One of former House Speaker Nancy Pelosi’s most infamous quotes was something she said during a 20-minute speech to the National Association of Counties’ 2010 legislative conference. Congress was considering the Patient Protection and Affordable Care Act, and the endless, breathless coverage of the contentious process, Pelosi explained, was preventing people from appreciating the significance of its contents.
“We have to pass the bill,” she said, “so that you can find out what is in it — away from the fog of the controversy.”
Conservatives — abetted by dozens of political journalists who should have known better — immediately seized on a truncated version of the quote. Pelosi was really expressing her confidence in the underlying merits of the bill, but it became instead a shorthand for the allegedly dodgy process through which Obamacare was passed.
But Pelosi never said the bill was enacted in secret or under cover of night, because it wasn’t. She said it was enacted in a fog of controversy. The controversy, naturally enough, focused on the most contentious aspects of the bill rather than on the most broadly popular. Much of it was about misunderstandings or misconceptions — claims that the bill contained death panels or did nothing to restrain health care costs — rather than on the Affordable Care Act’s concrete benefits.
Once the bill was in place, Pelosi was saying, people would come to value and appreciate its contents. She was mocked for this relentlessly for years. But everything that’s happening this winter shows she was right all along.
Republicans aren’t even challenging the “patient protection” part
The ACA itself contained many, many, many moving pieces. The most discussed elements of it expanded health insurance coverage to millions of previously uninsured Americans. But most Americans who aren’t on Medicare get their insurance through their jobs, not in the individual market or through Medicaid, and so the parts of the law relevant to the largest number of people dealt with regulatory changes.
- A ban on “lifetime limits” on insurance coverage that’s saved thousands of families from bankruptcy.
- A ban on “rescission,” or retroactive cancellation of an insurance policy, a practice by which insurers used to seek out any possible pretext for dumping customers who fell gravely ill and became unprofitable.
- A guarantee that young adults could stay on their parents’ health insurance plans up to the age of 26, increasing their early-career flexibility and providing valuable peace of mind to millions who don’t wind up incurring large health care bills while delivering lifesaving care to the relatively small number who do.
- Guaranteed coverage of a full suite of preventive health care services that it’s in the long-term economic (and public health) interest of the country to cover, but that don’t always deliver an immediate benefit to the insurers covering them.
- A guarantee that insurance companies actually spend the bulk of their revenue on providing health care services by requiring them to offer rebates to consumers if they don’t.
These and other consumer protections were added to the law over the course of the legislative process by various congressional Democrats who’d been fighting for them for years but had never been able to overcome opposition from insurance companies. The big push for a major overhaul became the perfect vehicle for them — the lifetime limits ban is largely due to the work of just one former senator, North Dakota’s Byron Dorgan — but the ideas themselves were not hotly debated during the legislative process.
Republicans would, of course, have been embarrassed to say that they were fighting for the right of an insurance company to cancel a cancer patient’s coverage because the patient hadn’t disclosed some earlier, unrelated illness or injury.
But it’s notable that now that the law is in place and Republicans are fighting to repeal it, absolutely nobody is talking about repealing this stuff. That’s in part because these regulations can’t be undone in a budget reconciliation package, so Republicans will need 60 votes to overcome a Democratic filibuster.
Still, Republicans will propose a lot of legislation over the next year and a half that requires 60 votes to pass. There are nine Democratic Party senators up for reelection in 2018 in states Trump won. When Republicans have ideas that they think are popular, they’ll try to either pressure those nine Democrats into voting for them or else use them as cudgels with which to win midterm elections.
A legislative program of large-scale deregulation of a widely despised health insurance industry would have just the opposite effect — a total political bailout for Trump Country Democrats. Any Senate Democrat facing an uphill reelection campaign would be able to brag about stopping Republicans from taking away health care from 23-year-olds or sick people. The Patient Protection and Affordable Care Act’s “patient protection” provisions are very popular. But Congress had to pass the law for people to see and appreciate these benefits.
Obamacare is popular when you try to take it away
The original version of the Social Security Act passed in 1935. Because Social Security has proven over the decades to be one of the largest and most popular federal programs, we’ve forgotten that the literal specific content of the Social Security Act of 1935 was never especially beloved. Conservatives hated it, of course, because they hated the idea of a big new federal guarantee of financial security in retirement.
But liberals, too, had little reason to be enamored of the actual legislation, which was incredibly cramped and limited compared with the program we know today.
Benefits weren’t paid to the widows and dependent children of beneficiaries until 1939. In 1950, domestic laborers (maids, nannies, and the like) became eligible for benefits, along with nonprofit workers and the self-employed. Four years later — nearly two decades after the law’s initial passage — hotel employees, agricultural workers, and most state and local government employees became eligible.
Like the initial Social Security Act, the 2010 ACA was stuck in a middle ground — hostage to the legislative whims of a relatively small number of moderate Senate Democrats, hated by conservatives, and unloved by liberals who favored more expansive reform.
But when Republicans started doing what the GOP of the 1940s and ’50s never tried and began proposing to take away existing benefits, the polling suddenly turned positive.
This, again, is exactly what Pelosi was saying. Of course nobody is excited about a bruising legislative battle followed by a compromise bill. But people liked getting health insurance coverage. And there’s a reason that Donald Trump, even while campaigning against the law, promised his reforms would mean even more generous coverage for even more people.
If Republicans pass the bill, people will find out what’s in it
Lately, the American Action Network, a conservative Super PAC, has been airing ads urging Congress to pass the American Health Care Act. According to the ads, AHCA “puts patients and doctors” in charge of health care rather than bureaucrats and also offers “more choices and lower costs.”
That sounds like a good idea to me, and I am sure it sounds like a good idea to many of the people who will see the ads. Similarly, Paul Ryan’s promise that AHCA will “lower premiums & improve access to quality, affordable care” sounds very good to me.
Unfortunately, none of this is true.
What AHCA does to premiums is raise them across the board. Premiums increase so much for older people that insurance will become unaffordable and some of them will drop out of the market. With insurance thus available only to younger and healthier consumers, insurance companies can charge less, and the average price paid falls in the long term. Premiums are more affordable for people who can get insurance, but only because those who need it most are pushed out of the market.
By the same token, patients and doctors are not in charge of health care under a system where more than 20 million people lose their insurance coverage. The care is just vanishing, and it’s likely more than 20,000 extra people will die each year as a result.
Of course, as long as the bill is merely a proposal, there are millions of people who will believe whatever Ryan and Trump and other GOP leaders tell them. Millions of other people will only hear that there’s a big dispute. But just as expanding insurance proved popular when people actually got their hands on it, taking it away will certainly be unpopular if it actually happens. No amount of semantic games about the meaning of “access” can change that.
If your bill does something popular, you need to pass it so people can find out about its benefits. If your bill does something unpopular, you may be able to come up with a good message about it, but when the bill becomes law and people find out what’s really in it, you risk reality crashing down on your head.