Subbing Trumpcare for Obamacare would be an historic oddity
Americans bemoan health care system constantly, change it rarely
WASHINGTON, D.C. — Today’s ballistic battle over health care — its extreme partisanship, intellectual dishonesty, “fake news,” “alternatives facts” and a precedent pulverizing president — seems like a brand new genre of political combat. It may be disorienting, distressing and ignoble, but not out character in this era typified by social media, reality television and culture conflict.
While there is no disputing this is a whole new ballgame, for better or worse, a look at the history of American arguments about medicine, insurance, doctors, hospitals and how to pay for it all reveals one stark reality: In the nation’s 230 years, there have actually been only two landmark legislation acts that fundamentally changed the structure of health care delivery in America — the laws creating Medicare and Medicaid in 1965 and Obamacare in 2010. Even narrow legislation is rare when it comes to fiddling with how we get and pay for doctors, hospitals and medicines.
Fierce, ideological debates over health care that are polluted by demagoguery, fictional statistics and crackpot economic theories are common in our history. Sweeping new laws come less frequently than Halley’s Comet.
“Many Americans think the debates about health care all began with Obamacare,” according to Drew Altman, president and CEO of the non-partisan Kaiser Family Foundation and a political scientist who has been in the trenches of all the recent health care debates.
In truth, health care debates first became prominent on the national stage in the election of 1912. Former President Theodore Roosevelt ran as the nominee of the new Progressive Party, the Bull Moose Party. Their platform demanded that workers in America’s new industries should receive health insurance. They lost.
“One lesson of history is that the burden is always on those who want change,” Altman said. “New plans always get less popular and acceptable in public opinion the more real they get.” That was the case for the next half century — and it is playing right now in the Obamacare/Trumpcare extravaganza.
Twenty years after his cousin’s campaign, Franklin Roosevelt wanted health insurance to be part of the first New Deal programs. He lost that fight and lost again later in his tenure, always opposed by the medical lobby and interested groups.
Veterans coming home from World War II needed medical coverage and so did their children — the Baby Boomers. The country was enjoying a can-do optimism after the war and it seemed an opportunity to find a sensible way to insure Americans. Harry Truman was a devoted advocate of universal health insurance. Some of his opponents, gripped by Cold War thinking, called it socialism. (Many still do.) Southern Democrats feared the proposed plan would desegregate hospitals. The medical establishment was against reform and had big clout. Truman failed.
By the 1960s, however a major hole in the health care system stressed nearly all Americans. Health care had become much better and much more expensive. Masses of old and retired people couldn’t afford it. Nor could they get health insurance. Their children couldn’t afford to pay their parents’ bills. President John F. Kennedy pushed a program to insure seniors somewhat similar to how Social Security supplanted their incomes. He failed.
The problem got worse. On July 30, 1965, President Lyndon B. Johnson signed the bill that created Medicare and Medicaid. Harry Truman was at his side. It was the first landmark legislation about health care, America’s first law establishing broad government-based health insurance.
In the 1980s, senior citizens faced a new and severe problem. Hospital bills and prescription medicines had become unaffordable for vast numbers on Medicare. Seniors, of course, vote in big numbers and they made themselves heard. In 1988, President Reagan signed legislation intended to better cover prescriptions and medical catastrophes. These new benefits, however, were funded by new Medicare premiums. When time came to pay those premiums, seniors went on the warpath. (They staged many flamboyant and aggressive protests when members of Congress returned home not unlike what today’s members encountered during their recent Presidents Day recess.)
The Reagan bill was repealed 17 months after it passed. Later legislation did provide coverage for prescriptions, but politicians relearned the unpredictable dangers of tinkering with people’s health care — even when they complain about it. “Most people have no particular thoughts about policy,” Altman said. “They just want a better solution for themselves and their families.”
That is exactly what Bill and Hillary thought they were offering in 1993 with the Health Security Act — quickly renamed HillaryCare.
There was a relatively broad, even bipartisan agreement on the problems that needed to be addressed: rising numbers of the uninsured, out of control costs and the health care sector was consuming such a large slice of the Gross Domestic Product that overall productivity could be slowed. But there was nothing approaching a consensus about solutions. The medical-industrial complex fought Hillarycare with one of mightiest lobbying efforts of the times. The Clintons, of course, failed as well.
President Barack Obama in 2009 faced a clearer and more acute problem: More than 15 percent of Americans lacked health insurance, some 45.6 million people. It was a crisis of economic justice and pure economics: the uninsured still received care at hospitals, clinics and emergency rooms. Those hospitals, municipalities and doctors were stuck with bills they had no way to pay. Some went bankrupt. Costs were passed on as higher insurance costs, bigger price tags for care and added taxes and debt. Insurance was hard to get if your employer didn’t provide it. Medical consumers — that is, everyone — were not only mad but scared.
Obama methodically pushed a reform agenda throughout 2009. He had substantial business support and episodic Republican cooperation. The Patient Protection and Affordable Care Act passed the House and Senate in 2010, though with no Republican votes. It was only the second comprehensive health care law enacted in American history.
It was not a moment for rejoicing or national congratulations. The legislative battle was bloody, bellicose and demoralizing for spectating voters on both sides. It seemed to most voters that this was what all health debates were like.
“For those people, it has always been an incredibly partisan debate and they view it is an incredibly partisan issue,” Altman said. “Health care has become the poster child for a whole group of other partisan issues.” That is hardy an optimal backdrop to improve one of the most structurally complicated, economically substantial and personally important political issues of them all.
If partisanship was intense and corrosive in 2009-10, it is supercharged and nuclear now. There is no bipartisan collaboration — zilch. The GOP is split on several basic fault lines. The lobbyists and business interests are further from the smoke-filled rooms than anyone can recall. And President Trump, well, is acting in hugely unfamiliar, idiosyncratic ways that can’t really be handicapped because there are no precedents.
“What is most different this time is that the most important factor is not the special interests. That isn’t true anymore,” Altman said. “The most important factor is partisanship.”
As disillusioning as that sounds, as poorly as it reflects on our leaders, our party system and our collective wisdom as voters, it might well be a sensible variation — though not an attractive one — on the traditional American civic habits of caution and dogged skepticism.
The most recent polls show that since the campaign and inauguration, most voters are getting cold feet about repealing the Affordable Care Act, aka Obamacare. “Even for Republican voters, now that they have some details about what repeal might really mean for them personally, they are getting mad and starting to recoil,” Altman said. You can even see Republican members of Congress recoil all day long on cable news.
This gives fresh credence to a history lesson that might be timely. History suggests that Americans will not easily accept any changes to the health care system that Congress and the president might come up with.