For all its imperfections and awkwardness, the Democrat-led legislative process that ended with the passage of the Affordable Care Act in 2010 benefitted from its relative openness (dozens of hearings, continuous debate), duration (more than a year), and honesty of intent. To this day, Republicans have defined that process by its warts, and painted a few of their own onto it.
President Barack Obama, to make the point that the ACA doesn’t interfere with the structure of the employer-sponsored insurance system, promised that people who liked their health plans—and their doctors—could keep them. He should not have said that—or, at least, he should not have been so categorical. And he paid dearly for it. Republicans never let go of Obama’s assertion, and in 2013 Politifact called it the lie of the year.
By contrast, then-House Speaker Nancy Pelosi’s infamous comment—“We have to pass the bill so that you can find out what is in it”—was wrenched from context in grotesquely dishonest fashion. In the conservative information bubble, it is considered indisputable that Pelosi was, like a cartoon villain, announcing her fiendish plan to conceal the contents of the health care bill from the cameras. But in reality she was merely predicting that the unpopular bill would become popular once it stopped being an abstraction and began to benefit real people.
The Republican depiction of the Obamacare debate, and of the law itself, is shot through with these kinds of caricatures and deceptions. In truth, whatever gamesmanship and spin that Democrats used to pass the ACA was a sideshow to a banal, tortuous effort to make the text of the law match a few simple goals. Though Obamacare doesn’t come close to to solving every problem with the U.S. health care system, it met most of those goals: expanding coverage significantly, and slowing the growth of health care costs. That the process winded on interminably allowed anyone paying attention (Democratic legislators and reporters, for the most part) to familiarize themselves with a head-splitting quantity of minutiae. Democrats could not have coasted on Trumpian panaceas in a climate like that.
Seven years hence, the Republican-led effort to repeal the ACA is so rushed and opaque that bullshit doesn’t merely seep into it, but thrives. Republicans are deploying their false depiction of the Obamacare debate and law as a benchmark for defending their supposedly superior process. If they succeed, they will have perpetrated one of the greatest swindles in the history of legislative politics.
Consider the statements that White House press secretary Sean Spicer made from the briefing room podium on Wednesday, taken in order:
If you get your insurance through Medicaid, Medicare, through the government, or an employer-based healthcare, you are untaxed, your employer is untaxed. It is those self-employed individuals, those small businesses that are paying the penalty for this. And that’s what I think we have to remember, is that we talk so often on the conservative side and on the Republican side about the importance of entrepreneurship, the importance of small businesses to our economy, and yet they’re the ones who suffer right now with an inequity in the tax system. And I think that by leveling that playing field, and by giving them more options and driving down cost, we’re actually doing a very conservative thing here by removing the mandate of a government-mandated “you must buy this program or you will pay a penalty,” and eliminating choice.
Spicer was describing a real problem that once defined America’s inequitable health care system, but it’s a problem that Obamacare went a long way toward solving. The ACA offered people who didn’t qualify for a government subsidized insurance plan a new subsidy. When that subsidy untethered people who relied on their jobs for insurance—freeing them to retire early, raise children, or (as Spicer prefers) start businesses—Republicans howled dishonestly to the press that Obamacare was effectively killing those jobs. (One of those Republicans was Sean Spicer.)
Spicer’s critical reference to the ACA’s individual mandate is just as obscurantist as his convenient omission of the ACA’s existing tax subsidy system. The GOP’s new Obamacare alternative, the American Health Care Act (AHCA) also penalizes people who go uninsured, but it funnels those penalty dollars directly to insurance companies, if and when those people decide to purchase coverage. Among other things, this may encourage people to free-ride on the system—to wait to pay their penalty until they become sick or injured.
SPICER: So one of the big issues with Obamacare was in order to fix a problem that faced 15 to 20 million people, is that the entire system got shattered, and prices on everybody got ratcheted up. People who were on Medicaid suddenly lost their ability…
The ranks of the uninsured were closer to 40 or 50 million when Obamacare passed. Since then, premium increases have been similar to, or smaller, than they were before Obamacare passed. Spicer trailed off before completing whatever claim he was contemplating about Medicaid because it almost certainly would have been false. People who were on Medicaid paid small-to-nonexistent premiums, continue to pay small-to-nonexistent premiums, and thanks to Obamacare they were joined by millions of poor and near-poor people who also pay small-to-nonexistent premiums. The AHCA would phase out that expansion beginning in three years, possibly earlier.
SPICER: [T]here’s a difference between having a card and having care. Being told you have coverage and not being able to use it is no good, and that’s the thing that I think is really important. When we get asked the question, so often, how many people are going to be covered, that’s not the question that should be asked—how many people are going to get the care they need? Having coverage with a high deductible and, in some cases—or not having a plan that allows you to get the coverage you need or afford it, isn’t real coverage. It’s a card.
