by Al Franken
It all came to a head on February 4, 2010, the day Scott Brown was sworn in. That day, President Obama spoke to Senate Democrats at a one-day emergency retreat at the Newseum, urging us to “finish the job” on health care. Except he didn’t explain how he thought we could do that.
When the president finished, the press left the room with him. Paul Begala, Tim Kaine (then chair of the Democratic National Committee), and David Axelrod were set to speak for about five minutes each and then take questions. “Okay,” I thought. “Here comes the plan.”
Begala spoke for five minutes. Nothing about health care. Kaine spoke for five minutes. Again, nothing. “Okay,” I thought. “I guess they’re having Axelrod do it. After all, he’s the president’s chief political adviser, his guru, his guy. He’s gonna tell us the plan.”
David started talking. First minute, nothing on health care. Saving it for the end. Classic.
Second minute, still nothing. Same with the third.
Between minute four and minute five, it occurred to me that one of two things was about to happen. Either Axelrod was going to run over his allotted time, or he wasn’t going to tell us the friggin’ plan. And indeed, when he finished his five-minute remarks, there was not one word about how we were going to solve the intractable political crisis facing the most important legislation in a generation.
“Questions?”
My hand shot up.
“Senator Franken?”
I exploded. “I’ve been doing a slow burn for the last five minutes. I cannot believe we’re not talking about health care. This is the president’s signature legislation. We’ve been working on this for a year now. The House obviously has to pass exactly what we passed, word for word. What is the plan to make that happen?”
That’s exactly what I said, except that I dropped the F-bomb maybe fifty times. For instance, before “slow burn,” “minutes,” “believe,” “health care,” “legislation,” “year,” “House,” “passed,” “word,” and “word.” And also “plan” and “happen.”
Axelrod responded that I wasn’t being fair to the president, and that if I could tell him how to get 218 votes in the House, he’d be happy to pass along my advice.
“That’s the president’s job!” I yelled, inserting a single F-bomb before “job.”
After some more back-and-forth, Bill Nelson and Carl Levin raised their hands. Each pointed out to Axelrod that he hadn’t actually answered my question, although they managed not to swear at him. Which was probably easy for Bill, a very devout Christian.
And later that evening, President Obama announced at a Democratic National Committee fund-raiser that he wanted the House to move forward with the Senate bill.
Finally, after a few hair-raising weeks of negotiations and arm-twisting, the House passed the Senate bill as it was by a 219–212 margin.* And the president signed the bill into law.
For Axelrod’s part, he didn’t take my outburst personally. I think it probably helped that after the bill finally passed, I wrote him a nice note. It read, “You’re welcome.”
The story of how the Affordable Care Act passed, then, goes something like this:
Democrats looked at all the people who were one car accident or cancer diagnosis away from disaster, and all the people who were getting sick or even dying because they were trapped in the Cambodian system, and they saw it as a moral crisis. And they were willing to do whatever it took to address that moral crisis. Navigating a narrow path through a political maze. Voting for elements of the bill that they felt were imperfect, or even counterproductive. Opening themselves up to demagoguery and maybe even losing their jobs. Swearing at David Axelrod.
And Republicans? Well, I’m sure many of them felt bad for people like Margie’s lupus patient. But I just think they cared more about winning the political fight: catering to the free-market ideologues and conspiracy theorists in their base and continuing to put up that unified front against President Obama. I don’t think they were willing to do the work or make the sacrifices necessary to solve the problem.
And I don’t think there’s any reason to believe that’s changed since 2010. Because they’ve spent the last seven years trying to stop the Affordable Care Act from working the way it was intended.
For example: A group of Republican state attorneys general filed a lawsuit claiming that the individual mandate—the second leg of the stool—was unconstitutional, because the federal government didn’t have the power to force people to buy something. For two years, as the case worked its way through the court system, we were treated to constant rhetoric about Obama’s unconstitutional overreach, and nobody was sure if the law would be allowed to stand.
This, of course, was despite the fact that the Republicans’ argument was ridiculous.
You see (and this is important!), the Founding Fathers wrote a constitution that gave almost all power to state governments and very, very little to the federal government. That constitution was called the Articles of Confederation, and it was a disaster, which is why I didn’t capitalize the “c” in “constitution” there.
Then the Founders wrote the United States Constitution, the one we have been living under since 1789. Article I, Section 8, Clause 3 of that Constitution grants Congress the power to regulate interstate commerce. Gee, you think the pharmaceuticals and medical devices used in health care involve any interstate commerce?
That’s why, as expected, when the Court ruled in June 2012, its four liberal justices correctly voted to uphold the individual mandate under the commerce clause. But after a series of earth-shatteringly, mind-blowingly partisan 5–4 rulings, everyone had worried that the five conservative justices would swallow the Republicans’ insane argument. And, believe it or not, they did!
