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A Senate staffer who helped shape Obamacare answers our readers’ questions

To understand what’s going on with the law, it’s helpful to look back at how it was created.

If anyone truly understands the Affordable Care Act, it is John McDonough. He was a key Senate staffer in Sen. Ted Kennedy’s office during the health care debate in 2009 and 2010, and had a front-row seat to how the 1,300-page bill came together. He even wrote an entire book about the experience, called Inside National Health Reform.

McDonough stopped by our Facebook community for Obamacare enrollees to answer questions for our book club, our most recent adventure within this group. As the Affordable Care Act changes, we want to make sure that the people who will be most affected understand the health care policy’s history, complexities, and possibilities in the United States. We hope the book club supplements the great discussions already taking place in the group.

The following highlights from this week’s discussion have been edited for length and clarity.

What will really keep insurers in the Obamacare marketplaces?

Anne Paulson

What kind of deal would [health care] insurers be likely to accept? What do they want, and what would they give up to get it?

John McDonough

Most insurers have a less than deep emotional attachment to the individual health insurance market, though they recognize its importance. If guaranteed issue is to survive, they want something that compels folks to sign up so that the risk pool does not only include sicker and older people. There are a number of ways to do it, and they mostly want a way that is as strong as it is positive. My take is that the strength of the mandate is far less important than the generosity of the premium and cost sharing subsidies in incentivizing maximum enrollment.

Will Republicans be able to get behind a single goal for health reform?

Anne Paulson

Is there a coherent message or goal the Republicans can get behind for health reform, other than cutting taxes for rich people? The Dems all agreed they wanted more people to have health coverage.

John McDonough

My favorite political scientist is Deborah Stone (Policy Paradox). She teaches that much of the policy process involves debates about values masquerading as debates about facts, numbers, data, and anecdotes. Each side hurls numbers and studies at each other and never changes the other sides' minds, because at the core, it's competing values at stake, not data or facts.

The values gap between the parties has only grown wider over the past years. The politics of the new situation is actually driving the sides a bit closer together because of another key value -- getting reelected to Congress!

Is “repeal and replace” actually a viable option?

Marta Culvers

After reading the chapters, it seems extremely difficult to repeal and replace: The ACA does not work if one of the "legs" is broken (guaranteed issue/mandate/subsidies). It seems the only possible way is to improve it. What do you think?

John McDonough

While I would agree that the structure is fragile and needs consistency, big parts of it are just deeply offensive to Republicans — especially the much larger role of the federal government in regulating health insurance and providers, and especially the taxes on high income families, drug companies (though drug companies supported this), insurance companies, and medical device makers. Plus, repealing these taxes would allow Republicans to claim credit for gigantic tax hikes. But they are not facing a tough reality that 2+2 can't = 9.

What do employers think about all of this?

Brandon Meline

Where does the business/employer world fall on this? How were the discussions in 2008 around employers funding a large cost of health insurance premiums, and the for-profit insurance industry?

John McDonough

I believe the health insurers are likely to cut a deal if they can get what they need. That's just their orientation. Hospitals are going to play it much tougher because the ACA took $350 billion in payment reductions from them to help finance coverage (they agreed to this). And if Congress roles back coverage, they want their money back — that would be a major problem for the Republicans in Congress.

Business groups, for the most part, wanted reform. (Except for the US Chamber of Commerce, which was never supportive in 2008-10.) But politically, they could not be on board with the Democrats’ bill because of too many new taxes and political opposition. The Business Roundtable (TBR) was the only business group that did not formally oppose the ACA (though they never supported it), and they played the negotiating role between the business community and the Obama White House and the Senate.

So are for-profit insurers the biggest block to a public option?

Brandon Meline

So, was one (and is it still) of the largest barriers to reform how to negotiate around the for-profit insurance industry? A public option takes that all away, correct? Was that elephant in the room discussed?

John McDonough

Public option was discussed incessantly. It wasn't the insurers who kept it out, Brandon. It was Sen. Ben Nelson of Nebraska, a former Nebraska insurance commissioner, who refused to vote for any bill with a public option. And he was vote number 60. So a bill with a public option could not get through the Senate despite huge lobbying by progressive groups.

Will insurers, hospitals, etc. be able to get Republicans to improve the ACA while leaving it intact?

T Pussi Brown

How effective do you think the insurers, hospitals, etc. will be in getting the Republicans to improve the ACA while leaving it intact? And how can they repeal funding and expect to deliver better?

John McDonough

I don't think anyone knows how effective the stakeholders will be because there is too much uncertainty in the environment — the weather is changing and the ground is shifting constantly. Hospitals and insurers are mighty influential, and they also lose sometimes as much as win. So it’s too hard to predict, except they know how to get heard.

Sabrina Corlette from the Georgetown Policy Center has an NPR interview about her study of insurers now. She finds insurers do not want to go back to being the bad guys who decide who gets coverage and who does not.


Join the conversation

Since its launch in December, our Facebook community for Obamacare enrollees has grown to more than 1,500 members. We’ve stepped back and watched group members make this space their own, a place where they share their stories and interesting articles, ask questions about health plans, and generally support one another in this uncertain time.

We’ve learned that a Facebook community can be an incredibly productive space for our readers to go through a shared experience together — and for us at Vox to interact with our audience in a completely new way.

Are you an Obamacare enrollee interested in what happens next? Join our Facebook community for conversation and updates.