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Nancy Pelosi cannot think of a single part of the Affordable Care Act that has underperformed her expectations.
Not the lack of competition in the marketplaces that has worried President Obama — or the double-digit rate hikes this past fall. Nothing.
“I can’t think of anything like that,” the House minority leader said about 40 minutes into an interview this week, when I asked her to name a part of the health law that had gone worse than expected.
Her only regret about the law? That other Democrats didn't step up to the plate to defend it — leading to what she called a sea of misinformation about her signature legislative achievement.
“If I had to fault myself, I would say I should not have trusted that other people were going to be the message piece while we were doing policy. We were in the foxhole; we were in the trenches fighting the fight,” she said.
Now she's gearing up to fix those mistakes, mobilizing House Democrats in a long-shot fight to save Obamacare.
Some circumstances surrounding the health care debate have shifted in Democrats’ favor. Millions of people have gained coverage, and the Democratic Party is roundly united around Obamacare — a far cry from 2009, when Pelosi had to fight aggressively to shepherd the law through the House. It is Republicans who are now dealing with those same political fissures over how to repeal and replace Obamacare.
“It's so hard to sell somebody on something that they don't know about it yet,” Pelosi says. “But to take it away, which is what the Republicans are doing now, it will have its obstacles.”
But while Pelosi easily admitted that the messaging around the Affordable Care Act had “missed the beat,” she was less explicit on what exactly would be different this time — why Democrats would be more successful salespeople in this new repeal fight.
Pelosi said she thought the repeal fight would give Democrats “a chance to have people to take a second look.” They would talk a lot about Medicare, she said, and tell the stories of people who have been affected by Obamacare.
These sound like some of the tools that Democrats have already used with the health care law. At the same time, this is the party’s only option: With minorities in the House and Senate, Democrats have no control over the legislative process. Their only hope is stirring up public opposition so intense that Republicans relent on the repeal promise they’ve now spent six years making.
A transcript of my interview with Pelosi follows, lightly edited for clarity and length.
Pelosi on the values she thinks Republicans and Democrats share
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Sarah Kliff
I was hoping maybe you could just start telling me a little bit of what you make of what we're seeing happen with Republicans right now with some of the fracturing around repeal and delay. I know you've worked on keeping a caucus together. How do you see this playing out right now?
Nancy Pelosi
Well, what the Republicans are going to find out is that it's one thing to criticize something that is coming. People don't know exactly what it is, so they're so receptive to the complaint. Then it's another thing to take something away. It's so hard to sell somebody on something that they don't know about it yet, but to take it away, which is what the Republicans are doing now, it will have its obstacles.
The Affordable Care Act’s purpose was to expand access, lower cost, and improve quality. No preexisting conditions, no lifetime limits, children in the program until 26, being a woman is no longer a preexisting condition.
There's certain other aspects of the health care law that are part of the health care system’s structure now. They address emergency and uncompensated care at hospitals. How are they going to address that, now that they're not taking care of the hospitals? That's why [in] 11 states, the hospitals came together last week, especially in rural states, to oppose this repeal. The AMA [American Medical Association] has written their letter opposing it.
This weekend, we had wonderful events around the country. You saw what the Senate did last night. It started last week, the first week of the Congress. We'll continue next week with rallies in the rest, but the stories are the amazing thing. There's nothing more eloquent. I can talk about statistics and rate of growth and access and the rest of that, but the stories of the people are so incredible.
Sarah Kliff
Republicans have spent a lot of time campaigning on repealing the Affordable Care Act. Do you expect them to be successful, and what will Democrats’ role be in that?
Nancy Pelosi
I don't expect them to be successful because the Affordable Care Act is a pillar now of financial and health security in our country. Can we find some ways to work together to sustain that to address some concerns they may have? I think that we can. Again, this is a marketplace initiative, and the uncertainty that [repeal and delay] thrusts into the marketplace is very disruptive to the marketplace.
They have to make a judgment. We understand that they really don't care that much about people who receive coverage through Medicaid expansion and the rest, but they do care about the cost to their constituents. I appreciated your article because it shows that they were not even understanding the reach of the Affordable Care Act. Your article talked about people in Kentucky who voted for Trump but don't want them to take their health care away.
