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Obama thinks he knows how to solve Obamacare’s problems — by making it more liberal

President Obama being interviewed by Vox’s Ezra Klein and Sarah Kliff on January 6, 2017.
President Obama being interviewed by Vox’s Ezra Klein and Sarah Kliff on January 6, 2017.
Kainaz Amaria/Vox
Dylan Matthews is a senior correspondent and head writer for Vox's Future Perfect section and has worked at Vox since 2014. He is particularly interested in global health and pandemic prevention, anti-poverty efforts, economic policy and theory, and conflicts about the right way to do philanthropy.

When President Barack Obama was pushing for passage of the Affordable Care Act, he went out of his way to court the right, making repeated concessions to moderate Senate Democrats and wasting months on an ill-fated effort to win Republican support. Seven years later, with Obamacare on the brink of repeal, he’s going the opposite direction.

In an interview with Vox’s Ezra Klein and Sarah Kliff, Kliff asked Obama why the Affordable Care Act had not become more popular. He replied not by citing the concerns of conservative opponents, but those of the left.

“Whenever you look at polls showing 40 percent are supportive of the law; 40 percent or so are dissatisfied — in the dissatisfied column are a whole bunch of Bernie Sanders supporters who want a single-payer plan,” he said. “The problem is not that they think it’s a failure; the problem is that they don’t think it went far enough. That it left too many people uncovered; the subsidies were not as rich as they should have been; that there was a way of dealing with prescription drug makers in a way that would drive down those costs.”

He also offered a few specific suggestions. To inject more competition, he argued, Congress should reconsider establishing a public option. To address spiking premiums on marketplace plans, Congress ought to offer more generous subsidies to better insulate consumers against price increases. He conceded the somewhat convoluted nature of the law, saying, “If I was starting from scratch, I would have supported a single-payer system because it’s easier for people to understand and manage.”

None of these pronouncements were new, per se. He’s expressed similar sentiments about single-payer before. He spent most of 2009 fighting for a public option. But the choice of what tweaks and principles to signal support for was revealing. Again and again, Obama went out of his way to express sympathy for the ideas and concerns of the left flank of the Democratic Party, people who like single-payer and supported Bernie Sanders and now find themselves politically energized but faced with defending from annihilation a law that falls well short of their ideals.

Some of this is an attempt to minimize the scale of opposition to the law, of course. But it also serves the purpose of reaching out to the vast grassroots Sanders mobilized last year and encouraging them to join the fight against repeal. And it encourages unity at a time when Republicans are fracturing over how to do repeal, and what replacement plan to offer in its wake. A divided GOP and united Democratic party offers liberals their best hope of preserving the law.

Why it makes sense for Obama to energize the left

If Obamacare is to stand any chance of surviving in its current form, a prerequisite is absolute, complete Democratic unity — much as Senate Republicans, led by Mitch McConnell, were nearly able to sink the bill in the first place by holding absolutely firm and never wavering in their opposition.

But strong opposition, as McConnell learned then, won’t be enough. Because Republicans want to use the budget reconciliation process to undo most of the tax and spending aspects of Obamacare, they will only need a simple majority in the Senate and House to pass legislation; Democrats can’t filibuster. With 52 Republicans in the Senate, and Mike Pence around to break ties, and a still larger House majority for the GOP, some repeal legislation can pass with absolutely no Democratic support whatsoever.

But cracks are already showing in the Republican coalition. At least six GOP senators — Rand Paul, Susan Collins, Tom Cotton, Lamar Alexander, Bob Corker, and Bill Cassidy — have expressed doubts or outright opposition to Republican plans to repeal and delay without first crafting an actual replacement bill to supersede Obamacare. Even if just three of those people defect, Republicans won’t have enough votes to make it through the Senate.

Democrats in those Senators’ states have an important role to play in showing up to town halls, calling into congressional offices, writing letters to the editor, and otherwise using their influence as constituents to pressure their elected representatives. It may sound surprising, but senators actually listen to this stuff; local activists can make the cost of defying a senator’s constituents greater than the cost of defying his or her party leadership.

What’s more, if some Republicans continue to waver, it’s probable that Senate Majority Leader Mitch McConnell will start trying to peel off some moderate Democrats in deep red states like Joe Manchin (D-WV), Heidi Heitkamp (D-ND), and Joe Donnelly (D-IN). Local Democrats will have, if anything, even more influence trying to keep representatives of their own party, already disinclined to buck their caucus, in line.

But the key to these strategies is getting a lot of high-information, high-interest Democrats to take costly, high-value actions like showing up to town halls. And more than 40 percent of Democrats active enough to show up in primaries voted for Bernie Sanders. If you limit the analysis to the subset of Democrats likely to work the phones or write letters to the editor, the share is probably higher. The strategy just doesn’t work if those people, many of whom share or have absorbed Sanders’s view that the Affordable Care Act doesn’t go nearly far enough, aren’t a part of it.

The best hope Democrats have organizationally, then, is to reach out to Sanders voters and throw them a few rhetorical bones — yes, premiums should be more subsidized; yes, there should be a public option; yes, single-payer would in principle be better — to let them know that they’re welcome and needed in the anti-repeal coalition. If the only people fighting are people who think Obamacare is great and in need of, at most, some modest tweaks, Democrats’ resistance will be seriously hampered. If a broad popular front emerges, the odds are better.

Leaving the door open for more left policy

Nearly as important is the policy signal this sends to Democrats less inclined toward the Sanders view. After the nearly decade-long, emotionally draining experience of first passing and then defending Obamacare, it’d be reasonable for more centrist-leaning Democrats to not be super-enthused about future efforts to expand health access.

Obama’s comments tell these people, in essence, “The battle’s not over. There are still policies we need to implement. We’re not where other rich countries are, not yet.”

On a federal level, that helps sustain interest among Democrats in expanding and improving upon Obamacare. But the more important signal might be at the state level. If Republicans do succeed in repealing Obamacare, and replace it with a policy that covers far fewer people and reduces access to health care, then it will be incumbent on liberal states like California, New York, Connecticut, and Oregon to come up with their own policies, or else see their residents lose coverage.

In theory, they could simply pass their own versions of Obamacare — much like Massachusetts did in 2006 before the national effort even began. Indeed, if, say, California decided to respond to Obamacare repeal by continuing to run an exchange, offering identical subsidies, and paid for through identical taxes, then the status quo for residents would not change a whole lot.

But it’d be unfortunate, from Obama’s perspective and that of most Democrats, for things to end there. California, after all, twice passed single-payer bills through its legislature, only to meet a veto from Arnold Schwarzenegger. The most Democratic-leaning states are probably capable of passing health legislation that goes substantially further than Obamacare.

In this worst-case national scenario, a potential silver lining would be renewed energy for more aggressive state-level policies that could cover more people, more simply, at lower cost. By welcoming more aggressive approaches, Obama is refusing to foreclose that option, and instead branding it as in keeping with the spirit of his own health reform effort.

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