In December 2003, Democrats in Congress overwhelmingly opposed President Bush’s Medicare Part D prescription drug program. With good reason. The new benefit included the infamous “donut hole,” a gap in coverage which still saddled many seniors with out-of-pocket costs for their prescriptions. Making matters worse for 45 million elderly and the United States Treasury alike, the law crafted by then representative and future PhRMA president Billy Tauzin (R-LA) prohibited Uncle Sam from negotiating drug prices directly with pharmaceutical companies as the VA and most industrialized economies have long done. Adding insult to injury, the Republicans’ new government program was completely unfunded, adding a projected $400 billion to the national debt over a decade because, as Senator Orrin Hatch (R-UT) later explained, “it was standard practice not to pay for things.”
But when its disastrous launch in January 2006 left “Bushcare” teetering on the brink of catastrophe, Democrats in Congress and in the states moved quickly to help the administration and American seniors. Computer systems failed. The web-based comparison shopping “exchange” experienced serious glitches. Some six million Medicare/Medicaid “dual eligibles” found themselves unable to get their prescriptions filled. As future House Speaker John Boehner (R-OH) put it, “The implementation of the Medicare plan has been horrendous.” Nevertheless, as the New York Times reported on January 16, 2006, 20 states—most of them Democratic—“announced that they will help low-income people by paying drug claims that should have been paid by the federal Medicare program.” As a freshman Senator named Hillary Clinton explained her party’s response to the Republican fiasco:
“I voted against it, but once it passed I certainly determined that I would try to do everything I could to make sure that New Yorkers understood it, could access it, and make the best of it."
To put it another way, both sides don’t do it.
As the unveiling of the Senate GOP health care bill this week once again showed, the subterfuge, sabotage and sheer cruelty of the 8-year Republican effort to abort the Affordable Care Act know no limits. A calamity a wiser Donald Trump might call “American carnage”—22 million more uninsured Americans, millions more facing financial ruin, gutted essential health protections, skyrocketing premiums to maintain comparable coverage, jacked-up deductibles, spiraling out of pockets costs and over 200,000 needless deaths by 2026, all to fund an $600 billion tax cut windfall for the wealthy—Mitch McConnell’s “Better Care Reconciliation Act” has nothing to do with “replacing” Obamacare. For 25 years, Republicans have never wanted to enable universal health care coverage for the American people, but only to prevent the Democratic Party from doing so.
We know this—that is, that Republicans feared not Obamacare’s failure, but its success—because they told us so.
Aside from the wealthiest Americans, the GOP bill is all pain, no gain for everyone else.
Barack Obama himself never fully articulated this crucial point. During an August 2013 press conference, President Obama pondered why the GOP's "number one priority, the one unifying principle in the Republican Party at the moment is making sure that 30 million people don't have health care." But in attributing the 40-plus Affordable Care Act repeal votes, the threats to shut down the government over Obamacare funding, the tens of millions of dollars in misleading ads and another summer of town hall rage to the GOP's "ideological fixation," the president was only partly right.
At its core, the Republicans' scorched-earth opposition to Obamacare has never been so much about "freedom" or "limited government" or any other right-wing ideological buzzword as it has been about political power, pure and simple. Now as for the past 20 years, Republicans have feared not that health care reform would fail the American people, but that it would succeed. Along with Social Security and Medicare, successful healthcare reform would provide the third and final pillar of Americans' social safety net, all brought you by the Democratic Party. To put it another way, the GOP was never really concerned about a "government takeover of health care," "rationing," "the doctor-patient relationship" or mythical "death panels," but that an American public grateful for access to health care could provide Democrats with an enduring majority for years to come.
But what Utah Senator Orrin Hatch called a "holy war" to block healthcare reform didn't start when Barack Obama took the oath of office in January 2009, but instead when Bill Clinton was inaugurated in 1993.
It was then that former Dan Quayle chief of staff and Republican strategist William Kristol warned his GOP allies that a Clinton victory on health care could guarantee Democratic majorities for the foreseeable future. "The Clinton proposal is also a serious political threat to the Republican Party," Kristol wrote in his infamous December 3, 1993 memo titled "Defeating President Clinton's Health Care Proposal," adding:
"Its passage in the short run will do nothing to hurt (and everything to help) Democratic electoral prospects in 1996. But the long-term political effects of a successful Clinton health care bill will be even worse—much worse. It will relegitimize middle-class dependence for 'security' on government spending and regulation. It will revive the reputation of the party that spends and regulates, the Democrats, as the generous protector of middle-class interests. And it will at the same time strike a punishing blow against Republican claims to defend the middle class by restraining government."