Sarah Kliff
Do you think there's anything Democrats could have done over the past six years to make the ACA more robust, to repeal threats or make it less likely that Republicans would just stick with this day after day campaigning the repeal?
Nancy Pelosi
Well, we didn't have the Congress in the past six years. Anytime you pass a bill of this level of consequence, whether it's a civil rights bill or Medicare, Social Security, you revisit an implementation as to how you can facilitate improvements. We certainly would have been able to do that, but we didn't win the election, so you can't do it without the Congress.
Are there places that we can work together? I think so, as long as the standard is we're not increasing the cost, we're not diminishing the package, and we're not decreasing the number of people who are covered. As long as we have those shared standards, we can find a way.
Sarah Kliff
Do you think Republicans share those standards?
Nancy Pelosi
I hope so. I hope so. I don't know who'd they want to tell, “We don’t want you to have health insurance,” that they want to tell the governors in expanded Medicare states, "Too bad." I don't know if they'd want to tell their perceived and their viewed constituency that “your package is going to be different.” I don't know that they want to increase costs for anybody.
Why Democrats “missed the beat” on Obamacare’s messaging
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Sarah Kliff
You had mentioned the reporting I did in Kentucky. One thing I was curious about, one thing that surprised me, was that every Obamacare enrollee I spoke to in Kentucky had voted for Trump. I'm curious: Does that go against what you expected when you were working the health care law? Did you think people who signed up for it would recognize that “we like these benefits and we want to vote to keep them”? That didn't really seem to happen.
Nancy Pelosi
Well, nothing surprises me when I hear that people are voting against their own interests. The Affordable Care Act is only one of several ways in which the Trump administration and the Republicans work against these people every day — in terms of wages, working condition, clean air, clean water.
For a long time now, for issues that don't relate to the economy but relate to social issues, people who get tinkled on by their trickle-down economics vote with the Republican Party for reasons that have nothing to do with the economic self-interest but have to do with some perceived insecurity they have about where society is going.
Sarah Kliff
Do you think Democrats had a chance to reach those people in this election? Was there some missed chance to reach these people who like these benefits and say, “Look, this is Obamacare”?
Nancy Pelosi
In this election?
Sarah Kliff
In this election.
Nancy Pelosi
I don't know that in this election. I think we missed a beat in messaging all along. I do think that right from the start, there was an assumption on the part of some that people would understand — but that isn’t true if the other side is poisoning the well for ideological reasons, not pragmatic reasons.
We could have done a better job to inoculate against their poison, to educate rather than assume people would understand it. That’s no reflection on the public’s inability to understand. They were just hearing what they were hearing.
Sarah Kliff
What would you have done differently looking back? How would you have messaged it? When you say, “We missed a beat,” what are the things you would have done differently?
Nancy Pelosi
Well, I may write a book on this subject.
Sarah Kliff
Would you care to give a preview?
Nancy Pelosi
I just don't want to put anything into anybody's doorstep. If you're idealistic enough to think that we're going to deal in a truthful environment, then you might not have to worry about inoculating against their poison. But if they're saying it’s about paying for terminating a pregnancy, which it does not, if they’re saying that there are death squads, which there weren't, then you're dealing with people who are not of goodwill and not of good faith.
Sarah Kliff
You still had the president in office. He had this big platform. [Republicans] were throwing a lot of poison, and you’re right, a lot of misinformation took. Why do you think Democrats couldn't combat that, given the bully pulpit the president has?
Nancy Pelosi
Why don't you go ask him? He said he was too busy doing the bill?
Sarah Kliff
He said there was a lot of work on policy. I don’t think I honestly —
Nancy Pelosi
The fact is that if I had to fault myself, I would say I should not have trusted that other people were going to be the message piece while we were doing policy. We're in the foxhole; we're in the trenches fighting the fight. We need their cover.
Sarah Kliff
From the White House?
Nancy Pelosi
One hundred million families of people and families that are affected by preexisting medical conditions. Over 100 million people affected by that. You would think there'd be some resonance that people know, “I couldn't even get insurance before.”
