J. Scott Applewhite/AP Photo
President Obama signs the Affordable Care Act, in the East Room of the White House, March 2010.
The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage
By Jonathan Cohn
St. Martin’s Press
Seven-plus years after the launch of the Affordable Care Act marketplace, it’s clear that that program is fundamentally flawed. It’s undersubsidized, unduly complex, and lacking mechanisms for controlling the underlying cost of care. Looking back, it’s easy to identify faulty assumptions held by the law’s creators. They believed that adopting conservative means to progressive ends would win Republican buy-in; that contorting the law to achieve budget neutrality as defined by the Congressional Budget Office (CBO) was worth making coverage less than affordable; that imposing large out-of-pocket costs on enrollees would control overall health care expenditures without harming enrollees’ physical and financial health.
Jonathan Cohn, a leading contemporaneous chronicler of the ACA’s formation and enactment, and now author of The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage, is well aware of these shortcomings and faulty assumptions, as well as of the law’s resilience and partial success, such as reducing the uninsured population by about 35 to 40 percent. The book’s chief value, for me at least, lies in illuminating the creators’ perspectives at various crunch points in the law’s conception and enactment.
Cohn takes us back to a long time ago, in a galaxy far, far away, in which Democrats still hoped to win Republican support for major legislation. Notwithstanding that by early 2009, Mitch McConnell had already announced the Republican minority’s intentions to block any legislative achievements, many Democrats in Congress had a history of co-authoring legislation with Republicans and put more stock in that past personal experience than in the available evidence of Republican intentions (e.g., Republicans’ near-total rejection and vilification of Obama’s stimulus bill). Max Baucus was the Democratic senator most notorious for pursuing the wandering fire of bipartisan buy-in. But at the outset at least, he was far from alone. Cohn reports that Democrats never seriously considered passing health care reform using budget reconciliation, the only means of bypassing the Senate filibuster:
But the notion [of using reconciliation] got even less serious consideration than it had in 1993. Several administration officials shared Baucus’s belief that bipartisan reform would be easier to sustain politically in the years after enactment, plus there were practical considerations. Moving quickly to reconciliation could alienate more conservative Democrats, who desperately craved the political cover a bipartisan bill would provide. “There were a whole bunch of senators who were hoping that this would be bipartisan both substantively and politically for their own electoral outcomes,” Peter Orszag said to me later.
The irony, of course, is that reconciliation was ultimately needed to complete the bill.
Cohn also clarifies why the ACA’s new programs were ring-fenced to serve only those lacking access to existing forms of insurance, chiefly employer-sponsored plans. The concept of a public option, in its earliest iterations (2003, 2006, 2007), was essentially what later became known as Medicare for all who want it: a public program, paying more or less Medicare rates, accepted by all providers that accepted Medicare, and available on a subsidized basis to anyone who opted in, including those with access to employer-sponsored insurance. Under that kind of reform, employer-sponsored insurance would either die on the vine or compete by paying providers rates comparable to those paid by the public option, as Medicare Advantage plans do today.
But that was never on the table in the ACA debate; the reform sought only to fill in pockets of uninsurance within the U.S., rather than open subsidized public insurance to all. Why limit subsidies to those who lacked access to employer plans? Cohn explains:
By 2006, a rough consensus about the ideal structure of reform was already gelling within the Democratic establishment. The focus was on minimizing disruption to existing insurance arrangements, since the threat of disruption had seemed to make the Clinton plan so toxic. Employer coverage would largely remain in place. Medicaid would too, but it would expand to cover all of the poor, not just those who fell into narrow categories like pregnant women. And then there’d be some kind of new market of private insurance options—with subsidies and guarantees of coverage for preexisting conditions—for the remaining population. It was still a purely hypothetical notion when Jeanne Lambrew cowrote a paper describing it for the journal Health Affairs. Then Romney and his allies passed such a plan in Massachusetts. It was proof of concept, and it got everybody’s attention—including Obama’s.
