Obamacare’s tenth life

This post is cross-posted at Medium.

Back in January, I recounted the Affordable Care Act’s many trials and tribulations in anticipation of what was poised to be its toughest battle yet. From Scott Brown cracking the Democrats’ filibuster-proof Senate majority in 2010, to John Roberts turning gun-shy before obliterating the individual mandate, through Ted Cruz’s government shutdown, Obamacare had more than its share of close calls.

Yet the law defied death again and again. “[F]or eight years, center-left health reform has prevailed against constant slings and arrows because its moral foundations are strong,” I wrote at the time. “Obamacare’s tendency to survive may just be what spares it again.”

And survive again it has. Trumpcare is dead, and Obamacare is alive. The GOP’s seven-plus year charge of repeal and replace went down in flames on Friday, having barely even made it out of the starting gate. And when it comes to the core of Obamacare, Republicans hardly even put up a fight.

That’s because the GOP long ago gave up on contesting the basic moral foundation of Obamacare: the notion that everyone is entitled to healthcare as a right. It was a quiet concession, drowned out by years of chest-thumping cries to repeal Obamacare, but the right implicitly acquiesced to Obamacare’s new normal years ago. That, more than anything, doomed the effort to repeal it.

Republicans tried to resist the moral force of universal healthcare by tarring it as “socialized medicine” and a government takeover of health insurance. But since Obamacare began delivering real benefits to real people, the center of gravity within Republican opposition shifted toward a more practical, less ideological critique about high premiums and inadequate coverage. Underneath the howls for repeal, the conservative objection increasingly moved from universal healthcare itself to the outcomes and mechanisms Obamacare employed to approximate it.

Donald Trump formalized this concession. Just days after his election, he announced that he intended to keep Obamacare’s popular guarantee of coverage for people with pre-existing conditions. Even earlier, Paul Ryan’s “Better Way” proposal agreed to preserve this protection, too. But to insure the sick, you must also insure the healthy — insurance markets cannot function any other way. And when it comes to universal healthcare, insuring both the sick and healthy is more or less the whole ballgame.

To keep protections for the sick in place, the Republicans would have to produce a plan that looked a lot like Obamacare. Under this constraint, the only way to differentiate it — and thus the only way to realistically claim to “repeal” Obamacare — would be to design a version of the law that was meaner, stinger, and outright worse.

That’s ultimately just what the GOP did, but only after abandoning their first strategy: so-called “repeal and delay.” This plan — to give Republicans the political catharsis of an immediate Obamacare repeal vote, but delaying the effective date of repeal for several years — implicitly conceded two important points: First, that it was unjust and untenable to simply repeal and toss people off of their healthcare. And second, that Republicans had no idea how to actually replace the law.

After it became clear that repeal and delay too would cause chaos on insurance markets, that half-baked plan was scrapped once enough leading Republicans (Trump included) clamored for simultaneous repeal and replace. And that course correction produced the monstrosity that was the American Health Care Act.

The bill was a horribly constructed, unloved mess from the day Ryan announced it from behind his smirk. But it was really its Congressional Budget Office score that did it in, for the CBO confirmed what everyone suspected: that AHCA grossly offended the prevailing moral principle of universal healthcare. In pursuit of that principle, Obamacare had normalized a baseline of widespread and affordable coverage. AHCA did immense violence to each of these, threatening to throw 24 million people off their insurance and jack up rates on millions more of the oldest and more vulnerable Americans.

With that, it was only a matter of time before AHCA collapsed in a heap. There were other factors, of course: The Republican Party was in a defensive crouch from the get go, and couldn’t coalesce around a replacement plan. A public enraged by the elevation of Donald Trump to the presidency and terrified of the threat to life and limb posed by repeal galvanized to mount a fierce resistance. But the common thread through all of them was the potent moral force of universal healthcare.

Granted, Obamacare hasn’t yet achieved the goal of universal coverage. But it made a major down payment toward that goal, lowering uninsured rates to historic lows. With the failure of AHCA, the country is refusing to turn back from those gains.

So for the second consecutive Republican presidency, grand conservative designs to gut a pillar of the welfare state have crumbled. When George W. Bush decided to spend his second-term political capital privatizing Social Security, his plan made it through the summer before being pronounced dead. What is remarkable about Obamacare repeal is that it fell apart so fast.

But like Social Security reform, AHCA crumbled under the weight of poor policy design, Republican factionalism, and public resistance. Call it loss aversion, status quo bias, third-rail entitlements — the welfare state has demonstrated an impressive staying power.

And it all comes back to the foundational moral basis for government forging ahead to better people’s lives and provide a sense of security. That’s the brick wall that Ryan’s now-aborted “rescue mission” ran into headlong. Universal healthcare is right and just, and that’s why Obamacare has survived yet again — and perhaps for good.

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Social democracy as the answer to Trump

I’ve been reading Tony Judt’s Ill Fares The Land, his 2010 plea for social democracy in the last days of his life.  It turns out that Judt presciently anticipated the appeal of Trumpian authoritarianism in our insecure age — and offered social democracy as our best hope to withstand it.

