Chapter 3
“Even If It Worked, I Would Oppose It”
Health Care

In his presidency’s third month, Barack Obama hosted a meeting with congressional Republicans at the White House, and the Democrat declared he was serious about pursuing an ambitious health care reform plan. GOP lawmakers, reminding the president about the rhetoric he’d used on the campaign trail a year earlier, demanded to know if Obama would follow through on his promises on bipartisan solutions.

The president responded by immediately putting a concession on the table: Obama didn’t want to include limits on medical malpractice awards in the legislation, and he knew such a move would be unpopular with his party and some of its supporters, but in the interest of bipartisan cooperation and constructive legislating, the president told Republicans he’d agree to the concession if GOP officials were willing to make reciprocal compromises.

What, Obama asked, were Republicans prepared to offer? Nothing, GOP leaders responded. As Time reported in May 2009, “Republicans were unprepared to make any concessions, if they had any to make.”1

By any fair measure, the multiyear debate over health care was the Super Bowl of policy fights. Officials from both parties had spent the better part of a century pursuing measures intended to bring health coverage to those who lacked it, while improving health security for those with insurance, and policy makers had volumes of research and scholarship upon which to draw.

It was a once-in-a-generation opportunity, and the expectation was that Democrats and Republicans, each with firm ideas about the future of American health care, would bring their A games to the debate.

GOP lawmakers, however, wasted little time proving that they had no A game to bring. In what was arguably the defining domestic policy fight of the generation, Republicans were wholly ill-equipped for the debate, uninterested in engaging on any of the substantive details, and indifferent to the real-world consequences of their apathy.

This was hardly an abstract debate for tens of millions of American families. On the contrary, unlike most domestic political disputes, the fight over health care reform was a life-or-death issue. From those with preexisting health conditions to those who were one serious illness away from financial ruin, practically everyone would be affected by the outcome, creating ample incentives for GOP officials to be fully engaged. They chose a less constructive path.

For all the bluster from the right about Democrats having “rammed through” the Affordable Care Act as part of a “rushed” process, the health care reform law was among the most carefully scrutinized pieces of legislation in recent American history. The process featured dozens of congressional hearings across five committees as part of a bicameral debate that lasted more than a year.2 In the U.S. Senate, after the committee debates, Democratic leaders held a floor debate that went on for twenty-five days.

As part of the months-long effort, Democratic officials spent countless hours meeting with stakeholders in the health care industry, holding town hall forums, and answering a myriad of questions from the public and the press.

The Republican approach was far less laudatory. For example, the idea of an individual mandate—a measure that requires the public to purchase insurance in order to control costs and spread risk—had been a staple of Republican policy making for decades. President Richard Nixon touted the idea in the 1970s, President George H. W. Bush supported it in the 1980s, and Bob Dole, the GOP’s former Senate leader and former presidential nominee, endorsed it in the 1990s. In 2006 Mitt Romney, then the governor of Massachusetts, incorporated the individual mandate into this reform model in the Bay State, and he continued to promote the idea during his 2008 presidential campaign, the first of his two tries for the White House.

In 1993 Republican senator John Chafee of Rhode Island wrote a plan with an individual mandate that enjoyed the support of twenty other GOP senators, including Utah’s Orrin Hatch and Iowa’s Chuck Grassley.

In June 2009, with the Democratic reform initiative under way, Grassley went so far as to tell Fox News, “I believe that there is a bipartisan consensus to have an individual mandate.”3 He said two months later that the proper way to get to universal coverage was “through an individual mandate.” The longtime Iowa lawmaker added, “That’s individual responsibility, and even Republicans believe in individual responsibility.”

It was after Democrats agreed to include the policy in their proposal that Republicans decided the individual mandate was the single most outrageous provision of the ACA and an unforgivable assault on Americans’ liberties. Hatch, after having cosponsored a bill with an individual mandate years earlier, condemned the idea as “totalitarianism.”4

When CNN asked the Utah senator in March 2010 to explain the contradiction, Hatch replied, “Well, in 1993, we were trying to kill Hillary-care.” He added that he “didn’t pay any attention” to the part of the bill that included the mandate provision.