Consistently, Cohn captures the pressures exerted upon—and exerted by—conservative Democrats and Democrats serving Republican-leaning districts, contrasted with the overlapping pressures exerted by health care industries. Among the most able, experienced, and progressive of Democrats in the House was Rep. Henry Waxman (D-CA), chairman of the Energy and Commerce Committee. Waxman earned the job by deposing longtime chair John Dingell (D-MI), a staunch Medicare for All supporter but someone opposed to progressive environmental reforms, reflecting his Detroit-area district (Dingell was known as the “Dingellsaurus” for his antiquated views on energy). The committee
included a significant delegation of more conservative “Blue Dog” Democrats Dingell had picked to resist what he considered overly aggressive environmental legislation. And by July, they were in an ornery mood … Waxman needed their votes, and so he made a major concession. The bill would have a public option, but it would have to negotiate reimbursements just like a private insurance plan.
Equally constraining were core assumptions that Obama absorbed from health care economists who had his ear. Prominent among these assumptions were variations on the premise that imposing large out-of-pocket costs on consumers would induce them to use care more efficiently and put downward pressure on provider payment rates. This idea was credible not only to Obama but to the CBO, which had not given much deficit-reducing credit to other provisions intended to reduce costs. Obama was warned of the political peril of taxing employer-sponsored plans deemed too generous, but according to Cohn, he “prided himself on being the kind of leader who took unpopular positions when necessary,” and he saw the tax as central to reining in health care costs.
In the early years of ACA enactment, employers made a habit of blaming increases in premiums (which were more moderate than in years immediately prior) and out-of-pocket costs (which were rising more rapidly) on the so-called Cadillac Tax, which was ultimately never enacted. That messaging may partly explain why more survey respondents in early years said the law harmed them than helped them. Meanwhile, a host of studies and surveys in recent years have indicated that high out-of-pocket costs induce enrollees to forgo needed as well as unneeded care.
Many of these points about Democrats’ assumptions and motives are familiar to those who were involved in the ACA’s creation, or closely watching it. Cohn notes that many of the legislation’s emerging flaws were pointed out forcefully in real time by critics including Marcy Wheeler and Jon Walker (a Prospect contributor). Still, the cumulative effect of Cohn’s narrative is to put the reader inside the collective struggle with a Rubik’s Cube of political, fiscal, and conceptual constraints. In fact, as Cohn notes, in White House meetings, “Obama would frequently raise his two hands like he was manipulating a Rubik’s Cube, twisting it this way and that, as if health care legislation were a puzzle to solve.”
That anecdote is attributed to “senior Obama administration officials.” The book is enriched by many such interviews, current and past, with the sources usually named.
Focused on the political process, Cohn takes a somewhat minimalist approach to describing ACA policy features and the nuances of implementation. You won’t find detailed discussions in this book about the ACA’s cost-sharing reduction subsidies, or “silver loading” (a complex, obscure source of plan discounts stemming from one of the ACA’s many drafting flaws and resulting political warfare), or the steep premium hikes of 2017–2018 that roiled the market. But that lack of granular detail is not really a problem. The contours of the law’s virtues and limitations are clear, as is the impact of flaws such as unaffordable premiums for many unsubsidized enrollees.
As a progressive policy journalist at HuffPost and author of a previous book, Sick (2007), detailing the suffering of uninsured and underinsured populations in the U.S., Cohn is deeply invested in the ACA enterprise. Yet after ten years of war, his assessment is rueful:
The mishmash of private and public insurance with its interlocking subsidies and regulations, the divided responsibility between federal and state governments—it’s a whole other beast and nobody’s ideal. But champions of universal coverage were willing to accept second-, third-, and fourth-best solutions because the specter of past failure loomed so large in their minds.
Fourth-best solutions! That’s the sober assessment of a sympathetic but fair-minded and fact-based reporter.
Cohn hopes that the U.S. will find its way to universal coverage made affordable by some variant of government rate-setting, either by setting a “global budget for health care” or having direct government regulation of prices. That could lead to a single-payer health insurance program, a network of private plans more tightly regulated than in the ACA marketplace, or something in between. This describes “the varieties of national health insurance that exist in the most economically advanced countries around the world,” Cohn explains. But our political sclerosis renders that eventual outcome (like, perhaps, the survival of U.S. democracy) doubtful. If we get there, the path will continue tortuous and tortured. Here’s Cohn’s final verdict:
The Affordable Care Act is a highly flawed, distressingly compromised, woefully incomplete attempt to establish a basic right that already exists in every other developed nation. It is also the most ambitious and significant piece of domestic legislation to pass in half a century—a big step in the direction of a more perfect union, and a more humane one as well. It is not nearly good enough, and yet so much better than what came before it. In America, that is what change looks like.
In 2021, perhaps that’s the best change Americans can believe in.
