A much more modest ACA

There's an argument that the drafting and early implementation of the Affordable Care Act delayed the recovery. Employers weren't sure about what would be required in plans going forward and thus were less willing to hire people full-time because of this uncertainty.

What if the ACA had been more modest in its goals and provided more certainty to employers during the recovery? Perhaps a combination of
1) Medicaid Expansion
2) Individual Mandate + Middle Class subsidies up to 400% of the Federal Poverty Line
3) Employers being offered a tax credit for covering employees, rather than mandated to have plans they aren't sure what will cost
4) Young people being able to stay on their parents' plans until age 26
5) A few additional requirements for health insurance plans (contraception must be covered, etc).
6) A medicare buy-in for those at age 55


Could a more modest ACA have resulted in stronger job growth, more business support (due to the lack of employer mandate), some moderate GOP support (Bennett, Collins, Snowe, etc), and less or no Tea Party backlash?
 
Putting aside the long, legitimate laundry list of issues with the ACA's implementation, the backlash wasn't just over the ACA - it was over it passing without a single GOP vote, with several kickbacks to get the Dem votes, and that Obama blew his entire political capital on forcing it through, all while the economy was still in the toilet.

Until unemployment dropped below 8%, the focus should have been "Jobs, jobs, jobs, job, and did I say jobs?".
 
Putting aside the long, legitimate laundry list of issues with the ACA's implementation, the backlash wasn't just over the ACA - it was over it passing without a single GOP vote, with several kickbacks to get the Dem votes, and that Obama blew his entire political capital on forcing it through, all while the economy was still in the toilet.

Until unemployment dropped below 8%, the focus should have been "Jobs, jobs, jobs, job, and did I say jobs?".

What if Obama made it part of a jobs package? Like if he decided to write it up in such a way that healthcare improvement went hand-in-hand with job creation or some kind of incentives for entrepreneurship.
 
Putting aside the long, legitimate laundry list of issues with the ACA's implementation, the backlash wasn't just over the ACA - it was over it passing without a single GOP vote, with several kickbacks to get the Dem votes, and that Obama blew his entire political capital on forcing it through, all while the economy was still in the toilet.

Until unemployment dropped below 8%, the focus should have been "Jobs, jobs, jobs, job, and did I say jobs?".


I just wonder if a more modest ACA could pass with some GOP support. A big issue for the GOP was the employer mandate IIRC, considering the individual mandate was originally their idea. Business, and thus the GOP, probably won't be as opposed if the program basically amounts to the government assuming a good chunk of their operating expense (health care).

If indy mandate is coupled with the the GOP idea of state-run high risk pools and perhaps there's some deregulation of the medical industry included with the increased provision of funds, I can imagine a deal being made.
 
Putting aside the long, legitimate laundry list of issues with the ACA's implementation, the backlash wasn't just over the ACA - it was over it passing without a single GOP vote, with several kickbacks to get the Dem votes, and that Obama blew his entire political capital on forcing it through, all while the economy was still in the toilet.

Until unemployment dropped below 8%, the focus should have been "Jobs, jobs, jobs, job, and did I say jobs?".

Pretty much this in a nutshell!
 
There's an argument that the drafting and early implementation of the Affordable Care Act delayed the recovery. Employers weren't sure about what would be required in plans going forward and thus were less willing to hire people full-time because of this uncertainty.

What if the ACA had been more modest in its goals and provided more certainty to employers during the recovery? Perhaps a combination of
1) Medicaid Expansion
2) Individual Mandate + Middle Class subsidies up to 400% of the Federal Poverty Line
3) Employers being offered a tax credit for covering employees, rather than mandated to have plans they aren't sure what will cost
4) Young people being able to stay on their parents' plans until age 26
5) A few additional requirements for health insurance plans (contraception must be covered, etc).
6) A medicare buy-in for those at age 55


Could a more modest ACA have resulted in stronger job growth, more business support (due to the lack of employer mandate), some moderate GOP support (Bennett, Collins, Snowe, etc), and less or no Tea Party backlash?

Okay, you're in my area of professional knowledge. Everything you're saying except for #6 is, to some degree, part of the actual ACA.

The major coverage expansion components of the ACA were Medicaid Expansion and a subsidized individual market that is guaranteed issue and mostly community rated (tobacco, geography, age). In ARRA (the stimulus), the federal Medicaid matching rate increased significantly for legacy Medicaid as a means of keeping states from cutting their budgets too rapidly. States had reasonably strong balanced budget constraints that are pro-cyclical and Medicaid is counter-cyclical in enrollment eligibility so ARRA Medicaid bump was a fast way to get money to the states and increase demand.