The cynicism surprised even jaded political observers, but Hatch’s antics were also emblematic of his party’s post-policy posture: the merits of proposals and the virtues of consistency were casually cast aside in the name of political expediency. If embracing the individual mandate meant trouble for Bill Clinton’s reform initiative, great. If rejecting the individual mandate helped undermine Barack Obama’s reform efforts, that was fine, too.

Grassley followed Hatch’s lead. Four months after he told a national television audience about the “bipartisan consensus” on the individual mandate, and two months after he sang the policy’s praises as part of a push toward “individual responsibility,” Grassley was asked what kind of changes he’d like to see to the Democratic bill before he considered supporting it. “I’m very reluctant to go along with an individual mandate,” he replied.5

There was no governing vision or genuine interest in addressing a life-or-death dilemma for millions of American families. This wasn’t even a negotiation position from which to leverage related substantive gains. There was only a pathological desire to defeat a Democratic priority.

When partisans go to war against their own ideas after their rivals agree with them, the prospects for constructive bipartisan policy making disappear.

What’s more, as the Affordable Care Act was taking shape, and Democrats pleaded with GOP lawmakers to partner with them on a bill, Republicans too often negotiated in bad faith. In the summer of 2009, the White House agreed to a significant delay in the reform process in order to allow the Gang of Six from the Senate Finance Committee to work on a possible compromise package. The group featured three Democrats (Montana’s Max Baucus, New Mexico’s Jeff Bingaman, and North Dakota’s Kent Conrad) and three Republicans (Grassley, Wyoming’s Mike Enzi, and Maine’s Olympia Snowe.)

The efforts proved pointless. Enzi hosted a discussion with a group of constituents in August 2009 and described his approach to the negotiations: “It’s not where I get them to compromise, it’s what I get them to leave out.” The Wyoming Republican made it clear that he had no intention of supporting a reform bill and participated in the talks solely to weaken the bill he’d inevitably vote against.

When other GOP lawmakers tried to critique Obamacare and highlight its flaws, many Republicans seemed wholly unaware of the legislative details of the plan they purportedly hated. In September 2009 the National Republican Senatorial Committee sent out a letter to supporters over Texas senator John Cornyn’s signature, claiming the ACA could establish a “lottery” system determining who would get priority treatment, while creating standards that allowed the government to discriminate against patients “on the basis of race or age.”6 The letter added that the idea of allowing federal officials to choose patients’ doctors for them was “up for debate.” Each of the claims were absurd, but the party made them anyway.

That same month, Representative Joe Wilson of South Carolina heckled Obama during a nationally televised address to a joint session of Congress—loudly shouting, “You lie!” at the president—because the right-wing lawmaker was convinced of the false idea that the health care reform law would cover benefits for undocumented immigrants.7 Senator John McCain said in a written statement that the reform bill would add “more than a trillion dollars to our country’s deficit,” would put medical decisions “in the hands of government bureaucrats,” and amount to a “government takeover of our health care system.”8 None of these claims had any relationship to reality.

House Minority Leader John Boehner inexplicably claimed that the Democratic plan required “a monthly abortion fee.”9 Senator Rand Paul, an ophthalmologist before getting elected, argued that those who believe Americans have a right to health care were endorsing a more dangerous position: “That means you have a right to come to my house and conscript me. It means you believe in slavery. It means that you’re going to enslave not only me, but the janitor at my hospital, the person who cleans my office, the assistants who work in my office, the nurses.”10

Some arguments were little more than lazy examples of post-policy thinking: Louisiana Senator David Vitter said he had “a fundamental problem” with legislation that had a lot pages.11 His GOP colleague Representative Roy Blunt of Missouri made the same case, as if the physical size of a proposal was relevant to its merits.

Fair and objective analyses made clear that there were real flaws in the Affordable Care Act. No law is perfect, and the architects of Obamacare had to make several difficult trade-offs, as is always necessary on legislation of this scope. But the plan’s GOP critics largely ignored those substantive flaws, focusing instead on nonsense, much of which had been made up out of whole cloth.

In November 2009 the Washington Post’s Ruth Marcus marveled at the “appalling amount of misinformation being peddled” by Republicans. Her column added, “You have to wonder: Are the Republican arguments against the bill so weak that they have to resort to these misrepresentations and distortions?”12

The question soon answered itself, as GOP officials, unwilling or unable to participate in a real debate, launched a concerted effort to convince the public that Obamacare featured what it called “death panels.”

