The Ten Year War review: Obamacare, Trump and Biden's battles yet to come

Once upon a time, the Affordable Care Act (ACA) was unpopular, viewed by many as welfare redux. Barack Obama’s promise that “If you like your healthcare plan, you’ll be able to keep your healthcare plan”, didn’t exactly work out. By the middle of the 2010s, so-called Obamacare had cost the Democrats both houses of Congress.

Yet one great recession and one raging pandemic later, the ACA is liked, if not necessarily loved, by a majority of Americans.

The political process “doesn’t stop just because a bill becomes a law”, according to Jonathan Cohn.

As if to prove Cohn’s point, the US awaits a ruling by the supreme court on another challenge to Obamacare, this one brought by the Trump administration and Republican state attorneys general. If they prevail, more than 20 million Americans may lose health coverage. Nearly a half-million have died from Covid. Markets don’t always deliver what is needed.

The Ten Year War is a look back at the “crusade” for universal healthcare coverage, and a sequel to Cohen’s earlier book, Sick: The Untold Story of America’s Healthcare Crisis. Cohn is a senior correspondent at the Huffington Post. His take remains informed and nuanced, not breathless. The Ten Year War also captures acrid and tectonic shifts in US politics.

Cohn persuasively argues that the combatants in the healthcare fight operated with less than perfect knowledge, and that preconceived convictions too often clouded their judgment. Cohn aims at both policy wonks and political junkies. Laced with interviews and quotes from both sides of the aisle, his book is definitely newsworthy.

Obama and Tom Price, Donald Trump’s short-tenured health secretary, speak on the record. David Axelrod, Obama’s counselor, and Michael Carvin, a veteran conservative litigator who unsuccessfully argued against Obamacare’s constitutionality, also talk to the author. Years earlier, in the 2000 election, Carvin was on brief in George W Bush’s winning supreme court gambit.

Obama admits his surprise over Republicans not moving on after the ACA passed, unlike Medicare in 1965 under Lyndon Johnson. “We got no take-up on any of that stuff,” he says. Left unsaid is that blue and red are more than just colors – they are tribes.

By the same measure, Obama acknowledges “that there were those … who suggested that we shouldn’t do anything other than the economy”. That is an understatement.

One of those “outsiders” was Chuck Schumer, now the Senate majority leader. Even then, Cohn writes, the New Yorker grasped the political consequences of going all-in on healthcare amid a meltdown in the jobs and housing markets.

Indeed, after the Democrats lost the Senate in 2014, New York’s senior senator unloaded on Obama before the National Press Club: “After passing the stimulus, Democrats should have continued to propose middle-class-oriented programs.” Said differently, the ACA highlighted the inherent instability of the Democrats’ upstairs-downstairs coalition.

Instead, in Schumer’s telling, “we took their mandate and put all of our focus on the wrong problem – healthcare reform.” Apparently, there are few things more gratifying in politics than telling a sitting president: “I told you so.”

Of course, political myopia is not the sole province of any one party. Price admits that Republicans too operated in their own universe.

“I think there was a lack of appreciation on the part of all of us in the administration about how difficult” repealing Obamacare would be, he says. Price is a physician as well as a former Georgia congressman.

Price criticizes Trump for fashioning policy to comport with the last voice to whisper into his ear, and for a fundamental lack of understanding of healthcare and insurance.

“We would make concrete decisions about what we were going to do,” he says, “get presidential sign-off, and then within 24 hours the decision would change.”

For Price’s boss, pulling the rug out from under others was standard operating procedure.

According to recent reports, Steve Bannon, then ensconced at the White House, believed Trump was in the throes of dementia and ought to have been removed. That didn’t happen but Price did leave government – amid a swirl of controversy surrounding his use of taxpayer funds to finance travel on private aircraft.

No book on Obamacare would be complete without a retelling of John McCain’s late-night thumbs-down on the Senate floor. Here, Cohn definitely delivers. Adding to the legend, Cohn relays the Arizonan’s loss of patience with Senator Lindsey Graham, his longtime wingman who was already morphing into a Trump acolyte.

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Hours before McCain dealt a death blow to ACA repeal, he appeared at a press conference with Graham to discuss the latest administration-backed gambit. As told by Cohn, “McCain seemed not to be paying attention to what Graham was saying.” One Republican aide saw what was happening, Cohn reports, and surmised that McCain had come to believe: ‘This thing is so fucking stupid I’ve got to kill it.’”

More than five in nine Americans believe it is the federal government’s responsibility to ensure that “all Americans have healthcare coverage”, a level of support actually smaller than 15 years ago. During the 2020 Democratic primaries, Joe Biden was the only top-tier contender who opposed both “Medicare for All” and efforts to abolish private health insurance.

He also understood the Democratic center better than Bernie Sanders or Elizabeth Warren. The core of the party wanted reassurance, not socialism or Massachusetts-style McGovernism. Neither senator would have beaten Trump.Utopia could wait.

When Biden, as Obama’s vice-president, exclaimed that the ACA was a “big fucking deal”, he was tacitly recognizing that Obamacare had pushed the boundaries of what was practicable. To quote Cohn, “In America, that is what change looks like”.