But Chief Justice John Roberts, custodian of the Court’s reputation, knew that killing health care reform with a third highly partisan, legally dubious, and immensely impactful 5–4 decision on the heels of Bush v. Gore and Citizens United might undermine any remaining confidence in the Court’s integrity once and for all. So Roberts voted with the liberals, agreeing that the mandate was constitutional. But he picked a different rationale, concluding that the mandate was allowable because the penalty it imposed on people who didn’t buy insurance was really a tax, which Congress is empowered by the Constitution to implement.
Roberts’s reasoning was so weird that Supreme Court reporters from both CNN and Fox News initially reported the ruling wrong.
Also, critically, Roberts’s decision included a drive-by shooting: It eliminated the requirement that states use federal dollars to expand their Medicaid programs, which would have helped cover millions more low-income Americans.
An expert marksman, Roberts had aimed directly at the ACA’s foot, weakening the law before it could go into effect. Republicans hadn’t succeeded in getting the Court to block Obamacare, but they could take solace in the fact that Chief Justice Roberts had made it less good.
The fact that the Affordable Care Act isn’t perfect isn’t entirely Republicans’ fault.
For example, there was the day in October 2013 when the new health insurance exchanges went live and HealthCare.gov—the website where people could shop for different policies—immediately crappedUSS the bed. This was a really bad unforced error by the Obama administration, and people were right to be mad about it. I was furious.
Another thing that really cheesedUSS me off was the phone number. The administration had set up an 800 number for people to call to get help finding the right insurance plan for them. Great idea. What was the number? 1-800-GET-CARE? 1-800-ACA-HELP? 1-800-NOT-SICK?
No. It was 1-800-318-2596. What does that spell? Nothing. If you added an extra digit to the end, you could get to 1-800-318-A-LYN(x). But come on! You know how earlier I said that the reason Democrats are bad at messaging isn’t that we’re idiots? Well, sometimes it is.
And, yes, some people have gotten the short end of the stick when it comes to the new law.
Just a fe
w weeks before the 2016 presidential election, voters learned that the average premium on the health insurance exchanges established by the Affordable Care Act was about to go up by nearly 20 percent.
These premium hikes presented a real hardship for many Americans, especially those in rural communities where the insurance markets feature less competition and offer consumers fewer choices in health insurers. Anyone who has to pay unreasonably high premiums or copays and whose income is just a little too much to qualify for a subsidy that could help has every right to be angry.
But ask yourself who you should be angry at.
That premium hike happened in no small part because fewer healthy people than expected signed up for health insurance through the exchanges, meaning the overall pool of people in the exchanges was sicker than expected, meaning that insurance companies participating in the exchanges were losing money, which led those insurance companies to bail on the exchanges.
Why did fewer healthy people than expected sign up? Well, it probably didn’t help that the Koch brothers ran ads featuring a demented Uncle Sam performing a gynecological exam on a Millennial to scare young people away from the exchanges. Also, Republican state health commissioners did “everything in their power to be an obstructionist,” which is in quotes because those words were actually spoken by Republican insurance commissioner Ralph Hudgens from Georgia.
That’s not the only way Republicans sabotaged the exchanges. They also deliberately changed the law to more or less guarantee that this would happen.
You see, when we set up Obamacare, we’d anticipated exactly this problem: that the people signing up for insurance might be sicker than expected. So we built into the law several programs to mitigate the risks insurers faced when they entered this new market, helping to make up for initial losses and keep them in the insurance market. One important program was called “risk corridors,” another example of Democratic messaging genius. But Republicans, led by the wilier-than-you-might-have-expected Marco Rubio, snuck a rider into a spending bill that killed off risk corridors, which meant insurance companies wound up only getting compensated for about 12 percent of what they were owed. Thus a bunch of insurers waltzed, premiums shot up, and Rubio and his friends rubbed their hands together while cackling gleefully.
Of course, we could easily be working on fixing the problem that caused these premium increases in the first place: perhaps by giving people more incentive to sign up for the exchanges, perhaps by changing the formulas for how insurance is subsidized for low-and middle-income people, perhaps by bringing back the idea of a public option to increase competition. As recently as November 7, 2016, I was very excited about implementing these ideas as part of the new Democratic Senate majority under President Clinton.
In fact, from the moment the law passed, Democrats have been open—even eager—to talk about how to improve it and address problems that have arisen as the law has taken effect. Because figuring how to improve laws and address problems is kind of Congress’s job.
But Republicans have shown no interest in fixing Obamacare. And while it may be easy to dismiss their intransigence as politics as usual, that isn’t how things usually go.
For example, many Republicans vehemently opposed the creation of Social Security and then of Medicare. But that didn’t stop them from supporting, and in some cases even suggesting, ways to improve those laws as it became clear where they needed improvement. One of President Bush’s signature domestic programs was an expansion of Medicare!
That’s how things are supposed to work. If you are privileged enough to have a job as a lawmaker, part of your job is to make laws. And if you don’t like the way a law is working, your job is to help make it work better.
