As the Trump administration continues its campaign to repeal Obamacare and Republican legislators dodge constituents in fear of losing their coverage, headlines paint the health care debate as a simple tennis match between the two major parties. During Obama’s first term, Richard Kirsch, who served as national campaign director for the group Healthcare For America Now and authored 2012’s Fighting for Our Health: The Epic Battle to Make Health Care a Right in the United States, was on the front lines of the fight to pass the Affordable Care Act. Kirsch and I talked by phone earlier this month about the long and winding road to the passage of the ACA, what a Republican-engineered repeal might look like, and broader visions for the future of health care in this country. Here is a partial transcript of our conversation, edited for length.
Emily Carroll: Can you tell me about your role in working towards the passage of the Affordable Care Act?
Richard Kirsch: I was the national campaign director for Healthcare for America Now, which was this huge national campaign to pass what became the Affordable Care Act. The campaign was a coalition of progressive organizations with organized networks, labor unions, online groups, C2C organizations. The heart of it was really what we did at the state level where we had local and state organizations with really deep relationships, like the ability to organize people at the local level who made their voices clear in a unified, strategic way and was able to put enough pressure on the Democrats who were wavering to enact the legislation.
EC: Maybe before we get into the Republican response, you’d like to say more about those wavering Democrats and how they affected the legislation, how it was written, some of the exceptions, and your feelings about that process.
RK: Well, I mean, it was very clear from the beginning that Republicans were not going to cooperate in any way with passing health care reform. They were going to uniformly oppose it. Max Baucus, a senator from Montana who chaired the Senate Finance Committee, actually spent several months trying to get Republicans on the Senate Finance Committee to agree to [health care reform] legislation—delaying the process, weakening the legislation and never reaching an agreement.[*] And so we had, always, the challenge of getting Democrats who were more conservative, who maybe came from more conservative states, to go along with the legislation, and they were feeling tremendous pressure in those states, [as well as from the] health insurance industry which, it turned out, laundered [over] $86 million through the U.S. Chamber of Commerce, [a conservative lobbying group].
As a result the legislation was not as strong as it could be. The biggest loss was the lack of a public health insurance option, which would have been a public plan like Medicare to compete with private insurance companies. That would have helped keep the price down, and ensured coverage that was a wide choice of providers and focused on peoples’ health, not profit. But in addition, another major loss was the fact that the president decided that there was something magic about not spending more than $1 trillion over a decade in subsidizing the cost of peoples’ health care rates or helping pay for Medicare. Basically, the amount of subsidy provided was not nearly enough to make it affordable for a lot of people. Particularly, the subsidies were not high enough for a lot of working families and middle-income families who still had to pay too much for health coverage.
That is the biggest place where the legislation was weakened in order to get support from Democrats who were a little more conservative. But most of those Democrats are gone now; most of the ones in the House and a lot of the ones in the Senate who were a problem are gone, too. But then we had sixty Democratic Senators for a brief time, for the seven months between Al Franken getting seated and Scott Brown getting elected, and that was necessary to get most of the legislation passed.
EC: Those limits on health care subsidies, we saw them play out in the weeks before the recent presidential election, with people receiving letters about their premiums going up just weeks before they had to go to the ballot box. How much of an effect do you think that has on the way the public perceives the Affordable Care Act?
RK: The unpopularity was, as much as anything else, because Republicans had relentlessly demonized the bill from its start and has blamed it for everything that’s wrong in the health care system, including things like big premium increases, which had been going on for years. [As far as] premium increases for 2017, health care premiums have been increasing at a lower rate under the Affordable Care Act than they were before it was passed. Health inflation’s at its lowest in the period after the law passed in fifty years. What’s happened is that because the law is seen as a big advance and the Republicans have demonized it as government taking over health care, then all the problems that it didn’t solve—continuing high deductibles, high out-of-pocket costs, premiums going up, narrow choice of doctors—things that were going on before the law which the law did not hurt, but did not help, were all blamed on the law. But of course, we’re seeing that now that it’s under attack [the ACA] is the most popular it’s ever been.
There’s still pretty robust enrollment after the election. People still signed up, people still wanted to be enrolled in its coverage, people really value it. Now that Republicans are saying they’re going to repeal it, it’s [become] popular, because people are worried about what they’re going to lose and realize how important it is to them.
What the Republicans want to do is incredibly unpopular.
EC: What do you think is the most realistic picture of what repeal would look like—what we will lose, what we won’t lose?
RK: Well, we know what would happen if Republicans could get what they wanted, which they don’t really have the power to do without Democratic support—which it doesn’t seem like they’re going to get.
But what’s true of other Republican replacement plans is that most of the people who have gotten coverage after the Affordable Care Act would lose it, and more, actually, because it would subtly disrupt the health insurance market. While 20 million people are covered, a study by the Urban Institute projects that 30 million people would actually lose coverage, and that’s because repealing the law would not just affect the coverage of those who get it through the law, but people in the private insurance market, because that market would basically totally unravel when the law is repealed.