Full up Medicaid expansion to 138% FPL at 100% Federal Match rate that started 6 months after the law was signed would have been a big deal especially once/if states figured out how to transform significant chunks of their standard Medicaid match rate population into enhanced match rate folks. Mechanically this is probably do-able if Congressional Dems were not worried about the CBO score.

#2, #3, #4 and #5 are basically what happened in the ACA. #3 almost no small employers have taken up the tax credits. Their is anecdotal tales of hour cuts and hiring deferred due to uncertainty, but on the macro scale, this story is not showing up in the data. Employers will hire when there is demand.

#6 is the most radical portion of your proposal. One of the fundamental liberal health policy goals for the past few decades has been to move more people to coverage regimes with administratively set prices. Medicare is the dominant policy universe with administratively set pricing. Provider groups have, are, and will go to war over moving people who are currently covered at significant multipliers of Medicare to Medicare-esque pricing. Provider groups were okay with moving the working poor (Medicaid Expansion) to Medicaid as most of this group was not covered or covered with high deductibles which meant a lot of bad debt. Medicaid pays a whole lot better than cash payments from people making near poverty wages. However, moving 55-64 year olds who earn between 138-1000% FPL to Medicare like pricing is a huge money loser for provider groups. This is a cohort highly likely to have commercial insurance AND highly likely to use a good chunk of services. A Medicare buy-in is a declaration of war against provider interests which probably sinks the ACA from passing.

Now going to another point --- the GOP had absolutely no interest in making a deal on healthcare. Their preferred policy is less subsidization of the sick (see AHCA, BCRA), less support for the old, and tax advantaged savings accounts that are nearly useless for the chronically ill and/or the bottom two thirds of the income distribution as either there is an equal inflow-outflow and thus no accumulation, or there is an inability to significantly fund HSAs build a significant cushion for a catastrophic year. Yes, Governor Romney saw the beta of Obamacare deployed in his state, but he was a Republican governor in a liberal state that had Democratic super-duper majorities in the Legislature. It was not his preferred health policy solution.
 
I just wonder if a more modest ACA could pass with some GOP support.

The Republican objection to the ACA was strategic on the assumption that once people get better healthcare the Republicans will not be able to get rid of it. They had no interest in passing any version of ACA—or any version of improved healthcare—ever. There is no compromise to get any votes.

If you wanna improve the economy nuke the filibuster, pass a stronger/better/cheaper ACA with a public option, quadruple the size of the stimulus package. All without Republican votes because we know from their own meetings their plan was to reject anything and everything Obama proposed to cripple his presidency.

If you want a bipartisan healthcare bill you have to go back to the 1970s or a Ford wins, Democrat 1980s scenario. Even by Clinton in the 1990s the Republicans were fixated on stopping healthcare.
 
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A few others have beat me to it, but #6 creates a much more expansive ACA than we had in the status-quo. A Medicare buy in for any portion of the population would also have peeled Baucus and Nelson off the ACA vote as well. Any public option was a non-starter with a few of the more conservative Senate Dems, and pretty much the entire GOP.

We can fight over this, but there wasn't much Obama could do to secure any GOP votes on the ACA. Part of it was what Electric Monk points out above about philosophical opposition to public health care and the irreversibility of government programs, but another part is that the Republicans were not giving an inch on anything. Even the stimulus passed with almost every Republican in the house opposition, and only 3 GOP votes in the senate. So, it's not like Obama had this slam dunk second stimulus he could have dragged through if he just didn't do the ACA.
 
This is from a conservative pundit on the day that the ACA passed the House (March 21, 2010)

https://www.thedailybeast.com/waterloo

It’s hard to exaggerate the magnitude of the disaster. Conservatives may cheer themselves that they’ll compensate for today’s expected vote with a big win in the November 2010 elections. But....

(2) So what? Legislative majorities come and go. This healthcare bill is forever. A win in November is very poor compensation for this debacle now....

At the beginning of this process we made a strategic decision: unlike, say, Democrats in 2001 when President Bush proposed his first tax cut, we would make no deal with the administration. No negotiations, no compromise, nothing. We were going for all the marbles. This would be Obama’s Waterloo – just as healthcare was Clinton’s in 1994.

Only, the hardliners overlooked a few key facts: Obama was elected with 53% of the vote, not Clinton’s 42%. The liberal block within the Democratic congressional caucus is bigger and stronger than it was in 1993-94. And of course the Democrats also remember their history, and also remember the consequences of their 1994 failure.

