April 7, 2020

The Difference

By Stephen Tuttle | Aug. 5, 2017

When the ACA passed in 2010, Democrats controlled the White House, Senate, and House of Representatives. Republicans now control the White House, Senate, and House.

The ACA discussion played out over several months, including input from all stakeholders, moving through three committees in the House and two in the Senate. There were nearly 80 public hearings, 130 amendments offered, and 79 roll-call votes. The Senate alone debated the measure for 25 straight days. 

The recently failed Senate repeal bill was put together by 13 senators — all Republicans and all men — in secret meetings. Democrats, many Republicans, and stakeholders were not invited. There were no public hearings and only 20 hours of debate was allowed. 

Obama, a noted policy wonk, knew details of the ACA and openly campaigned for it. He made campaign-style speeches, held town halls, and made an ACA-specific speech to a joint session of Congress. He assiduously courted recalcitrant legislators, praised them publicly, made deals for their state, and made more deals with insurance companies. (His less charitable critics called them bribes.) 

President Trump clearly did not know the details of either the House repeal bill — he called it “great,” only to refer to it as “mean” a few days later — or the Senate version. He made no supporting speeches and had minimal involvement with stakeholders or the legislative process. He insulted and threatened recalcitrant legislators. 

In the end, all Democrats and no Republicans voted for the ACA, and all Democrats and three Republicans voted against the repeal. The ACA became law, and the repeal efforts failed.

None of that proves Obama is a better president than Trump but does demonstrate, when it comes to legislative issues, he was both a better dealmaker and salesman. In a circumstance ripe for deal-making (remember the 130 amendments in the ACA?), Trump's self-proclaimed expertise was invisible.

To be fair, the Democrats of 2010 had an advantage over the Republicans of 2017. Providing something people needed but didn't have — access to healthcare — was an easier sell than taking it away years later. And while Democrats temporarily unified, Republicans are still split between some who don't want ACA benefits repealed and those who don't support the benefits at all. 

The ACA now enjoys a slim margin of public support, according to the most recent polls. Conversely, only 17 percent and 19 percent respectively supported either the House or Senate repeal plan. It seems we don't love the ACA but prefer to keep it.

Is it working? Depends on who is talking.

The cold numbers, supplied by the U.S. Department of Health and Human Services (HHS) which oversees it, are open to interpretation.

Since it began, a bit more than 20 million Americans have availed themselves of some kind of health care coverage through the ACA. The majority have benefited from the expansion of Medicaid coverage in 31 states and the District of Columbia. About 11 percent of the country is still not covered, compared to the peak of 18 percent in 2013. 

The insurance marketplaces have spotty trouble areas. Rates in rural areas have increased dramatically. More than 40 percent of U.S. counties now have only one insurance provider. Premiums are likely to increase another 10 to 18 percent this year and next.

Overall, ACA premiums have increased 59 percent since 2013, but real customer costs have risen significantly less. For example, the most popular ACA insurance, the silver plan, has increased its deductible to nearly $4.000. But individual and insurance company tax breaks and subsidies will reduce that amount by 70 percent or more for most families.  

Once the subsidies and tax breaks are included, the overall cost for an average family of four has actually remained fairly stable. 

The Republican approach, so far, has been to meet in secret and emerge with a plan no one has seen that eliminates health care benefits for about 20 million Americans, a very tough sell. Trump has done almost nothing to close the sale because he doesn't know what he's selling. 

This is a rare instance when Republicans and President Trump might want to take a page out of the Democrat and President Obama playbook and proceed carefully and openly. The difference is staring them in the face: The ACA is still law and their seven years of repeal are not.


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