administration and party in power at the time of a political failure owns that failure, even if the seeds of that failure were planted earlier. Barack Obama was often charged with the economic failures and never-ending military losses in the Middle East that were rather clearly caused by policy choices from preceding administrations. And so it will be with Donald Trump, assuming the Democrats can get it together and speak with one clear voice.

Further, as cited in my July 14^th New and Improved Death Panels blog (based on a study from the prestigious Kaiser Family Foundation), despite the confusion, the ACA is beginning to stabilize and generate a sustainable economic path. Additionally, the Democrats (led by a bi-partisan group of governors) have been prepared to sit down and work out either a new statute (that probably will look a lot like the ACA) with more than a few “fixes” that are desperately needed. Like allowing sparsely-populated states to combine with other such states for bigger and more coordinated multistate healthcare exchanges or allowing those exchanges to use their bargaining power to force pharmas to cut their prices (or even to allow consumers to buy their prescriptions from preapproved foreign markets). What the GOP probably cannot get from the Democrats is the substantial reduction in healthcare coverage needed for them to fund their pledge of tax cuts for the rich.

But political novice, Donald Trump, believes he can sabotage the ACA and blame the resulting failure on the Democrats. His White House statement on July 18^th, knowing that the GOP Senate could not muster enough votes for either “repeal or replace” or simple ACA “repeal” says it all: “It’ll be a lot easier… We’re not going to own it. I’m not going to own it. I can tell you the Republicans are not going to own it. We’ll let Obamacare fail, and then the Democrats are going to come to us.”

What should the Democrats do? Continue to build bi-partisan support as they have, starting with those moderate Republican governors. Tell the world exactly what they intend to “fix” in the existing legislation (including my fix-it-notes above). Be specific and talk costs and coverage in detail. Repeat an ongoing willingness to sit down with their GOP counterparts to craft a “healthcare solution” that will work best for most Americans. And most of all, repeat until it wears American ear drums out: “Hey Mr. President, if you continue to sabotage the ACA and it fails, you will OWN IT, OWN IT, OWN IT!” Are we tired of winning yet?

I’m Peter Dekom, and the Democrats better start standing for something with a clear unified voice, and healthcare is the obvious and most important starting point.