The relatively recent passage of Obamacare has obscured some important historical context from the entirety of the 20th century regarding this push undertaken by the GOP: healthcare reform is hard. In brief:
- FDR initially proposed federally funded healthcare programs as part of his Social Security legislation. As a result of a campaign by the American Medical Association, Roosevelt ultimately removed the healthcare provisions from the bill in 1935.
- A cornerstone of Truman’s Fair Deal, introduced in 1949, was the establishment of universal healthcare. After a series of intense debates, legislation to this effect failed to pass.
- Medicare and Medicaid were created under Johnson in 1965, but he had absurd Democratic majorities to work with (68 senators and 295 House reps).
- Health insurance was a major policy issue under Nixon, with three separate universal care bills introduced in 1970. Failure to reconcile differences within the Democratic leadership, as well as a near-single-payer proposal by Nixon himself in 1974, ultimately stalled the advance of any plans during his administration.
- Ford called for health insurance reform when he took office, but shortly afterward, the chairmanship of the House Ways and Means Committee (hey, remember committees?) passed to somebody who was opposed to the financing routes that most proposed bills had taken. After a deep recession took hold in 1975, Ford expressed that he would veto any health insurance reform bill.
- Carter negotiated at length with Ted Kennedy over a universal healthcare bill in 1977 and 1978, but Carter refused to commit to a single bill with a fixed schedule for the phase-in of universal coverage.
- Clinton’s universal healthcare plan, which involved mandatory enrollment in insurance, flamed out spectacularly in 1993 and 1994.
- The ACA itself, it should be noted, was ultimately passed, but it took a unified federal government over a year from conception to signing, and the House votes were 220-215 and 219-212 respectively after substantial whip discussions leading up to both votes. (Remember that 34 Democrats voted against the ACA in that second vote.)
Republican leadership spent 121 Senate legislative days in an effort to score this win. (The typical 2-year legislative schedule contains roughly 340 legislative days, with 20 of those being in the lame-duck session.) A set of hasty revisions and a furious vote-whipping effort resulted in 217-213 passage of a bill through the House, and a 51-50 passage of a motion to open debate in the Senate.
No substantive version of the GOP bill got fifty votes in the Senate. The only one that got more than 45 included three yes votes from senators who had held a press conference substantively trashing that version of the bill earlier in the evening (and indications were that perhaps a half dozen more felt the same way, even if they didn’t have the courage to vote that way).
I don’t say this to imply that the GOP attempts to repeal and replace were always doomed. I also don’t say this to imply that the AHCA/BCRA/HCFA were anything but attempts to score political points on the backs of the impoverished.
I say this to highlight the difficulty of the road ahead. A reminder that although the various iterations of the Republican healthcare proposals would remove health insurance for 21 to 23 million Americans, those absurd numbers are still smaller than the 28 million Americans uninsured under current law. Presumably more states will move to expand Medicaid soon, which would drop that number further (get on it, Kansas), but the current law is still not good enough.
But we can’t just write “ok single payer” on a piece of paper and call it a day, either. There are still substantial policy differences between different single-payer proposals:
- Who gets covered? All people in the United States at any time? Just residents? Just lawful residents? Just citizens?
- Are hospitals nationalized? Are private hospitals allowed to remain? Are those hospitals subject to greater regulation in some way?
- Is there only one single plan? Or are there tiered plans so that people can still pay more for additional care and procedures?
Those are just a couple fundamentally basic questions. Consider, too, that given the low chance that a single-payer bill will comply with reconciliation, one of the following will have to happen in order for a single-payer plan to pass:
- Democrats gain 60 seats in the Senate (and, given what just happened in tonight’s vote, probably substantially more), a majority not surpassed by either party since the 1970s
- The legislative filibuster is removed
- The Constitution is amended to provide a different legislative system (parliamentary, most likely)
- Republicans come around on single-payer
Which one of these seems most likely? The last one is the easy answer, particularly given the increasing approval of single-payer, but remember that Joe Manchin, a centrist Democratic senator from a state Donald won by 42 points, did not even come close to wavering in his Senate votes this week. And yet, during a vote on a single-payer amendment where he had Bernie Sanders’ blessing to vote “present”, he chose instead to come out strongly against the idea.
And what happens if we get to 60 (or close)? What if there’s a key senator’s vote that you need, but they’re pro-life? Does your bill now include an that abortions are not covered by the government? Are more women forced to rely on Planned Parenthood or to pay for their own procedures?
This journey to figure out what the rest of the world has figured out is already a long one. This fight wasn’t the first step, and it’s nowhere near the last step. And everything we know indicates that every further step is going to be difficult.
But that is why resistance is not the end. Why the big ideas still matter.
The work continues.