Here Spicer is at least referencing a real complaint about the ACA: Many of the qualified health plans with affordable premiums have deductibles that render them useless for the purposes of financing routine care, making them, in effect, catastrophic coverage plans. The AHCA will make both problems worse by reducing premium assistance to most people, particularly the elderly, who will thus buy cheaper plans with higher deductibles.
SPICER: [Democrats] passed [the ACA] and then told us we could read it. [Our] bill is online for every American to go to ReadTheBill.gop.
This is a bastardization of the decontextualized Pelosi quote. A lie built on top of a lie. Early drafts of the ACA were always posted online, often for many days at a time, before Congress took any action on them.
SPICER: If you’re looking at the CBO for accuracy, you’re looking in the wrong place. They were way, way off last time in every aspect of how they scored and projected Obamacare…if you look at the number of people that they projected would be on Obamacare, they are off by millions. So the idea that we’re waiting for a score—it will be scored. But the idea that that’s any kind of authority based on the track record that occurred last time is a little far-fetched.
This is effectively an admission of the GOP’s most astounding hypocrisy—an acknowledgment that they faked years of outrage—couched as a broadside against the work of anonymous, diligent government economists who can’t defend themselves. House Republicans are rushing the AHCA through the legislative process without a cost estimate from the Congressional Budget Office to ballpark the bill’s effect on coverage, cost, spending, and revenue.
No CBO cost estimate will ever be perfect, but the “miss” Spicer cites here is one of the worst ways to illustrate that point. There are fewer people enrolled in ACA qualified health plans than CBO anticipated, but that’s because CBO anticipated many employers would send their workers to the exchanges for insurance, rather than provide it to them through the employer-sponsored insurance system, and few did. The precise mix of coverage matters less than the extent of it. CBO predicted Obamacare would expand coverage dramatically, and it did. To the extent that it forecast a greater dip in the uninsurance rate than we’ve seen, it’s because the Supreme Court made the ACA’s Medicaid expansion optional, and several Republican state governments subsequently declined to make their constituents’ lives better, simply out of spite.
SPICER: We would love to have every group on board. But this isn’t going to be—every single deal we heard about it getting through, “the Cornhusker Kickback,” this and that. Over and over again, it was one deal after another to get to—to buy votes to get it through the Senate.
In 2009 Democrats attempted to induce embattled senators to support reform with provisions that would have benefitted their states. Republicans portrayed what we would normally call legislative horse-trading as unheard-of corruption, and gave each individual deal its own name. The “Cornhusker Kickback” would have secured full federal financing for Nebraska’s Medicaid expansion. Amid blowback, that basic arrangement was ultimately extended to every state in the country.
SPICER: Nancy Pelosi put out three criteria for how they judge Obamacare. And by their own standards, they fail on all three. Costs are up. Choices are down. There is no other way to judge that. By every account, every single premium by every standard is up.
Costs, again, are rising at historically low rates. Some marketplaces could use more competition, but choices are way up, as evinced by the fact that millions of people who had zero choices before Obamacare are now insured. Premiums have increased, on average, and significantly in some markets, but there’s a reason they call them averages. Not every single premium in the country has increased. Some have fallen. And, crucially, as premiums rise, ACA provides that subsidies rise as well, limiting or eliminating consumer exposure to the higher rates.
SPICER: [W]e work this bill through, through daylight—not jam it through in the middle of the night.
The ACA passed once and for all well before midnight on March 22, 2010, after a year’s worth of debates and votes nearly all of which occurred or concluded before midnight. The earliest Democrats ever envisioned passing health care reform was July 2009. The day Spicer said this, Republicans reported ACA repeal out of the House Ways and Means Committee at 4:30 in the morning. The bill has been public for two days.
Sean Spicer was not alone in obfuscating. On Tuesday, House Speaker Paul Ryan played his part as well.
QUESTION: I know you’re waiting [for the CBO score] to come back, but by some estimates, 10 million people could lose their coverage. Is that acceptable to you?
RYAN: What matters is that we’re lowering the cost of healthcare and giving people access to affordable healthcare plans. The government will always win the war on government-run plans, saying, if we mandate, everybody buys what we say they have to buy, then the government will always estimate that they’ll buy it. I just think that’s bogus. That entire premise of that comparison doesn’t work.
Translation: fewer people might be insured under the Republican plans, but only because, unlike the ACA, the Republican plan, in its majestic equality, will allow rich and poor alike to go without insurance.
QUESTION: What would you say to folks who say that this bill is just a big, fat tax break?
RYAN: Read the bill. Go to readthebill.gop.
Here is what the bill says.