Health care is his biggest achievement, but will it last?
It might go down as President Barack Obama’s signature achievement or his greatest disappointment: sweeping health care legislation aimed at bringing coverage to every U.S. citizen while reshaping the industry with a focus on healthy outcomes.
The plan Obama signed looks, in its broadest outlines, like what he campaigned on: expanding the current system by creating insurance marketplaces, expanding Medicaid for the poor, adding consumer-friendly protections and making investments in electronic health records and innovative medicine.
Its greatest success has been a huge expansion of coverage. More Americans today have health insurance — coverage reaches 90.9 percent of the country — than ever before. That’s roughly 20 million people who didn’t have insurance before the law.
But the law failed in important respects, too.
It didn’t save people money. Obama campaigned on a promise of lowering premiums, but that hasn’t happened, and PolitiFact rated it Promise Broken. (The best he could say is that premiums didn’t rise as fast as they used to.)
The law also became a marker of Obama’s failure to bring Democrats and Republicans together. Nearly seven years after passage, Republicans in Congress oppose it, and President-elect Donald Trump said he intends to repeal and replace it. Polling suggests Republicans and Democrats are more divided on health care than ever. Roughly equal numbers of people say they oppose the law (45 percent) as support it (43 percent).
Obama places the blame on congressional Republicans. In December, he accused them of playing politics as he urged the public to sign up for 2017 insurance.
“Don’t let Republicans in Congress take us back to the days when you could be denied insurance for having a pre-existing condition, or you could be charged more simply for being a woman. Tell them we want to build on the progress we’ve made, not abandon it,” Obama said. “I’ve put forward a bunch of ideas for how we could do that. I hope that Republicans can put politics aside and work with Democrats on behalf of all Americans to make the program work even better.”
Obama can hope, but Republicans seem more committed than ever to opposing the law. The 2016 elections sent control of the presidency and Congress over to the GOP, and they have a huge say in Obamacare’s future.
A long road to law
Newly elected President Obama said that he hoped Republicans would come to the table and negotiate with him. But first he had to navigate the health care politics of his own party.
When Obama first proposed a health care plan during the presidential campaign of 2008, it was considered by many Democrats to be the least effective, especially compared with Democratic rivals Hillary Clinton and John Edwards, because it didn’t have a requirement that everyone buy insurance, a policy known as the individual mandate.
Once Obama won office, at the urging of fellow Democrats, Obama changed positions and accepted the requirement that people buy insurance with little protest, as members of his party in the House and Senate started hammering out details.
On the big priorities, Congress went along with Obama’s campaign promises, allowing Obama to keep promises to give tax credits to people who needed help to buy insurance; to require insurers to cover pre-existing conditions; to require large employers to provide insurance or pay a penalty; to invest in health information technology and to expand seniors’ prescription drug coverage.
On others, Congress gave Obama some of what he wanted but changed details. Instead of Obama’s one national health insurance marketplace, Congress created state-based marketplaces. It also appropriated less money than Obama wanted for electronic health records. Both promises rated Compromise.
Congress rejected Obama’s idea to allow people to buy government-run insurance, called a “public option.” That rated a Promise Broken. And Obama abandoned his own promise to negotiate the law on C-SPAN, also a Promise Broken.
Gail Wilensky, a health policy expert who served in President George H.W. Bush’s administration, said Obama may have had to compromise on specifics, but he actually achieved his goals by delegating details.
“The fact is the specifics of health care reform were defined much more by the Congress and not so much by the administration. That’s actually a good thing, not a bad thing,” she told PolitiFact.
But the bill picked up very little Republican support as it went along. The final passage of the law in March 2010 came with only Democratic votes. Part of it had to be achieved using budget reconciliation, a special maneuver that requires only 50 Senate votes.
All along, Obama and other Democrats said Republican opposition would soften as the process went on and the law was fully implemented.
Democratic House Speaker Nancy Pelosi made the point in a speech the month it passed. “You’ve heard about the controversies within the bill, the process about the bill, one or the other. But I don’t know if you have heard that it is legislation for the future, not just about health care for America, but about a healthier America,” she said. “But we have to pass the bill so that you can find out what is in it, away from the fog of the controversy.”
Republicans mocked her remarks for months afterward, saying Pelosi was purposefully trying to trick the American public. The fog of controversy never lifted.
'If you like your health care plan …'
After getting the law through Congress, Obama’s health plan faced the courts. In 2012, the U.S. Supreme Court ruled that states didn’t have to expand the Medicaid program for the poor. Giving states the option on Medicaid meant health care returned to the field of politics, this time in debates in state legislatures across the country. (It also turned Obama’s promise of Medicaid expansion from Promise Kept to Compromise.)
The Supreme Court’s move infuriated supporters of the law.
“Absolutely no one saw that coming. The Supreme Court made up a theory out of whole cloth,” complained Timothy Jost, a professor at the Washington and Lee University School of Law who studies health care and supports Obama’s law.
Republican governors like Rick Scott of Florida and Rick Perry of Texas seized on the chance to oppose the law’s implementation. In other states where governors and state legislatures were of opposing parties, major battles ensued.
For the states that didn’t expand Medicaid, it meant that some of the poorest people couldn’t get coverage. Today, roughly 2.6 million Americans in 19 states can’t qualify for Medicaid coverage; about half of those people live in either Texas, Florida or Georgia.