But that’s not what Republicans thought their job was. Just like with the stimulus, they first tried to stop health care reform from happening at all, which was their right. But then they tried to make it as ineffective as possible so they could complain that it wasn’t working. Since then, they’ve voted more than five dozen times to repeal it, even shutting down the government over health care reform in an effort led by Ted Cruz, about whom I’ll have a word or two later in the book, neither of them good.
And, of course, they’ve lied about it the whole way.
Before it passed, they confidently predicted horrors that never wound up happening. Obamacare is going to force more Americans into working part-time so their employer doesn’t have to provide them health care. Employers are going to stop covering their employees and dump them into the exchanges. Nope. That didn’t happen.
And after it passed, they started inventing horrors to complain about.
“Obamacare has killed millions of jobs!” they’ve said, millions of times. In fact, since the ACA passed, our economy has created more than sixteen million new jobs.
And even though some people have had a bad experience with the new law, the fact is that, for most Americans, the law is unquestionably a net winner. Most Americans, around two-thirds of workers, continue to get their insurance through their employer. In the decade before Obamacare became law, their premiums rose at an average of 7.1 percent per year. In 2016, their premiums rose by an average of 2.9 percent. As for the 4 percent of Americans who get their insurance through the exchanges, roughly 80 percent of them receive subsidies, and nearly three out of four have the option of purchasing coverage for less than $75 a month.
As for our health care system, it’s on steadier footing than it’s ever been.
Before the ACA, the growing cost of health care had become unsustainable, more than doubling over the previous ten years and even threatening the long-term future of Medicare. That’s why the law included measures designed to try to restrain that growth—what’s known as “bending the cost curve.”
This isn’t the most exciting part of health care reform (except to me), which is why we had to sex it up with an exciting catchphrase like “bending the cost curve,” but it’s important, so bear with me for a minute.
Early on in the debate, I became fascinated with an article in the New Yorker by Atul Gawande, a surgeon, public health researcher, and professor at Harvard’s School of Public Health who had been a frequent guest on my radio show.
His piece compared Medicare spending in McAllen, Texas, with Medicare spending at the Mayo Clinic in my home state. McAllen was spending three times more per person than Mayo was, even as Mayo was delivering far better outcomes.*
Huh. Clearly, Mayo was delivering health care more efficiently and effectively than McAllen. If we could figure out how, and spread those methods to other places, we could improve outcomes even while—here it comes!—bending the cost curve.
One of the methods Mayo used was something called “coordinated care.” By the time people get into Medicare, they usually have more than one thing wrong with them. As a seventy-something woman told me at the Minnesota State Fair that summer, “At my age, everything is preexisting.”
So the Mayo Clinic has every specialty—cardiology, orthopedics, oncology—in one location. Smart!
Another thing: At Mayo, all the doctors are on salary. What they get paid doesn’t depend on how many tests they order or how many procedures they perform. Doctors at Mayo see their patients as patients.
In McAllen, on the other hand, doctors were paid by the procedure, which meant they were incentivized to see patients as profit centers. For example, as Gawande reported, doctors in McAllen owned the imaging centers, so they made money on every CAT scan and MRI they ordered—and, no surprise, they ordered a lot of CAT scans and MRIs. Meanwhile, a doctor in a system like that gets nothing if a patient avoids getting diabetes, but there’s a big payday for a surgeon if he gets to remove a diabetic’s foot!
No wonder so much money was getting spent on health care that didn’t actually make people healthier. Because of screwy incentives, doctors in McAllen, like in much of America, weren’t delivering health care. They were delivering “sick care.”
If we could get more places
to do health care like Mayo, and not like McAllen, we could make a big difference. This area of focus is known as “delivery reform,” and there’s another reason I was so focused on it: As it turns out, Minnesota is really good at delivering quality and cost-effective care, consistently leading national rankings. If every state did health care as well as Minnesota does it, we’d spend less and have better outcomes.
I’ve always seen it as part of my job to bring the best of my state to Washington. And I was able to bring two Minnesota innovations to the health care debate that made it into law. One is called the National Diabetes Prevention Program, and it offers nutritional instruction and physical training to prediabetics, reducing the odds that they’ll develop diabetes (which is far more expensive to treat than it is to prevent). The other is called medical loss ratio, or MLR, which mandates that insurance companies spend at least 80 cents of every dollar you pay in health insurance premiums on actual health care (as opposed to administrative costs, marketing, CEO salaries, or profits)—and that if an insurance company fails to meet that standard, it has to rebate the difference to policyholders.
Thanks to these reforms and many others, the law has been hugely successful in bending the cost curve. Since it passed, the cost of health care has indeed continued to rise—but it has been rising at about half the rate it had during the previous decade.* And in four of the last five years, the growth in health care spending has been slower than at any other time in the last half century.
As for McAllen, Texas? The city that had the highest Medicare spending per capita in the country? McAllen brought down the cost of its health care for Medicare recipients by nearly $3,000 per capita because of incentives in the ACA to reward coordinated care and other health care delivery reforms.* Forget about bending the curve—this was reversing it altogether.
