Obamacare? Never heard of it

“Americans right now are paying so much money for their healthcare, ask people about the reality of premiums, deductibles, co-pays, out-of-pocket expenses,” said New York City Mayor Bill de Blasio. “We are on our way, just a handful of years [to] literally spending 20 percent of our economy, one out of every five dollars spent on healthcare,” said Sen. Cory Booker, D-N.J. “And we spend more than every other nation, on everything from MRIs to insulin drugs, multiple mores than other countries — multiple more than other countries.”

“We have tried the solution of Medicare, Medicaid, and private insurance,” said Sen. Elizabeth Warren, D-Mass. “And what have the private insurance companies done? They’ve sucked billions of dollars out of our healthcare system. They’ve made everybody fill out dozens and dozens of forms. Why? Not because they’re trying to track your healthcare. They just want one more excuse to say no.” Sen. Bernie Sanders, I-Vt., declared flatly, “Nobody can defend the dysfunctionality of the current system.”

But this isn’t George W. Bush’s healthcare system or the “terrific” Republican plan President Trump promised during the last campaign. Despite the GOP’s best — or at least persistent — efforts, Obamacare remains the law of the land. The legislation’s popular name went unmentioned the night Biden wasn’t onstage in the most recent debates. Biden was the only one to call the Affordable Care Act or aspects of the existing system “Obamacare” the night he did participate.

“There are a number of debates going on in the Democratic Party about what the future of healthcare will look like,” said Eagan Kemp, a healthcare expert for Public Citizen, a liberal advocacy group. “Though the ACA made a lot of significant progress, there is a lot more that needs to be done.”

Those debates include whether to build on Obamacare or to achieve single-payer healthcare by expanding Medicare, a government-run program that primarily covers senior citizens. And if Medicare eligibility is to expand, Democrats disagree about who exactly should be covered and what role, if any, private health insurance will continue to play. While the details differ depending on which plans individual candidates support, the popular name for these proposals is “Medicare for all.”

“I don’t know what math you do in New York, I don’t know what math you do in California, but I tell ya that’s a lot of money,” Biden said of the competing “Medicare for all” price tags as he squared off with de Blasio and Sen. Kamala Harris, D-Calif. The former vice president had some company, however.

“This plan that’s being offered by Sen. Warren and Sen. Sanders will tell those union members who gave away wages in order to get good healthcare that they’re going to lose their healthcare because Washington’s going to come in and tell them they got a better plan,” protested Rep. Tim Ryan, D-Ohio. “You know, it took us decades and false starts to get the Affordable Care Act,” said Montana Gov. Steve Bullock. “So let’s actually build on it. A public option, allowing anyone to buy in.” “I believe we should finish the job we started with the Affordable Care Act with a public option that gives everybody in this audience the chance to pick for their family, whether they want private insurance or public insurance,” concurred Sen. Michael Bennet, D-Colo.

Former Rep. John Delaney, D-Md., devoted much of his time arguing that he was the person with the most experience in the healthcare business — “It’s not a business!” Sanders interrupted — and that he had better ideas for achieving universal coverage than the liberals on stage. “Folks, we have a choice,” Delaney insisted. “We can go down the road that Sen. Sanders and Sen. Warren want to take us, which is with bad policies like ‘Medicare for all,’ free everything, and impossible promises that will turn off independent voters and get Trump reelected.”

Delaney said he had history on his side. “That’s what happened with McGovern. That’s what happened with Mondale. That’s what happened with Dukakis,” the ex-congressman said, going down the list of failed liberal presidential candidates. Delaney’s only problem is that Democrats know they can win a national election running to the left of Bill Clinton (Obama did it twice) and suspect they can win one running to the left of Obama.