At issue was an unremarkable provision in the bill intended to help elderly patients receive advice from their doctors on end-of-life directives and living wills. In July 2009 John Boehner claimed the provision “may start us down a treacherous path toward government-encouraged euthanasia.”13 The same week, Representative Virginia Foxx of North Carolina delivered a speech on the House floor, insisting that health care reform would “put seniors in a position” in which they may be “put to death by their government.”14

This evolved into the death-panel talking point—the most disgusting of all the anti-ACA lies—touted by Alaska governor Sarah Palin, conservative media, and a few too many Republican members of Congress who knew better.

Senator Johnny Isakson tried to argue that end-of-life directives and living wills actually empower people “to be able to make decisions at a difficult time rather than having the government making them for you.”15 The conservative Georgia Republican added, “I don’t know how that got so mixed up.”

It was around this time that Chuck Grassley hosted a town-hall event in Iowa and was asked about the death-panel issue. “You have every right to fear,” the senator told his constituents, adding, “We should not have a government program that determines if you’re going to pull the plug on Grandma.”16 Asked on CBS’s Face the Nation why he’d peddled such garbage, Grassley replied, “I was responding to a question at my town meetings. I let my constituents set the agenda.”17

There was no great mystery as to how, in Isakson’s words, things “got so mixed up.” His GOP allies, unprepared for a proper policy debate, searched in desperation for something they could use to terrify the public and undermine support for the legislation.

It didn’t work: the ACA was signed into law in March 2010. It wasn’t until the dust had fully settled that the scope of the GOP’s defeat came into sharper focus. Republicans had spent more than a year working from the assumption that if they stood firm, slapped away every outstretched hand offering an olive branch, opposed the ideas they used to support, lied uncontrollably, and refused to work in good faith, it would be enough to deny Obama and congressional Democrats a historic victory. They were mistaken.

Had GOP officials acted more like members of a governing party, they would have been in a position to move the reform law in more conservative directions and include more of the party’s goals—which Democrats would have gladly embraced in exchange for bipartisan support. Republicans chose a more self-defeating strategy that left them empty-handed. They didn’t even have a rival health care solution to point to as evidence of their alleged seriousness on the issue.

Indeed, throughout the lengthy debate, Republicans would occasionally confront an awkward question: If they hated the ACA so much and had superior ideas about how to bring health security to Americans, why didn’t they present an alternative reform plan of their own?

In June 2009 House GOP lawmakers presented a brief outline of their health care priorities, though it was vague to the point of comedy.18 The document shed no light on who would benefit from the Republican approach, how much it would cost, or how it would be financed. The GOP plan was missing a key ingredient: a plan.

The day of the outline’s unveiling, Roy Blunt, a member of the House Republican leadership and the chairman of what he labeled the House GOP “Health Care Solutions Group,” declared proudly, “I guarantee you we will provide you with a bill.”19 The same week, Eric Cantor told reporters that the official Republican version of Obamacare was just “weeks away.”20

In the years that followed, Jeffrey Young of the news website Huffington Post (now HuffPost) got quite a bit of mileage out of a running joke, documenting each of the many instances in which GOP officials said their reform plan was poised for its big unveiling. The list of examples wasn’t short—some even included specific, self-imposed deadlines—but every promise about the plan’s imminent release was broken.

All the while, Republicans seemed unable not just to package their own ideas but also to engage in a meaningful debate on the Democratic proposal. Several weeks before the final congressional votes on the ACA, the White House hosted a health care summit with the bipartisan congressional leadership from both chambers, whom the president invited for what he’d hoped would be a substantive discussion.

GOP leaders had very little to say. Toward the end of the event, John Boehner told Obama, “I’ve been patient. I’ve listened to the debate that’s gone on here. But why can’t we agree on those insurance reforms that we’ve talked about? Why can’t we come to an agreement on purchasing across state lines? And why can’t we do something about the biggest cost driver, which is medical malpractice and the defensive medicine that doctors practice?”

The trouble was, the policy makers sitting around the table had just spent hours answering each of those questions in excruciating detail. The House Republican leader wasn’t posing these questions in an opening statement, hoping to lay the groundwork for additional discussion; he was posing questions that everyone in the room had already answered.

The Impostors: How Republicans Quit Governing and Seized American Politics