Sarah Kliff
Recognizing that you felt like the messaging didn't go perfectly over the first six years of the Affordable Care Act, what do you think are the messages you're going to use to defend the health care law now? What do you think will work for Democrats right now?
Nancy Pelosi
Before you go there, let me just say that I really commend the administration. First of all, we have the bill because of the intellectual and inspirational leadership that the president provided. They have implemented it very well, but for the first day. I really give them very high marks for how they have dealt with it.
I think they deserve a tremendous amount of credit. If you have to have your choice between the best possible implementation and the best possible messaging, you would take the best possible implementation.
Personal stories, defending Medicare will factor heavily into strategy
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Sarah Kliff
What kind of messages are you going to be using now to defend the health care law? What do you think will be successful?
Nancy Pelosi
To take something away from someone is a different story than to promise them something. Promises mean I don't know if this is going to happen or not. Taking something away — Is this is something I have, and where am I without it?
First of all, we’ll talk about the impact on people's lives directly. Nothing I could ever say to you is more persuasive or eloquent than the stories, and there's millions of them. Millions of them that are just so overwhelming. People will tell their stories. We had a meeting with 100 groups Friday.
On the policy side, what they will do is very damaging to Medicare. We prolonged the life of Medicare by at least 10 years with the savings that we've found there. They took the same savings in the [Paul] Ryan budget and gave tax breaks to the wealthy. They don't believe in Medicare, and they don't believe in the guarantee. If you combine the Ryan budget with the Affordable Care Act [repeal], you have a real existential threat to Medicare, an assault on Medicare. And we will fight that, and that is a place that people do understand.
Sarah Kliff
I know you mentioned you had your meeting of groups. Do you expect industry to be vocal supporters of the health care law? We've seen AHIP and pharma really sitting on the sidelines so far at this point.
Nancy Pelosi
Look. What did the insurance industry get? Millions more customers subsidized.
Sarah Kliff
You’re right, it was a pretty good deal. That's why I would expect them to be out here defending you guys, but I haven't seen that.
Nancy Pelosi
It's not a good thing for them. Now, again, I think at the proper time, don't you think?
I've been in the trenches before, but now it's certain cavalries are coming, and we're not going away. You see the House and the Senate are united on this. The back and forth we have is, “Yes, of course we want to work together to get something done,” but if they're not going to that place, the public will know that that is what that is.
Sarah Kliff
I have a question that I asked the president that I was really interested in his answers. I was curious to ask you as well. What part of the health care law has overperformed expectations, done better than expected, and what part do you feel has underperformed and really not been as robust as you would have liked?
Nancy Pelosi
The three pillars, the three principles that I said that we have to find common ground on on all — lowering cost, increasing access, and improving the package — it has absolutely done beautifully in all three of those areas. The part, I don’t know, the negative part, I can’t think of anything like that.
The whole thing of the fight on it is something that will give us a chance to have people to take a second look. Take a second look at the Affordable Care Act. Think about what it means to you. Purge yourself of whether you like President Obama or not. They named it Obamacare as a derogatory term. We embrace it as a positive term. In any case, we see this as a chance for them to take a second look at it. This is what it means to you if you have a preexisting condition, if you have a child under 26, 26 and under, if you're a woman, and the rest. Women have so much to lose in this.
Sarah Kliff
Do you think people will change their minds when they take a second look? People have had a long time to look at the health care law.
Nancy Pelosi
A lot are benefiting from it and don't know it because the messaging has not worked. What do people hear the most about it? Twenty million more people have access to health care. That's not the point. The point is the overwhelming number of people in our country get their benefits from their employer, from the workplace, and their benefits’ cost and access are all improved. That has to be part of selling it too.
The lack of knowledge on the part of some, including an elective office, is stunning. Well, we can't beat Canada — no, we're not Canada. This is a marketplace initiative for people to buy insurance. If you want to really, sincerely have a healthy country, let's talk. I think there's real opportunity just to say to people, “Calm down and listen and think about what this means to you, your family.”
