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The Republican Party and the Affordable Care Act

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In the fall of 1993, President and Mrs. (as she was then know, before she became brand "Hillary") Clinton were gearing up for the introduction of what became known as "The Clinton Health Plan" to Congress.   At the Annual Meeting of the American Public Health Association, held in Washington, DC in November that year, a session was held looking for volunteers to speak on behalf of the plan at community meetings to be held the following year.   I had a long background in what we used to call " health care delivery systems analysis ."   And so I went along to that first session, really a tryout.   Each participant was asked to give a brief presentation on the problems facing the US health care system and how they thought that the Clinton Health Plan could help to ameliorate them.   I was pleased that I was chosen to participate and invited to come to Washington a couple of weeks later to begin training.   I was dismayed, however, when, with no further discussion and certainly no interview for the job, I was asked to become a trainer myself.  

These folks did not know me, had engaged in no training for trainers, and it quickly became apparent that they were more or less shooting from the hip.   Nevertheless, when we chosen "speakers on behalf of the Clinton Health Plan" were invited to a plenary session at the White House, I fully expected that we would be presented with marching orders and a detailed plan, including talking points, for dealing with the policy and political problems with which we would be expected to deal out on the CHP campaign trail.   Instead, there were several speeches from the designers of the plan about its contents, which were already well-known, and that was about it. No strategy, no tactics, no group meetings, just sitting in lectures.    I remember coming home from that meeting and telling my wife at the time, "if this is all they've got, the CHP is going to lose."

In December of that year I came across a FAX (email was not in common usage way back then) sent out by Bill Kristol (yes, THAT Bill Kristol, and I still have the FAX in my files) to about 1200 Republicans in and about Washington on why they had to oppose the Clinton Health Plan as strongly as they could.   Kristol's focus was not that it was bad policy but because if it passed it would guarantee both a Democratic Congress in 1994 and the re-election of President Clinton in 1996.   And of course they defeated it, helped mightily by President Clinton himself, who maintained a studied silence all through the Spring of 1994 while the Republicans ripped his plan apart.   In fact, not knowing whether they had seen the Kristol FAX or not, I sent a copy in to the CHP office suggesting that they use it to show up the Republican opposition.   I got no response and they never did use it.

From http://www.flickr.com/photos/30651729@N05/10916872816/: Elephant at National Museum of Natural History: Will the GOP elephant be there someday too?
Elephant at National Museum of Natural History: Will the GOP elephant be there someday too?
(image by intrepid00)

Ironically, the anti-CHP campaign in the Senate happened to be led by Bob Dole, the same Bob Dole who, as then Republican Minority Leader in the Senate, in 1974 had introduced a comprehensive National Health Insurance Plan that was similar in many ways to the Clinton Health Plan.   In fact, had it not been for Watergate and President Nixon's forced resignation, it is likely that we would have national health insurance in the United States no later than the run-up to the 1976 Presidential elections.   But it was politics, not policy, that counted for the Republicans in 1994, just as it does now.

As is well-known, the Affordable Care Act squeezed through the Congress and was signed by the President in 2010.   Following the Clinton example, President Obama has remained generally silent on the ACA since that time, while Republicans have periodically been ripping it to shreds while totally mis-describing it as "government-run health care."   It is of course, nothing of the sort.   Rather it is a massive government subsidy system for the private health insurance business, plus a major subsidy for Medicaid (which subsidy, however, each state has to decide to accept, or not --- many Republican states have chosen to decline the aid --- couldn't be for political reasons, could it?).   And it happens that the program would still not cover everyone in the country for the costs of health care.   The ACA is complex and the President and his men and women have done nothing over the years since its passage to make it at least somewhat understandable to the public.  

However, we are now seeing that the President made one huge mistake when he did speak about it occasionally, the "you will be able to keep your health insurance if you like it" mantra.   Whether he did not know of the niggling detail about the difference between private (often very inadequate) and employer-provided policies or did know of it is a matter for White House historians.   However, if in every one of his speeches on the subject he had simply said "if you have health insurance provided by your employer you will be able to keep it and insurers providing privately-held policies will be required to bring them up to snuff" the present contretemps on that subject would not be on the table.   But it is, and the President over the years since the passage of the Act simply handed the Republicans a mallet with which to beat him and his program over the head.  

