A week before the election and two weeks before the Supreme Court hears oral arguments to get rid of his signature healthcare law, former President Barack Obama released a look back on his fight to get the Affordable Care Act passed in a New Yorker essay drawn from his forthcoming memoir.
Many of the political obstacles he faced prior to passage of the law on Christmas Eve 2009 seem familiar today as the ACA faces final elimination after slowly being dismantled by the Trump Administration.
With new Justice Amy Coney Barrett sworn in last night, the Supreme Court has a 6-3 conservative majority with which to rule the law unconstitutional because there is no longer an individual mandate to buy health insurance.
It was the individual mandate that originally anchored Obama's push for the ACA, partly because with it insurers could be appeased by the argument that there would be more consumers in the market to make up for the other mandate that they cover consumers with preexisting conditions.
Current opponents fear Democrat Joe Biden's plan to strengthen the ACA and offer a public option, but the individual mandate and the rest of the ACA grew out of the healthcare initiative of Mitt Romney, former Republican governor of Massachusetts. Under Romneycare every person was required to have health insurance; subsidies were determined on a sliding scale based on income; and a central online marketplace exchange allowed consumers to shop for the best deal.
Importantly, insurers were not allowed to deny coverage based on preexisting conditions.
Romney called the individual mandate "the ultimate conservative idea," because it promoted personal responsibility, Obama said.
"These two ideas – the individual mandate and protecting people with preexisting conditions – went hand in hand," Obama said. "With a huge new pool of government-subsidized customers, insurers no longer had a financial incentive for trying to cherry-pick only the young and the healthy for coverage. And the mandate would prevent people from gaming the system by waiting until they got sick to purchase insurance."
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Politically, Obama needed both Republican and Democratic support to pass the Affordable Care Act. And it would have been a huge blow to his own early tenure as president if it had failed.
While presidential efforts for more universal healthcare can be traced back to Teddy Roosevelt in 1912, Obama and his team needed to look no further than the unsuccessful efforts of President Clinton and First Lady Hillary Clinton. Their "crash and burn" legislative proposal failed to involve key Democrats in the process so that they would feel a sense of ownership of the bill, Obama said.
The Obama Administration was already using up political capital to fast-track the passage of the Recovery Act, a major economic-stimulus package.
And he was dealing with the H1N1 virus, which killed 12,000 Americans.
"The question was whether we could get it done," Obama said. "Any major healthcare bill meant rejiggering a sixth of the American economy. There was also the question of how to pay for the changes."
But Americans were ready for reform as healthcare innovations drove up costs and they began paying more out of pocket. When Obama took office, he said, more than 43 million Americans were uninsured; premiums for family coverage had risen 97% since 2000; and costs were continuing to climb.
"Beyond wanting some margin for error, I also knew that passing something as monumental as healthcare reform on a purely party-line vote would make the law politically more vulnerable down the road," Obama said in the piece. "So we thought it made sense to shape our legislative proposal in such a way that it at least had a chance of winning over a handful of Republicans."
Obama said the battle for healthcare reform was personal to him and to Senator Ted Kennedy, who, while battling terminal cancer, told Obama not to give up the fight.
"My interest in healthcare went beyond policy or politics; it was personal, just as it was for Teddy," Obama said. "Each time I met a parent struggling to come up with the money to get treatment for a sick child, I thought back to the night Michelle and I had to take three-month-old Sasha to the emergency room for what turned out to be viral meningitis. I remembered the terror and the helplessness we felt as the nurses whisked her away for a spinal tap, and the realization that we might never have caught the infection in time had the girls not had a regular pediatrician we felt comfortable calling in the middle of the night. Most of all, I thought about my mom, who had died in 1995, of uterine cancer."
His mom was in between consulting contracts and didn't have coverage, a stress she carried to her hospital bed, Obama said.
Obama's team made certain policy concessions, such as promising pharmaceutical lobbyists that the bill wouldn't include provisions allowing the reimportation of drugs from Canada, something that President Trump, by executive order, has said he would allow.
"Drug reimportation was a great political issue, but, at the end of the day, we didn't have the votes for it, partly because plenty of Democrats had major pharmaceutical companies headquartered or operating in their states," Obama said.
The Republican Minority Leaders, McConnell and John Boehner, had already announced their vigorous opposition to his legislative efforts, arguing that they represented an attempted "government takeover" of healthcare, Obama said. Conservative Senator Jim DeMint said defeat would be Obama's "Waterloo." And the Tea Party, with its anti-tax, anti-regulation, anti-government manifesto, was against it.
"At the White House, the mood rapidly darkened. Some of my team began asking whether it was time to fold our hand," Obama said.
Strategist Phil Schiliro said to him, he said, "'I guess the question for you, Mr. President, is, Do you feel lucky?'
"I looked at him. 'Where are we, Phil?'
"Phil hesitated, wondering if it was a trick question. 'The Oval Office?'
"And what's my name?
"I smiled. Barack Hussein Obama. And I'm here with you in the Oval Office. Brother, I always feel lucky.
"I told the team that we were staying the course."
Obama said, "On Christmas Eve, after twenty-four days of debate, with Washington blanketed in snow and the streets all but empty, the Senate passed its healthcare bill, titled the Patient Protection and Affordable Care Act – the A.C.A. – with exactly sixty votes. It was the first Christmas Eve vote in the Senate since 1895."
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