Politico by David Nather –
August 18, 2013:
President Barack Obama says he’s not worried that all the Obamacare fights will kill the law — because people fought the creation of Medicare and Social Security too, and now they’re more popular than ever.
Democrats have always wanted to believe Obamacare would follow the same pattern: Opponents tried to block passage of the new programs, but once they became law, the public saw the benefits and the opposition faded away.
But this time there’s a difference. Political opposition to Obamacare is still as strong as ever, more than three years after it was signed into law.
That means the administration’s task in launching the health care law — the biggest new social program since the creation of Medicare in 1965 — is harder than anything its predecessors had to face.
Between now and Oct. 1, the Obama administration has to get ready to enroll millions of people, just as Lyndon Johnson’s administration did during the rollout of Medicare. And it has to put the infrastructure in place and make sure the health care industry is ready to participate, just as Johnson’s people did.
But on top of all that, Obamacare has a huge extra layer of political hurdles LBJ didn’t have to worry about like battling Congress for money, persuading Republican governors and legislatures to go along, and quieting the well-funded outside groups.
Republicans insist that this is what Obama and the Democrats signed up for when they decided to push ahead without Republican votes. “It’s very short-sighted to think you can do something this big on a partisan basis,” said Senate Minority Whip John Cornyn (R-Texas). “At some point, you’re going to need bipartisan support for the implementation.”
Democrats insist that they tried to win GOP support — especially Senate Finance Committee Chairman Max Baucus, who spent months trying to negotiate a compromise with Senate Republicans — and they wouldn’t bite.
They also say it’s hardly the first time a major health program was created by one party. The Medicare prescription drug program, created under the George W. Bush administration, passed Congress in 2003 almost entirely with Republican votes, including a pre-dawn House vote that was held open for nearly three hours while GOP leaders twisted arms.
And Obama administration officials don’t buy the comparison to either program. The real model for Obamacare, they say, is the Massachusetts health reform law — the one signed by Mitt Romney. It inspired the structure of Obama’s health care law, and it’s now so popular in that state that repeal isn’t even a remote possibility.
But at least one veteran of the launch of Medicare — Joseph Califano, one of LBJ’s top domestic aides at the time — isn’t too surprised with the fallout of the decision to move ahead on Obamacare without GOP support.
Even though LBJ had huge Democratic majorities in 1965, he insisted that “we have to shoot for half the Republican votes, because if we don’t, they’ll drive us crazy — they’ll kill us on appropriations, they’ll kill us with the Republican governors,” recalls Califano, now the founder and chairman emeritus of the National Center on Addiction and Substance Abuse at Columbia University. It was a different GOP back then, but LBJ still managed to win half of the House Republicans and nearly half of the Senate Republicans.
“I don’t know if Obama’s problem was the incalcitrance of the Republicans or his inexperience — probably both,” said Califano. But whatever the reason for the failure to get Republican buy-in, he said, “they’ve got a hell of a difficult couple of years ahead.”
One Obama administration official acknowledged that the ongoing Republican resistance is “unprecedented, and it creates new challenges.” But the political mood is very different in the states that are trying to implement it, the official said, and there will be “enormous successes” in the states that give the law a genuine effort — “and there will be many of those,” citing California, Maryland, New York and Nevada.
But former administration officials acknowledge that the Obama administration never anticipated the battles would drag on this long. One said the view within the administration was that, once the Supreme Court upheld the law last year, “it would be a new environment” and the law would become more accepted.
The congressional fights are an enormous problem. Obama needs Congress to drum up money for the Department of Health and Human Services and the Internal Revenue Service for next year. He’s has asked for $1.5 billion for staffing and other needs. But the Republicans are facing strong pressure within their ranks — including the high-profile voices of Marco Rubio and Ted Cruz — to cut off the funding even if it means a government shutdown this fall.
But that’s only the beginning of the problems. House Speaker John Boehner has promised to hold more votes to chip away at the law, even after the House has already held 40 votes to roll back some or all of it. And the investigations and hearings will continue in the House, pouncing on everything that goes wrong with the law — including the latest problems with the “data hub” for checking people’s eligibility for coverage, which has had so many delays it’s not clear it will be ready for prime time on Oct. 1.
The data hub, which is supposed to allow real-time checks of an Obamacare customer’s income and other information, is one example of a logistical problem that will get an even harsher spotlight because of the ongoing Republican resistance. A recent report by the HHS inspector general’s office said that because of all the delays, the official security authorization for the hub is now expected on Sept. 30 — one day before enrollment begins.
