And although Republicans could try to soften the impact, every adjustment to legislation would force them to sacrifice other priorities, creating angry constituents or interest groups and, eventually, anxious lawmakers.
All of those predictions proved correct. It demands unglamorous, grinding work to figure out the precise contours of rules, spending, and revenue necessary to accomplish your goal.
It requires methodical building of alliances, endless negotiations among hostile factions, and making painful compromises on cherished ideals. Most of all, it requires seriousness of purpose—a deep belief that you are working toward some kind of better world—in order to sustain those efforts when the task seems hopeless.
It was a big reason they were able to pass their once-in-a-generation health-care legislation. Those are big reasons their legislation failed. The ensuing political backlash, which saw them lose control of both the House and Senate, had left top Democrats in no mood to revisit the issue.
At conferences and private dinners, on chat boards and in academic journals, officials and policy advisers obsessively analyzed what had gone wrong and why—not just in and but in the many efforts at universal coverage that had come before. They met with representatives of the health-care industry as well as employers, labor unions, and consumer advocates. Out of these parallel efforts, a rough consensus on substance and strategy emerged.
Democrats would put forward a plan that minimized disruption of existing insurance arrangements, in order to avoid scaring people with employer coverage, and they would seek to accommodate rather than overpower the health-care industry. Proof of concept came in , in Massachusetts , when its Republican governor, Mitt Romney, teamed up with the Democratic state legislature to pass a plan that fit neatly into the new vision. It had the backing from a broad coalition, including insurers and progressive religious organizations.
Ted Kennedy, the liberal icon and U. Kennedy was not alone in his belief that the champions of universal coverage would have to accept big concessions in order to pass legislation.
Obama had a similar experience putting together health-care legislation in the Illinois state legislature—where, despite proclaiming his support for the idea of a single-payer system, he led the fight for coverage expansions and universal coverage by working with Republicans and courting downstate, more conservative voters. He also was a master of policy detail, and as president, when it was time to stitch together legislation from different House and Senate versions, he presided over meetings directly highly unusual for a president and got deep into the weeds of particular programs.
Obama could do this because the concept of universal coverage fit neatly within his conception of a just society as one in which people act through government to protect themselves from harm. It helped that he had surrounded himself with policy advisers widely recognized as thought leaders in the field of health policy.
That included Lambrew and Nancy-Ann DeParle, who had been in charge of Medicare and Medicaid during the Clinton administration, as well as Zeke Emanuel, a physician, bioethicist, and prolific writer on health policy. The key Democratic lawmakers had similarly deep benches of seasoned policy advisers. And as the legislative effort got under way in , those advisers were in constant communication with one another and with the White House.
There were daily and sometimes twice-daily conference calls led by DeParle or Lambrew, in order to coordinate messaging and keep the proposals from diverging too much. But the insurance regulations are sustainable only if both the healthy, who cost less to insurers, and the sick, who cost more, carry health insurance.
And without the mandate and the subsidies, young and relatively healthy customers are much less likely to reach into their pockets to pay for coverage than older and sicker patients. The result? Ever higher premiums, insurance company bankruptcy, or both. So, they promise a replacement. Now, Donald Trump and at least one of his close advisors have made the problem even harder. Rivlin Tuesday, January 3, So the goals are at least as much coverage and no increase in out-of-pocket costs without requiring people to carry insurance or spending any more to make it affordable.
Is there any way to achieve these objectives all at once? The reason is that the young and the healthy will disproportionately drop coverage, triggering the upward premium spiral. Without a replacement plan, repeal of Obamacare will add an estimated 30 million people to the ranks of those who have no health insurance. Elected Republican officials are belatedly awakening to this risk. The chairman of the House Freedom Caucus also said he wants to see more details about an Obamacare replacement before voting on repeal.
Some Republican governors in states that expanded Medicaid are raising concerns about repealing that element of Obamacare. Full repeal of Obamacare would take 60 Senate votes to overcome a virtually certain Democratic filibuster. Repeal of only those Obamacare provisions involving spending and taxes can be enacted under Senate procedures barring filibusters with only 51 votes.
As there are only 52 Republican Senators, they cannot afford more than one defection if Democrats remain united. With the likely defection of at least a few Republican senators, the possibility of even partial repeal is fading. The president-elect and other Obamacare opponents are in for a dose of humiliation as they realize belatedly that the promises they have been making for six years are empty. Share Tweet. How many people would lose their health insurance if the ACA were repealed?
How many jobs would be lost if the ACA were repealed? State Drop in overall state employment Number of jobs lost Jobs lost per 1, jobs in the state Billions of federal health care dollars lost Alabama 0. Economic Policy Institute.
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