This time, when we went for all the marbles, we ended with none.​
 
Now circling back to the original poster's core question -- was there a politically plausible health care bill in the summer/fall 2009 and winter 2010 that could pass that could have faster positive political and economic impacts that benefited Democrats?

Looking retrospectively, the optimal health care bill was one that improved the economy significantly. And that bill would have been making Medicaid a 100% Federal responsibility to incomes up to 150% FPL as quickly as the ink dried. This would have sent a huge second stimulus to counter-act state government budget cuts and might have saved some Democratic seats in November 2010. But that bill was never going to see the light of day.

Moving back to plausible pathways, as long as we assume that there is a legislative filibuster, there is no real game changer that can be plausibly argued. I could see minor tweaks here and there. I could see language getting cleaned up a bit better to avoid a few hard edge cases (family glitch is the easiest one) and court challenges (King v Burwell).

If we assume that there is no filibuster so that the minimum winning coalition is 218 in the House and 51 in the Senate (VP inclusive), a bigger and faster implemented bill is far more likely. The House passed a bill in November 2009 (http://www.cnn.com/2009/POLITICS/11/07/health.care/) that is a bit to the left of the ACA. It had a higher benchmark, richer subsidies and a soft public option in it. If the marginal Senate vote was Senator McCaskill instead of Sen. Nelson (D-NE) or Lieberman (I-CT), that bill is more plausible in the Senate. As it was, in our timeline, it was merely a placeholder/preference indicator of what the House wanted in conference committee.

I think the more important implication of the assumption of no filibuster in the Senate is that the Gang of Six (https://www.politico.com/story/2009/09/gang-of-six-could-hold-obamas-fate-026879) of three moderate/conservative Dem senators and 3 GOP Senators on the Finance Committee would not have placed everything on hold for three months over the summer of 2009 which allowed for Tea Party opposition and screaming to organize itself. My theory is that the process of Sen. Baucus and other conservative Dems repeatedly not being able to get to YES with three GOP Senators who had a reputation of being able to cut deals was necessary for conservative Dem Senators to be willing to go with only Democratic votes. And since in a 60 vote world, Senator Majority Leader Reid had no spare votes, that process was needed.

If Reid knew in April 2009 that healthcare coverage expansion only needed 50 votes + Biden, his strategy would have changed. We may have seen final votes in July or September 2009 instead of March 2010. As a side effect, the self-imposed limitation of the bill being deficit reducing and having no more than a trillion dollars in net spend in the first decade are probably relaxed incrementally as Speaker Pelosi most likely had at least a couple spare votes in her back pocket. Every day past August that the ACA dragged out, the worse the short term politics were for Democrats.
 
But in his first 100 days, Pres. Obama and Congress did lower taxes. :)

http://www.politifact.com/truth-o-meter/statements/2010/jan/28/barack-obama/tax-cut-95-percent-stimulus-made-it-so/

' . . . Under the stimulus bill, single workers got $400, and working couples got $800. The Internal Revenue Service issued new guidelines to reduce withholdings for income tax, so many workers saw a small increase in their checks in April 2009 [Emphases added]. . . '
But . . .

From Obama, the Tax Cut Nobody Heard Of

New York Times, Michael Cooper, Oct. 18, 2010

https://www.nytimes.com/2010/10/19/us/politics/19taxes.html

" . . . In a New York Times/CBS News Poll last month, fewer than one in 10 respondents knew that the Obama administration had lowered taxes for most Americans. . . "

Maybe the Obama administration should have mailed out checks, like the Bush administration had done.
 
The ACA was pretty modest and was based off of ideas since Nixon that the GOP had. But under McConnell, the GOP were steadfast refusing to play ball with the Obama Administration and I doubt we’d get anything better without the Medicare for All folk around.

You’d need to go back further to implement this. Either a bipartisan thing as mentioned earlier via the 70s, or have the Dems undergo a reshift to the left and abandon neoliberalism while the GOP messes up so badly the new Dems get a supermajority in House, Senate and maybe in Supreme Court too
 
The ACA was pretty much focused entirely on who is insured and how they pay. There wasn’t any real focus on reducing the cost of healthcare or denied services. That might sway a couple GOP votes.
Examples:
Restricting advertising to publications aimed at health care providers.

Have HHS determine which procedures and medications are experimental instead of individual insurers.
 
