Election Watch: Obamacare counterfactuals

By Luke Freedman

Democrats have consistently predicted that Obamacare would become increasingly popular as its changes took effect. So far, that hasn’t been the case, and now, facing the very real possibility that the Supreme Court will strike down the law, some on the left have taken to questioning the way President Obama approached health care reform.

The latest example of this Monday morning quarterbacking comes from Juliet Lapidos at the New York Times. In her piece, “Healthcare: What Might Have Been,” she sympathetically quotes former Congressman and amateur photographer Anthony Weiner, who told President Obama in 2009:

“I think you’re looking at this entirely the wrong way. You need to simplify it. Just say that what we’re doing is gradually expanding Medicare.”

Lapidos hypothesises that if citizens saw the reform as expanding a popular program instead of creating a new one, it might have been more widely embraced.

I’m drawn to the idea of a Medicare-style single-payer health care system, but I disagree with the notion that it could have been more politically palatable than the reform that ultimately passed.

A health care system reflects and must be understood in the context of a country’s unique “cultural values and institutions.” It’s not a coincidence that the United States, with its emphasis on individual liberty and suspicion of centralised government power, is the only first world country without a universal national health insurance program.

Single-payer insurance systems have been better than the US model at holding down health care costs in large part because they possess the centralised authority to set and enforce strict price controls. One of the most frequent attacks on health care reform was that Democrats were attempting to ration medicine. Those critiques would have been even more scathing if a Medicare-for-all program  had been at stake. Any attempts by the government to set limits or regulations on health care expenditures would have been portrayed as an Orwellian attack on patient autonomy. Medicare is a popular program, but that doesn’t mean that citizens would readily embrace it on a universal scale. Adopting this sort of system would necessitate a large-scale shift in the way many Americans view healthcare.

Republican opposition to Obamacare was strong, but can you imagine the lengths they would have gone to defeat the bill if single-payer was on the table? The individual mandate was a conservative invention, and, until a few years ago, was extremely popular within Republican circles. In 2009, Mitt Romney even penned an op-ed in USA Today arguing that President Obama should look to his Massachusetts plan as a model for federal health care reform. Seeing how vehemently conservatives fought against one of their own ideas, it's clear they would have done anything in their power to try and stop a proposal that they have actually consistently opposed.

Of course, one might object that the bill ultimately passed without any Republican support. The opposition certainly has the power to channel the discontent of the public and pressure members of the other party, but if Democrats banded together they still could have passed a Medicare for all system on their own.

Considering the extreme difficulty that Speaker Nancy Pelosi and Senate Majority Leader Harry Reid had in getting the votes to pass Obamacare, it’s almost unfathomable that they could have convinced their party to approve a substantially more progressive piece of legislation.

In the 2006 and 2008 elections, Democrats picked up a number of seats in traditionally Republican districts. While these new members were Democrats by name, they were more moderate than most of their colleagues. With the political climate changing, these representatives knew that holding their seats in 2010 would be a challenge, and were acutely aware of the dangers of embracing a health care plan that could offend their relatively conservative constituencies.

The influence of these Blue Dog Democrats was apparent from the early stages of the reform process. Legislation must pass through relevant committees before it can go to the House floor for a vote, and moderate Democrats in these committees demanded numerous modifications to the bill before granting their approval.

The Senate would have proven an even greater challenge. The threat of a Republican filibuster meant that Democrats needed all 60 members of their caucus to pass legislation. Does Lapidos really think there was a good chance of convincing a Ben Nelson or Blanche Lincoln to vote for single-payer?

It’s impossible to comprehensively evaluate these counterfactuals, but the debate over a public option serves as a helpful proxy variable. A public option is a government-run insurance program that competes against private insurers. It is not, in any way, a full takeover of the insurance industry by the government. After all, private insurers endorsed Obama’s proposed reforms early on, knowing that there potentially could be a public option in the final bill.

Still, this government-run plan was killed in the Senate.  Senator Joseph Lieberman made it clear that he would not support any legislation that included a public option. You have to really play with logic to think that the same Senators who were against a new government insurance option would have somehow endorsed an exponentially larger expansion in government run insurance.  

Many on the left think that objections to health care reform can be condensed down to a dislike of the individual mandate: If we passed a different bill, we wouldn’t have had these problems.

That’s just wishful thinking. Republicans were excellent at framing Obamacare in terms of its least popular provision. If Democrats passed a single-payer plan, conservatives would have found controversial parts of that bill to highlight.

Do I hope we can have something like Medicare for all in the future? Yes. Could Obama and Co. have done a better job organising the reform effort. No doubt.  Do I sometimes wish Democrats would be more courageous in defending their principles. Absolutely. But concluding that, because Medicare is fairly popular, a single-payer plan would have been politically feasible is simple minded analysis of the highest degree.

1 May 2012