And that, for Kristol, meant it had to be stopped at all costs:
"The first step in that process must be the unqualified political defeat of the Clinton health care proposal. Its rejection by Congress and the public would be a monumental setback for the president; and an incontestable piece of evidence that Democratic welfare-state liberalism remains firmly in retreat."
As the American Prospect recalled, Kristol's war plan:
[...] darkly warned that a Democratic victory would save Clinton's political career, revive the politics of the welfare state, and ensure Democratic majorities far into the future. "Any Republican urge to negotiate a 'least bad' compromise with the Democrats, and thereby gain momentary public credit for helping the president 'do something' about health care, should be resisted," wrote Kristol. Republican pollster Bill McInturff advised Congressional Republicans that success in the 1994 midterm elections required "not having health care pass."
So, Republicans and their media water carriers followed Kristol's advice to the letter. In the Senate, long-time healthcare reform supporter Bob Dole adopted Kristol's mantra, declaring "Our country has healthcare problems, but no healthcare crisis." Long before she introduced the easily debunked "death panels" fraud, Betsy McCaughey almost singlehandedly undid the Clinton healthcare reform effort with the false claim that "the law will prevent you from going outside the system to buy basic health coverage you think is better." In 1993, GOP Senators Hatch and Chuck Grassley, among those who would 16 years later call the ACA's individual mandate unconstitutional, joined 19 other Republican senators in proposing their own bill that "would have required everyone to buy coverage, capped awards for medical malpractice lawsuits, established minimum benefit packages and invested in comparative effectiveness research." (As Hatch later justified his turnabout, "We were fighting Hillarycare at that time.")
The rest, as they say, was history. At least, that is, until history began repeating itself with the election of Barack Obama.
The dire warnings from the right began within days of Obama's election. Michael Cannon of the Cato Institute parroted the think-tank's claim that Obama's healthcare proposal is "socialized medicine" and sounded Kristol's old clarion call:
"Blocking Obama's health plan is key to GOP's survival. Ditto Baucus' health plan. And Kennedy's. And Wyden's."
Approvingly citing Norman Markowitz' assertion at PoliticalAffairs.net that "national health care [and other measures] will bring reluctant voters into the Obama coalition," Cannon fretted that "making citizens dependent on the government for their medical care can change the fates of political parties." For arch conservatives, that formula spells trouble for the GOP.
James Pethokoukis of the American Enterprise Institute also picked up Kristol's baton. Concerned that "creating the Obamacare Class would pull America to the left," Pethokoukis echoed Cannon's obstructionist line. Writing in US News, he recounted the grim warning from a Republican strategist who told him:
"Let me tell you something, if Democrats take the White House and pass a big-government healthcare plan, that's it."
Just two weeks after Barack Obama was sworn in, Kristol left no doubt that he believed the Republican Party should repeat the obstructionism that destroyed the Clinton healthcare plan in 1993 and 1994. GOP leaders in Congress, Kristol told Fox News's Neil Cavuto, should emulate the roadblock Republicans of the 1990s to halt Obama's economic recovery package now and everything else—including healthcare reform—later:
"But the loss of credibility, even if they jam it through, really hurts them on the next, on the next piece of legislation. Clinton got through his tax increases in '93, it was such a labor and he had to twist so many arms to do it and he became so unpopular. [...]
[...]That it made, that it made it so much easier to then defeat his health care initiative. So, it's very important for Republicans who think they're going to have to fight later on on health care, fight later on maybe on some of the bank bailout legislation, fight later on on all kinds of issues. It's very important for them, I think, not just to stay united at this time, though that's important, but to make the arguments."
Of course, the arguments Republicans made during the right-wing's healthcare "hissy fit" of 2009 and 2010 were all specious ones. But when they weren't inventing "facts" out of whole cloth, the GOP's best and not-so-brightest in rare moments of candor gave away the Republican game on healthcare reform. In November 2009, Senator Hatch confessed his darkest fear about a Democratic win on health care:
HATCH: That's their goal. Move people into government that way. Do it in increments. They've actually said it. They've said it out loud.
Q: This is a step-by-step approach—
HATCH: A step-by-step approach to socialized medicine. And if they get there, of course, you're going to have a very rough time having a two-party system in this country, because almost everybody's going to say, "All we ever were, all we ever are, all we ever hope to be depends on the Democratic Party."
Q: They'll have reduced the American people to dependency on the federal government.
HATCH: Yeah, you got that right. That's their goal. That's what keeps Democrats in power.