Obama’s team kept pushing forward with implementation. The law’s requirement for insurance would start in 2014, and the online health insurance marketplaces had to be up and running by the fall of 2013.
But creating the marketplaces proved much more difficult than expected.
Some states didn’t want to create their own marketplaces; other states found it was more than they could handle. So the federal government stepped up to create HealthCare.gov. Bumps in the road turned into a full-scale breakdown. The site debuted on Oct. 1, 2013, but it didn’t work, and problems lingered for weeks.
Meanwhile, new regulations were kicking in. The regulations, unveiled in 2010, were much stricter than what Obama had previewed on the campaign trail. Back then, Obama had told people if they liked their plans, they could keep them.
But some people had bare-bones plans that the Obama administration decided wouldn’t meet the new law’s insurance requirement. While most Americans were able to keep their plans, many Americans couldn’t. Eventually, an estimated 4.7 million people would receive cancellation notices, according to an Associated Press analysis.
The canceled plans tended to not offer that much coverage. New plans were more comprehensive, but pricier. PolitiFact named Obama’s claim that if you liked your health care plan you could keep it as the Lie of the Year. The Obama administration moved to quell controversy by offering extensions to people with canceled policies and by launching an all-out rebuild of the website HealthCare.gov.
Though the cancellation numbers were small — less than 2 percent out of a total insured population of about 262 million — there was no shortage of powerful anecdotes about canceled coverage. Those stories turned into political ads in the 2014 midterm races. Though health care wasn’t the only campaign issue, Republicans made major gains that year, winning back control of the U.S. Senate.
Still, the ranks of the insured continued to grow. Jonathan Gruber, an MIT professor who helped the Obama administration model the health care law, said the law has increased coverage and slowed health care costs.
“My big-picture takeaway is that given the political opposition that it faced, the law did everything it was supposed to,” Gruber said. “The failures of the law have not been policy based, they’ve been political.”
Opponents of the law were much less sanguine, especially as 2016 arrived.
Welcome to 2016
In the early days of 2016, Republicans got legislation to repeal parts of the health care law to Obama’s desk. Obama vetoed the measure.
Out on the campaign trail, Hillary Clinton and Donald Trump each went to their respective corners on health care, with Clinton supporting the law and Trump promising repeal. Trump’s health care ideas came from the Republican playbook, but were very general: give tax breaks to people to buy insurance (already in place for some with Obamacare) and allow the sale of insurance across state lines. His website said other ideas “might be considered if they serve to lower costs, remove uncertainty and provide financial security for all Americans.”
Fall 2016 marked both the election and the fourth year that people could go online to shop for insurance in a health care marketplace. The marketplaces are far from standing on their own, though. Aetna, United Healthcare and Humana all withdrew from some of the states they were in before the 2016 signup period, which meant fewer choices for consumers. Not enough healthy people are seeking insurance through the marketplaces, which means insurers are dealing with more expenses from older, sicker customers. The average rates on the marketplaces also jumped as insurers continued to adjust their pricing.
“You really needed a lot of those young and healthy people to sign up, and they didn’t,” said Michael Tanner, a senior fellow at the libertarian Cato Institute and a critic of the law. “Even with the penalty, they didn’t buy insurance. The penalties were always a lot less than the cost of insurance.”
Tanner said it will be difficult for Republicans to undo the entire health care law. Repeal-and-replace will likely be a gradual process, and parts of the health care law will likely survive.
Full repeal “is easier to do in theory than in practice, but they’ve really boxed themselves in,” Tanner said. “If they don’t repeal this, the grass roots will never forgive them. It’s the one promise they have to keep.”
Among opponents of the law, most say they oppose it because the law gives government too big a role in the health care system (31 percent), or because it’s an indication that President Obama took the country in the wrong direction (27 percent), according to the Kaiser Family Foundation.
But after Trump’s victory, signups on HealthCare.gov jumped. By the end of December, the administration announced that 6.4 million people had signed up for insurance on HealthCare.gov, an increase of 400,000 compared with the same time the year before. It’s not clear if that means people are coming around on the law or if they wanted to sign up before Republicans closed the gates on getting insurance regardless of pre-existing conditions.
When asked about the difficulties of repeal at a news conference in early December, Senate Majority Leader Mitch McConnell of Kentucky said Republicans still intended to move forward on changes. “Will there be challenges? Absolutely, yes. This has been a very, very controversial law. We have an obligation to the American people to change it and to do a better job. And if we can get Democratic cooperation in doing that, that would great,” he said.
The Senate’s next minority leader, Charles Schumer of New York, said later that day that McConnell’s comments masked a political quandary for the GOP.
“They have nothing to put in its place, and believe me, just repealing Obamacare -- even though they have nothing to put in its place, and saying they'll do it sometime down the road -- will cause huge calamity from one end of America to the other. They don't know what to do. They're like the dog that caught the bus,” Schumer said.
In the final weeks of his presidency, Obama met with congressional Democrats on Capitol Hill to strategize about how to preserve the law that so many people now call Obamacare.
After eight years and a law on the books, partisan rancor means the final chapter in Obama’s health care legacy remains to be written.