That would have gotten attention from Congress anyway, but the stakes are even higher with the ongoing political battles. Republicans have already been spreading fears about the security of the hub, suggesting that people’s private information could be at risk, while administration officials are just as determined to press ahead so enrollment can start on schedule.
“In a major IT operation, you’d never see something like that,” said Dan Schuyler of Leavitt Partners, which has been consulting on the development of Obamacare’s new health insurance marketplaces. “The security testing would have been completed by now, the issues would have been resolved.”
But even though Republicans will shine a spotlight on problems like those, it’s not because they want to fix them. The broader issue, which most Republicans and their supporters are pretty open about, is that they don’t want to do anything to help a law they don’t support.
That means the Obama administration can’t even ask Congress for minor tweaks or technical fixes when something goes wrong with the law — so it has had to take action on its own. At his press conference on Friday, Obama basically admitted he would have gone to Congress “in a normal political environment” to delay the employer coverage requirement, but he couldn’t do that because Republicans are still fighting the law.
In fact, some on the right are openly rooting for failure — especially the organized interest groups that are encouraging outright resistance to the law. And that’s another layer of extra hurdles Obamacare faces: The organized opposition is stronger and more stubborn than the creators of other major health programs faced.
“They’re making every effort to keep people from learning about the program’s benefits so they can claim it’s a failure when people don’t sign up,” said Jon Kingsdale, a Boston-based consultant who used to run the Massachusetts health insurance exchange under Romney’s health care law.
Business groups, led by the U.S. Chamber of Commerce and the National Federation of Independent Business, have never stopped pushing for repeal. FreedomWorks, one of the main tea party-affiliated groups, is urging people to “burn your Obamacare card” and stay uninsured. And a group called the Citizen’s Council for Health Freedom — which is organizing a “Refuse to Enroll” campaign —is even going after drugstores that cooperate, giving CVS a hard time for providing information on Obamacare enrollment in its stores.
That goes well beyond the organized resistance LBJ faced with Medicare. The American Medical Association had fought against its passage, calling it “socialized medicine” — but after it was signed into law, he convinced its doctors to participate in Medicare fairly quickly (by putting AMA’s leaders on the spot in front of reporters, Califano says).
It doesn’t even compare with the launching of the Medicare prescription drug program. Mark McClellan, who ran the Centers for Medicare and Medicaid Services at the time, says the Democratic criticisms of the program lasted for a while — they thought it was designed in a way that gave away too much to drug companies. But by the time the program launched, McClellan said, many Democrats decided to give their constituents helpful information about it — after he and other Bush administration officials went around the country talking to local officials and community leaders about what kind of information would help.
The Democrats’ message was, “I didn’t vote for this, I would rather have had a different program, but this is the program we have in front of us, and we’re going to give you information so you can make an informed choice about it,” McClellan said.
There’s also a third layer of extra hurdles: the Republican governors and legislatures that won’t cooperate. Obamacare has a bigger role role for the states than Medicare or its prescription drug program ever did, because that’s the only way it could get the blessing of moderate Senate Democrats — but that also gave an outsized role to GOP governors who didn’t want to set up the new health insurance marketplaces or expand Medicaid.
In some cases, it isn’t even the governors who have put up the fight — it’s the Republican-controlled legislatures. Arizona Gov. Jan Brewer had to prod her legislature to approve an expansion of Medicaid coverage under Obamacare, although she eventually won the fight. In Michigan, Gov. Rick Snyder has slowly making progress after facing resistance from the legislature on the same issue.
All of this adds to the unique obstacles the law would have faced even if the political fights had actually faded away after Obama signed it. For one thing, the Obama administration and its allies — including outside groups like Enroll America — will have to find and sign up young, healthy people who may not think they need health insurance. That’s not a problem the creators of Medicare faced — it’s not like they encountered a lot of seniors who didn’t care about health coverage.
But Obama administration officials say it’s a different dynamic when they talk to local officials, even in the red states that are putting up the biggest fights against the law.
Health and Human Services Secretary Kathleen Sebelius, for example, has visited Dallas, Austin and San Antonio — three of the biggest cities in Texas, where Gov. Rick Perry has not only resisted Obamacare but heckled Sebelius for visiting the state. After Sebelius’s Dallas visit, local leaders held a follow-up meeting Thursday with a regional HHS official to discuss strategies for Obamacare outreach and enrollment.
And McClellan noted that the Obama administration does have one advantage on its side: It has microtargeting strategies, including social media outreach, that weren’t available in the past and could make it easier to reach Obamacare’s ideal customers more effectively.
“You can still have the big philosophical fights — that’s not going away — but it’s easier to separate that from the practical issue of ‘what does this mean for me,’” McClellan said.