In August 2011, the very short-lived GOP White House frontrunner Michele Bachmann echoed the point that the successful entrenchment of healthcare reform would be mean a permanent Democratic majority. As CNN reported, Bachmann explained why at a campaign event in South Carolina:
Bachmann stressed the need to repeal President Obama's health care reform law, or so-called Obamacare, before it "metastasizes" like a cancer and "we will not be able to get rid of it." "You can't put socialized medicine into a country and think that ever again you can elect a Republican as president—or a conservative or even a tea partier as president—and think that somehow we're going to get back to limited government," Bachmann said. "It won't happen because socialized medicine is the definition of big government."
It's wonder that after President Obama signed the Affordable Care Act allowing adult children to join their parents' policies, ending lifetime caps, prohibiting insurers' bans on preexisting conditions, enabling over 30 million Americans to get insurance cover and more, conservative analyst and former Bush speechwriter David Frum admitted as much, announcing "Conservatives and Republicans today suffered their most crushing legislative defeat since the 1960s."
No illusions please: This bill will not be repealed. Even if Republicans scored a 1994 style landslide in November, how many votes could we muster to re-open the “doughnut hole” and charge seniors more for prescription drugs? How many votes to re-allow insurers to rescind policies when they discover a pre-existing condition? How many votes to banish 25 year olds from their parents’ insurance coverage? And even if the votes were there—would President Obama sign such a repeal?
Frum was more prescient than he knew. Republicans did in fact score mammoth victories in the 2010 and 2014 midterm elections precisely by whipping “the Republican voting base into such a frenzy” about “somebody who wants to murder your grandmother.” The 2010 wave was made possible by perhaps the greatest misinformation campaign in modern American domestic politics. There were no “death panels” (Politifact’s 2009 Lie of the Year) and no “government takeover of health care” (Politifact’s 2010 Lie of the Year”). No one was going to “pull the plug on grandma” or “stick it to seniors” or mount an “$800 billion raid on Medicare.” (In 2012, then RNC Chairman Reince Priebus slander the President on this very point, accusing Obama of “having blood on his hands” over savings from Medicare providers that every subsequent Republican budget and health care proposal maintained.)
For his part, Mitch McConnell both before and after the signing of the Affordable Care Act catapulted the propaganda. During the heated debates and Tea Party shout-downs at town hall meetings in the summer and fall of 2009, McConnell denied that 47 million Americans go without health care (as President Bush had put it, “you just go to the emergency room”) and warned that an insurance public option “may cost you your life.” But for more than seven years after the Kentucky Senator promised his 2010 midterm slogan would be ’repeal and replace, repeal and replace, repeal and replace,” neither Leader McConnell nor future Speaker Ryan put out a plan to replace Obamacare.
With nothing to offer but 20 years of recycled GOP sound bites about health savings accounts, selling insurance across state lines, undersized tax credits and tort reform, Republicans in Washington and in the states launched the most damaging public policy sabotage since the segregationist South’s reaction to Brown v. Board of Education.
The GOP’s scorched-earth strategy against the ACA.
GOP-led states refused to establish their own health care exchanges. Many defunded outreach efforts, ordered state insurance monitors to refuse take action on claims against health insurers and halted the work of Obamacare “navigators”—often the very same hospitals, churches, universities and non-profits helping enroll seniors in Medicare programs in their states. The Republican Congress and Republican state attorneys general brought lawsuits to kill the ACA insurance mandate (which failed), stop the mandatory Medicaid expansion under the ACA (which succeeded), challenge the funding of “cost sharing reductions” (CSRs) for individuals and families earning up to 250 percent of the federal poverty level and even Obamacare’s insurance subsidies for the 31 states using the federal health exchange. Despite the use of reinsurance and risk corridor programs by Medicare Advantage and Medicare Part D to help offset the losses of participating insurers, Congressional Republicans led by Senator Marco Rubio (R-FL) slashed the federal dollars they had been promised. The result was the closure of most of Obamacare’s non-profit coops and the withdrawal of many private insurers. Most spiteful of all, 19 states foolishly rejected the expansion of Medicaid, leaving millions of their residents in a “coverage gap,” undermining the financial stability of rural hospitals and draining state coffers now responsible for the uncompensated care of the uninsured in their states.
As President, Donald Trump has only ramped up the GOP’s schemes to disrupt, diminish and destroy Obamacare. Despite Trump’s promises to deliver “insurance for everybody” and “take care of everybody,” his administration is actively undermining the ACA’s insurance marketplaces nationwide. Under Secretary Tom Price, the Department of Health and Human Services declared it would not enforce the mandate’s penalties for failing to obtain insurance, encouraging younger and healthier Americans to opt out. Trump has repeatedly threatened to withhold those cost-sharing payments to insurers. As the New England Journal of Medicine reported this week, President Trump is doing his damnedest to make Paul Ryan’s myth of an Obamacare “death spiral” become a self-fulfilling prophecy.