The debate among Democratic presidential candidates is slightly less varied than it first appears when measured by their public support. Bennet is at 0% in the RealClearPolitics average of national polls. Bullock is at 0.4%. Delaney is at 0.7%, though a Quinnipiac poll following the debate at which he railed against “Medicare for all” had him at 0%. Of the four candidates leading the race by hovering around the double digits, only Biden — admittedly, the steady front-runner — has framed his healthcare plans as building on Obamacare’s success. The rest will defend the Affordable Care Act when Republicans try to repeal it in Congress or overturn it in courts. The same goes for the pursuit of regulatory actions to undercut it inside the Trump administration, but they are looking at Medicare as the way forward. They raised their hands in the first Democratic debate when asked if their plans would eventually eliminate private insurance.

At first blush, it seems odd Democrats would abandon Obamacare now. For years, the law was unpopular. Voters opposed it, often by double digits, and pluralities favored repeal. The public split was on average 39.4% in favor and 52.6% against in 2014, as Republicans gained in the midterm elections. The spread was 9.4 points against Obamacare as late as 2016.

In July, a Fox News poll of 1,000 registered voters found 52% favored Obamacare and 43% opposed it. A late March, early April Politico/Morning Consult survey showed respondents supporting the law by 48% to 40%. The RealClearPolitics polling average between March and July was a 10-point spread in favor of the law.

“We haven’t seen this level of support for the ACA since its passage,” Kemp said. “The Trump administration’s sabotage efforts made people more attached to all aspects of the ACA. Once it was under fire, people said, ‘I could end up losing that.'” The polling mostly bears this out.

Obamacare’s favorability spiked and support for repeal collapsed after congressional Republicans, with Trump’s backing, engaged in a failed attempt to scrap and replace the law. The abortive effort appeared to rally the public around Obamacare’s most popular provisions, such as the ban on denying coverage due to preexisting conditions and adults staying on parents’ insurance until age 26. Republicans did succeed in effectively gutting its least popular element, the dreaded individual mandate, by eliminating the penalty for not enrolling in a plan.

“In 2018, healthcare was the issue, as Minority Leader Kevin McCarthy, R-Calif., acknowledged, that cost the GOP the House,” said Democratic strategist Brad Bannon. “According to the exits, 41% of the midterm voters said healthcare was their top electoral priority. These voters voted Democratic by a 3-to-1 margin.”

So why not stick with what’s suddenly working for Democrats? Liberals noticed the exchanges, seen on the Left as Obamacare’s main concession to free-market reformers and private insurers, were troubled. Meanwhile, the Medicaid expansion, a government-run program for the poor, was popular. It was true despite studies that question Medicaid’s impact on healthcare outcomes due to its low physician reimbursement rates. Liberals cited dueling studies purporting to show people dying because of the failure to expand Medicaid in Republican states.

Hillary Clinton ran on building on Obamacare’s momentum, calling it “a heck of a lot better than starting from scratch,” in 2016 and lost. Many, though not all, Democrats ran on various permutations of “Medicare for all” in 2018 and won. There is considerable momentum, both in terms of progressive activism and liberal policy wonkery, behind more ambitious reforms.

“There’s a large movement behind ‘Medicare for all’,” said Public Citizen’s Kemp. “Much larger than for any other Democratic or Republican healthcare policy proposal. It includes unions, communities of color, a lot of grassroots movement.”

Finally, there was always a certain amount of incrementalism and political strategy involved in shaping Obamacare’s precise contours. During the 2008 Democratic primaries, Obama opposed the individual mandate while Clinton supported it. There was initially supposed to be a public option (the ability to enroll in a government health plan) included in the Affordable Care Act. Centrists and Democrats from states where insurance companies had headquarters balked in the Senate. As the parameters have expanded, why shouldn’t Democratic healthcare policy too?

“My response is, Obamacare is working,” Biden said in the most recent debate. “The way to build this and get to it immediately is to build on Obamacare. Go back and do — take back all the things that Trump took away, provide a public option, meaning every single person in America would be able to buy into that option if they didn’t like their employer plan, or if they’re on Medicaid, they’d automatically be in the plan.”

The concern is that Obamacare was unpopular when it was disruptive to people’s existing healthcare arrangements. Obama’s “If you like your healthcare plan, you can keep your healthcare plan” promise proved false. The law gained popularity when repeal, with uncertainty about the details of any GOP replacement, became similarly disruptive. What if, under the more aggressive forms of “Medicare for all”, Democrats become disrupters again? What if they gradually or quickly move people away from private health insurance they would prefer to keep?