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Tony Judt (New York Times)

Judt was a steadfast if begrudging admirer of social democracy–a political ideology that “does not represent an ideal future; it does not even represent the ideal past.  But among the options available to us today, it is better than anything else to hand.”

Social democracy is the true center of modern political thought.  Where socialism outright rejects capitalism, social democracy accepts it.  Social democracy aims to harness the engines of capitalism while tempering its rough edges, crafting the institutions and guardrails necessary to balance capitalism’s chaotic dynamism with a measure of ordered security.

That sense of security is dangerously amiss today, roiling much of the West with anxiety.  “We have entered an age of fear,” Judt wrote.  “Insecurity is once again an active ingredient of political life in Western democracies.”  This is the insecurity of terrorism, of technological change, of globalization, of economic inequality, of the prospect of job loss.  “And, perhaps above all,” Judt wrote, “fear that it is not just we who can no longer shape our lives but that those in authority have also lost control, to forces beyond their reach.”

This combination — an electorate both gripped by fear and inflicted with skepticism of their leaders’ ability to do anything about it — produces anti-democratic movements that offer stability by turning aggressively inward.  “If we can have democracy, we will,” Judt observed.  “But above all, we want to be safe.  As global threats mount, so the attractions of order will only grow. [. . .]  Outsiders, however defined, will be seen as threats, foes and challenges.  As in the past the promise of stability risks merging with the comforts of protection.”  That’s the lure of Trumpism that Judt saw coming.

The fearful society craves stability.  This stability can be provided one of two ways: First, it can be anti-democratic stability.  This is the order promised by a strong man — one who exploits this insecurity by vilifying the weak and the “other.”  One who looks at blighted communities cast to the margins of the American story and declares “I alone can fix it.”  One who assures those forgotten communities that he will “give you everything. I will give you what you’ve been looking for for 50 years.”

“Unless the Left has something better to offer,” Judt warned, “we should not be surprised to find voters responding to those holding out such promises.”

Fortunately, the Left does have something to offer — Trumpism isn’t the only answer to insecurity.  Stability can also be provided through democracy by crafting institutions to truly protect people from the risks of modern life.  “Social democracy in Europe, the New Deal and the Great Society here in the US, were explicit responses” to challenges and threats wrought by previous eras of insecurity, Judt wrote.  Where Trumpism offers recriminations in response to insecurity, the Left must offer reassurance.

What does that reassurance look like?  By and large, it means insuring individuals against commonly-shared risks in the twenty-first century.  Political scientist Lane Kenworthy laid out a full agenda for a Social Democratic America, including wage insurance to protect workers from cuts in pay, sick leave to insure workers in case of illness, a child benefit to insure parents against the costs of child rearing, and other social insurance programs.  It might also include an aggressive program of targeted government investment to stimulate stagnant communities, coupled with a federal works program, to function as a form of insurance against creative destruction discarding whole regions of the country.

Of course, a program of that scale and ambition will directly confront a public with ever-diminishing expectations in the capacity of its civic institutions and their leaders.  As Chris Hayes wrote in The Twilight of the Elites, we face a crisis of authority in the United States after a generation of catastrophic elite failure at every turn across virtually every pillar of society. This makes for a receptive audience for the authoritarians promising anti-democratic stability that bludgeons these very institutions, and a much more doubtful audience for those looking to achieve democratic stability through better and more comprehensive institutions.

Which means the Left’s message and messenger matter.  A compromised center-left version of social democracy in the hands of a leader closely tied to decades of institutional failure won’t be compelling.  While Hillary Clinton pushed an agenda packed with progressive technocratic reforms and programs, her institutional ties were too unshakable and her ambition to restructure the American economy too trimmed to compete with the vociferous anti-democratic stability offered by Trump.

The Left will need an outsider insurgent that can credibly lay claim to moving the country in the direction of social democracy.  Barack Obama pushed a centrist progressive agenda, but did so as an outsider reformer offering hope and relief from the failures and disappointments of the previous generation.  Bernie Sanders positioned himself as an outsider to the political class vowing social democratic revolution of the country’s institutions, but lacked the inspirational and heroic appeal of Obama that cut across all core Democratic constituencies.  Some combination of the two is what’s called for.

Moreover, a social democratic response to Trump isn’t necessarily about specific policies.  Rather, it requires making an unabashed positive case for the role of government to better citizens’ lives; for the capacity of a democracy to craft institutions to guard against threats new and old; for the ability of elected leaders to chart a course that enlivens struggling communities and ensures that prosperity is broadly shared.

Even if Trump’s presidency crumbles under the weight of chaos, incompetence, and scandal, the resonance of his dark message won’t necessarily follow suit in four years.  As the closest approximation of the Left in mainstream American politics, Democrats will only defeat Trump by offering voters their own vision of how to achieve security in the twenty-first century.  In an age of fear, the hostile illusion of security of the Right can only be matched by a hopeful communal security of the Left.