Perhaps if Obama had focused more on the economy and less on healthcare, the Democrats would have held the House in 2010 (though they would still have suffered some losses).

As the economy improved going into 2012, Obama still would have won reelection (perhaps with an even larger electoral vote), and the Democrats would have picked up seats in the House and Senate. Now with a fresh mandate, and an improving economy, the Democrats could have worked on healthcare.
 
Obama could have gotten a much larger/impactful reform through if he'd sold it differently. Instead of selling healthcare reform on social justice/communitarian grounds, all he needed to do was sell it on economic competitiveness/efficiency grounds. He didn't need to water it down or tie it to a jobs package or any of the stuff mentioned itt, just sell it the way i propsoed it.
 
Obama could have gotten a much larger/impactful reform through if he'd sold it differently. Instead of selling healthcare reform on social justice/communitarian grounds, all he needed to do was sell it on economic competitiveness/efficiency grounds. He didn't need to water it down or tie it to a jobs package or any of the stuff mentioned itt, just sell it the way i propsoed it.


The GOP would still not buy it on the principle that they were going to oppose Obama. They were going to be irrational about the whole dang issue.
 
No healthcare plan was going to get ANY gop support until sometime 2025-35ish because of baby boomers/the first half of generation x's extreme anti-populism. Incidently that's the same reason why we only got the ACA instead of say copying a developed nations' healthcare system.
 
No healthcare plan was going to get ANY gop support until sometime 2025-35ish because of baby boomers/the first half of generation x's extreme anti-populism. Incidently that's the same reason why we only got the ACA instead of say copying a developed nations' healthcare system.

We got a twist on the Swiss system in the ACA. Plenty of ways to get near universal coverage, single payer is actually a fairly rare choice.

Obama could have gotten a much larger/impactful reform through if he'd sold it differently. Instead of selling healthcare reform on social justice/communitarian grounds, all he needed to do was sell it on economic competitiveness/efficiency grounds. He didn't need to water it down or tie it to a jobs package or any of the stuff mentioned itt, just sell it the way i propsoed it.
Nope. Obama is fundamentally irrelevant. The key decision makers are the marginal votes in the House and Senate. In the House that was a freshman or a sophomore Rep from a lean GOP district and in the Senate, that is a cluster of Dems from R+10 to R+25 states. Anything they approve Obama will sign. Many things he would sign, there were not 218/60 votes for.

Under this theory of messaging/marketing, Bush would gave privatized Social Security and Trump would have repealed the ACA.
 
No. The theory of messaging would only apply to things that majorities want like healthcare reform. Privatizing SS or Trump's trying to repeal the ACA aren't desired by normal people.
 
No. The theory of messaging would only apply to things that majorities want like healthcare reform. Privatizing SS or Trump's trying to repeal the ACA aren't desired by normal people.

It is very rare that significant health care delivery and health finance reform is popular once past unopposed slogans as there are numerous vested stakeholders who don't want to see things change.

Kaiser Family Foundation routinely polls on healthcare.

There are two questions to look at:
First from April 2009 when the first subcommittees were getting together to flesh out what would become the ACA (https://www.kff.org/wp-content/uploads/2013/01/7891.pdf)

59-37 in support of the healthcare reform even as the economy is bad....

So there is a 3:2 split in favor of generic reform even conditional bad economic times. As to what that looks like, that was a major question mark as campaign promises had not been reduced to legislative text.

And then an interesting question in November 2009 (https://www.kff.org/wp-content/uploads/2013/01/8020.pdf)

What response best represents your view:
Need to take on reform now and like what they’re hearing about proposals currently being considered : 35%
Need to take on reform now and don’t like what they’re hearing about proposals currently being considered :33%
Don’t think should take on reform now: 26%​

There is still strong support for the idea of reform. Support actually went up (68-26) for the concept but details have changed support for this particular reform.

The popularity of healthcare reform goes down as soon as pen commits legislative text to paper as that simple act produces clear winners and losers. The way around that (politically) is to turn on a federal fire hose of money with no other choices (Medicare Part D) being made that produce any net losers of any sort. As soon as Congress tries to partially pay for a program in a way that produces obvious losers (ACA, Medicare Catastrophic from the late 80s etc), opposition mobilizes not against the concept but against the particulars. Some of the Medicare for All proposals are trying to go the Medicare Part D route with an unspecified promise that taxes will be raised on the upper classes to pay for everything, and other M4A proposals lay out explicit pay-fors.

Sorry for beating a dead horse but this is my area of professional expertise.
 
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