But why do the Republicans really want to repeal, or at least inactivate, what they call "Obamacare?"   For exactly the same reason that Bill Kristol went out early on the campaign against the Clinton Health Plan: politics (and who better to lay that one out now than Karl Rove ).   Not policy, for the ruling class of the US health care delivery system, very much the protectorate of the Republican Party, is kept very much in place by the ACA.   For the private insurance companies, the ACA keeps them at the center of the system.   For the hospitals there is no "public option" that could seriously bargain with them over reimbursement rates.   At the same time, the expansion of coverage means that they will have to provide much less uncompensated care than they do now. For Big Pharma there is no built-in competition on drug prices.   For the states there would be major increased subsidies for Medicaid.   These are all Republican ideas, ideas drawn in fact (as is very well-known) from a plan developed by the Heritage Foundation that became the foundation for "Romney-care" in Massachusetts.

But of course now, the big Republican fear is that if the ACA goes into effect, as jerry-built as it is, it will work, and then politically it will work for the Democrats and against the Republicans. They in fact are fully self-revealing on this point, because they offer no alternatives to the ACA that deal with the problems the ACA at least attempts to deal with.   And no, their favorites such as allowing health insurance companies to work across state lines and ending the opportunity for patients grievously harmed by physicians and hospitals to get just compensation, otherwise known as "tort reform," just don't deal with lack of coverage, no coverage for pre-existing conditions, and so on and so forth.

And so, failing in the Congress at the time of its passage, failing even in the Republican-controlled Supreme Court, they are now engaged in a rear-guard action, first with the an attempt at Modern Nullification (which failed, at least for the time-being) but now with a new set of tactics that John Boehner is very clear about: " "Remember the strategy for stopping Obamacare we laid out to you back in July. It had two components: Aggressive, coordinated oversight, and targeted legislative strikes aimed at shattering the legislative [political] coalition the president has used to force his law on the nation,' Boehner said , closely following his earlier comments. "That plan is being executed as we speak.' "

Of course, this strategy would probably not have a chance of working if the Federal website had worked.   But it didn't.   Why not?   Since just about since the time the news of the trouble with the healthcare.gov website came out I've had the following thought.   How much did and does a possible GOP hacking machine, as well as the internal defects in the system itself, have to do with the website trouble we've seen.   A top-level computer programmer friend of mine told me that it is very easy to do "service denial."   The target website is just overloaded with incoming requests.   It takes a fairly sophisticated security system to defend against such an effort.

As another friend of mine said, we could ask the ghost of Mike Connell , Karl Rove's "IT guy," who was on his way to testify in a trial about the Ohio vote-rigging scandal of 2004 when his single-engine plane mysteriously (sic) crashed, killing him. But even the NSA would have a difficult time talking with ghosts these days.   And one has to add that the few state exchanges that there are seem to be working pretty well.   Maybe they are better protected.

I'm not the only one to raise this possibility (although the cited reports concerned the security or lack thereof of website applicants' data). I do wonder if six to 12 months from now, in the possible wreckage of the ACA, as delays and attempted reconstructions make its truly jerry-built structure fall apart, we will see one of those multi-authored New York Times stories, like the one that revealed GOP long-range planning on the government shutdown , about how the GOP arranged to hack the website.   Time will tell on that one.   But we already know that half the present problem is due to the fact that the Obama Administration did just about as poor a job of selling the ACA to the public as the Clinton Administration did of selling the CHP.

Note 1 (added, 11/19/13).   On November 18, 2013, in a column in Common Dreams, Norman Solomon said in part:

" The problems with Obamacare involve far more than simply bad website coding. They're bound up in the enormous complexity of the law's design, wrapped around a huge corporate steeplechase for maximizing profits. As a Maine physician, Philip Caper,  wrote  this fall, the ACA "is far too complicated and therefore too expensive to manage, full of holes, will be applied unevenly and unfairly, be full of unintended consequences, and be easily exploited by those looking to make a quick buck.' The ACA is so complicated because it has been so relentlessly written for the benefit of--and largely written by--insurance companies.

"Along the way, the "individual mandate' cornerstone of the ACA--required by government yet actually enriching the private insurance industry--is a tremendous political boost to demagogic GOP leaders. I'm not engaging in hindsight here. Like many others, I saw this coming before the ACA became law,  writing  in March 2010: "On a political level, the mandate provision is a massive gift to the Republican Party, all set to keep on giving to the right wing for many years. With a highly intrusive requirement that personal funds and government subsidies be paid to private corporations, the law would further empower right-wing populists who want to pose as foes of government "elites' bent on enriching Wall Street.'

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http://thepoliticaljunkies.org/

Steven Jonas, MD, MPH, MS, is a Professor of Preventive Medicine at the School of Medicine, Stony Brook University (NY) and author/co-author/editor/co-editor of over 30 books on health policy, health and wellness, and sports and regular exercise. In (more...)
 
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