A recent NPR/Marist poll found that 70% believed it was a “good idea” to provide Medicare “for all that want it,” allowing Americans to “choose between a national health insurance or their own private health insurance program.” Only 25% thought it was a “bad idea.” But support dips to 41% once it gets described as “a national health insurance program that replaces private health insurance”; 54% say that is a “bad idea.” Require the healthcare program to cover illegal immigrants as some Democratic presidential candidates appeared to want to do in the first debates and support drops further to 33% and opposition spikes to 62%. “This is yet another example of Democrats putting at risk what should be a very winnable election for the sake of appealing to the fringes of their political party,” said Republican strategist Christian Ferry.

That’s why many Democrats are trying to triangulate on this issue. Harris has tried to position herself right in the middle between Biden and the progressive duo of Warren and Sanders. “In response to Sen. Biden about the Affordable Care Act, it is important that you understand that our “Medicare for all” plan has actually by the architect of the Obama Affordable Care Act been described as one of the most effective ways to bring healthcare to all,” she said at the most recent debate. “Kathleen Sebelius has endorsed our plan as being something that will get us to where we need to go.”

The pitfalls here are obvious, however. Harris’ plan remains vulnerable to attack on both her Left and Right. When Gabbard brought up Sebelius’ role both in advising Harris and a “a private insurance company who will stand to profit under her plan,” the California lawmaker shot back, “Well, unfortunately, Rep. Gabbard got it wrong. Kathleen Sebelius did not write my plan.”

“Every estimate that I’ve seen of expanding ACA even through a public option still leaves millions of people uninsured and also means that people are not guaranteed the healthcare that they need, as the example that Sen. Warren showed us,” said Beto O’Rourke. His solution? “I think we’re being offered a false choice, some who want to improve the Affordable Care Act at the margins, others who want a ‘Medicare for all’ program that will force people off of private insurance,” O’Rourke said. “I have a better path … Medicare for America.”

“So let’s just stand up for the right policy, go out there and defend it,” thundered South Bend Mayor Pete Buttigieg. “That’s the policy I’m putting forward, not because I think it’s the right triangulation between Republicans here and Democrats there, [but] because I think it’s the right answer for people like my mother-in-law who is here — whose life was saved by the ACA, but who is still far too vulnerable to the fact that the insurance industry does not care about her.”

Can’t we all get along, asked Booker? “Well, first of all, let me just say, that the person that’s enjoying this debate most right now is Donald Trump, as we pit Democrats against each other, while he is working right now to take away Americans’ healthcare,” he told CNN’s debate moderators, saying that his “two civil rights parents” taught him “always keep your eyes on the prize.”

“The Democratic presidential candidates recognize the GOP’s vulnerability on the issue and the vast voter dissatisfaction with the current system,” said Bannon, the Democratic strategist. “Democrats understand that voters want Medicare expansion but also recognize that they can’t antagonize voters who want to keep their current plans. So the Democratic presidential candidates are calling for expansion of Medicare rather than a complete overhaul of the system. This idea is very popular with voters and the GOP ignores the desire for reform at its own peril.”

Obamacare had the buy-in of healthcare providers and, especially, the pharmaceutical industry. That’s one reason it became law while the Clintons’ 1990s reform efforts never even got a recorded vote in a Democratic-controlled Congress. But it is also why the system retains so many features unpalatable to liberals and why Democratic arguments against the healthcare status quo scarcely sound like Obamacare exists.

All except Joe Biden, who happens to lead in Iowa, New Hampshire, South Carolina, and every national poll. “If the 160 million who have it say they like their employer insurance, they should have a right to have it,” the former vice president told the Democratic debate audience. “If they don’t, they can buy into the Biden plan, which is Obamacare.”

If the Democrats still like Obamacare, they can keep it — or keep this healthcare debate going through next year.

W. James Antle III is the editor of the American Conservative.