The President has also sown doubt about whether the federal government will continue to reimburse insurers for cost-sharing subsidies that they are legally required to provide to most marketplace enrollees. In 2014, House Republicans filed a lawsuit alleging that the ACA did not formally appropriate funding for those reimbursements. A federal district court judge ruled in favor of the plaintiffs but stayed her decision pending appeal. Now the administration has suggested that it may drop the appeal and stop these reimbursements. The Kaiser Family Foundation estimates that ending the payments would require insurers to raise premiums for “silver” plans by 19% on average across states using the HealthCare.gov enrollment platform.
These steps have been all the more damaging because they appear to be part of a deliberate strategy to undermine the ACA. President Trump has noted that withholding cost-sharing reduction payments could seriously damage the individual market and that market turmoil increases his leverage in seeking repeal of the ACA. To that end, the administration reportedly opposed adding language to recent appropriations legislation giving it clear legal authority to continue the cost-sharing reduction payments.
Paul Ryan and Mitch McConnell aren’t taking any chances. Ryan’s “American Health Care Act” gets rid of the cost-sharing reductions immediately; McConnell’s BCRA within two years. Each dramatically reduces the subsidies for older, sicker and less affluent Americans to purchase private insurance, forcing many out of the marketplace altogether. Both Trumpcare bills slash Medicaid spending and cap its growth, costing as many as 14 million people their insurance coverage by 2026. (Almost 65 percent of the 1.4 million Americans in nursing homes are dependent on Medicaid for their care.) By enabling states to waive Obamacare’s 12 essential health benefits (EHB’s), the GOP would encourage flimsy insurance policies which don’t even meet the CBO’s definition of “coverage.” Even the tens of millions of Americans who have employer-provided coverage are at risk: the nonpartisan Congressional Budget Office says 4 million of them could lose their coverage as a result of the Senate bill. And as CBO warned, it is Trumpcare which poses the greatest risk of a death spiral:
Several factors could lead insurers to withdraw from the market—including lack of profitability and substantial uncertainty about enforcement of the individual mandate and about future payments of the cost-sharing subsidies to reduce out-of-pocket payments for people who enroll in nongroup coverage through the marketplaces established by the ACA.[...]
Community-rated premiums [for those of same age group and geography] would rise over time, and people who are less healthy (including those with preexisting or newly acquired medical conditions) would ultimately be unable to purchase comprehensive nongroup health insurance at premiums comparable to those under current law, if they could purchase it at all—despite the additional funding that would be available under H.R. 1628 to help reduce premiums.
The ultimate irony of the GOP health care bill may be this. Fueled at this point only by the twin Republican imperatives of appeasing their hardline base and delivering a tax cut payday to the rich, Trumpcare will hit some of the President’s most devoted backers most severely. Rural red staters not only have the fewest choices of insurers and the highest premiums, they also happen to be most likely to have preexisting conditions. Voters over 50—the people AARP calls members and the GOP calls it base—will see their premiums jump most sharply even as number of them without insurance is forecast to jump from five to 10 million. It’s no wonder Trumpcare is wildly unpopular and polling underwater in every state. Even in that Trumplandia that also happens to be Mitch McConnell’s home state of Kentucky.
Support for Obamacare is at an all-time high.
While support for the GOP bill has dropped to a low of 12 percent, Obamacare now enjoys the backing of 51 percent of Americans. That’s the highest level in seven years the Kaiser Family Foundation has been tracking the Affordable Care Act. That is not to say Obamacare doesn’t need improvements, a fact the law’s supporters and President Obama himself admit and explain. But it does explain why even Mitch McConnell is warning Senate Republicans they may have to work with Democrats on some of those fixes.
Republicans should try it. After all, George W. Bush’s Medicare Part D drug benefit was unpopular when it passed in late 2003 and even more so when it launched in January 2006. But thanks to Democratic help, Part D’s approval equaled its disapproval by that June. And by 2014, fully 90 percent of seniors supported the prescription program by 2014.
Republicans may remain as devoted as ever to their permanent tax cuts for plutocrats, but even their own supporters are onto them. “‘Repeal and replace’ was once a unifier for the GOP,” Dan Balz wrote this week, “Now it’s an albatross.” It’s no mystery as to why. “The House and Senate proposals benefit those at the top explicitly at the expense of the lower middle class,” Ronald Brownstein explained, “And voters are beginning to notice.” Increasingly, it seems that for the GOP to kill Obamacare now would be an act of pure political spite—and possibly political suicide.