So we know that the Republicans want to drastically reduce subsidies people can get to afford coverage. They want to increase the premiums for seniors in order to bring them down for younger people, and of course seniors have the most need of health care so the premiums would be really high for them. They want to repeal the expansion of Medicaid which has provided more than half the increase of coverage to people. We know that they want to push high deductible plans with health savings accounts where everyone has to have saved enough money [for care] every month, which very few people can afford to do. And while the President says he doesn’t like high deductibles, in fact the whole plan is based on really high deductibles. . . .
So [most of what] they want to do is incredibly unpopular. They say they want to preserve the pre-existing condition exclusion, but no, they want to drive a huge loophole through it, where you’d only be able to get coverage with a pre-existing condition if you didn’t [ever] lose your coverage. So if you lost a job or you couldn’t afford to pay your premium, which would be much harder since the premiums are going to be so much more expensive for folks, then you could be denied because of pre-existing conditions, and could be charged a huge amount more because of pre-existing conditions.
The problem now is that while Republicans can make some of these changes with just fifty votes, they can’t make all the changes to the insurance law like laws about not denying people because of pre-existing conditions. . . . Those laws require sixty votes the way that Senate rules work, so they require Democratic participation. The reason that Republicans are in such extraordinary disarray at this point is the only things they can do without Democrats’ [support] would totally destroy the insurance market because you’d have very little subsidies, but still have insurance companies required to cover people with pre-existing conditions. As a result, many insurance companies would abandon the market, the few that would stay would charge incredibly high rates, and the tremendous disaster of 30 million people losing coverage would be on the Republicans’ heads. And they’re scared of that. And so the danger of course is that they will threaten Democrats that they’re going to let the whole thing collapse unless the Democrats agree to pass a “less worse” version of their plan; and we have to be sure that Democrats won’t go along with that.
EC: So if you were a person who had coverage through the ACA right now, how confident would you be that they’re not going to manage to get that Democratic participation?
RK: Well, I feel that folks absolutely have a right to be worried, and they’ll have to be really calm and have to put lots of lots of pressure on those Republicans or Democrats who represent them. I feel like if that happens, then we’ll see the kind of energy that actually can continue to force them to never actually implement the repeal. There’ll still be some bad things coming down the road, but I think if people really stay engaged we can block this from actually happening.
EC: What do you think the press is losing in covering this debate? What would you want people to know that you don’t think is well covered or well understood?
RK: I think the biggest thing that people aren’t seeing at all is the huge attack on Medicaid that’s coming. The press hasn’t covered it, it’s not on anybody’s radar. It’s 33 million children and 77 million people. It’s the way that people with disabilities get their health care paid for, it’s the way that families can afford to send their elderly parents to a nursing home or get home care. That’s a huge, huge attack that Republicans are going to try to force through really quickly. And that’s the thing that’s basically getting the least attention. I think the public has got that Republicans want to repeal the ACA.
EC: Can you give us a little historical context for Medicaid, where we are now, and what might be lost?
RK: The whole thing the Republican party is trying to do is to get rid of any government guarantee of health, security, and affordability for people. So their plan is not only to repeal the Affordable Care Act but to slash a trillion dollars in funding that the states get for Medicaid and radically change the program so that it’s no longer a reliable program to provide health coverage and states are forced to make huge cuts. And they also want to privatize Medicare, to replace Medicare with a limited voucher for private insurance. So Medicare, Medicaid, the Affordable Care Act, the first two enacted with the Great Society and then the Affordable Care Act enacted under Obama—these three programs basically cover more than 100 million Americans. They affect virtually every family and anyone who lives to be over 65. And they basically want to gut those programs, because they hate the idea of governments playing a leading role in health security and affordability. That’s where you have to start. Of the two ways people got coverage, one was the Health Marketplaces, which people hear about more, but actually, only about 9 million people got covered that way. But 100 million people got coverage through the expansion of Medicaid to cover many more people. And not every state did it; there are still nineteen states that didn’t even do it, because the Supreme Court said that states have a choice. And so repealing just the Medicaid expansion would be about a trillion dollars over the next twenty years, but then on top of that [we face] another trillion dollars of cuts from what the New York Times called radical change in Medicaid, because right now if you’re sick and you’re eligible for Medicaid in the state, the federal government will pay a fixed percentage for it. . . .
[Under the Republican plan] if the costs go up because more people get enrolled or there’s high health care inflation, states will have to cut health care coverage for seniors and people with disabilities and children—33 million people. Around the country, children rely on Medicaid, and mothers, and working parents. Medicaid pays half the cost of longterm care for people in nursing homes and home care, seniors with disabilities. This is all so the Republican Congress can shirk their responsibility to pay for coverage and because they hate the idea that government would actually provide health security to people.
EC: At this point, is the health insurance lobby a little scared of this administration and this Congress?
People need to see that we have ideas and can give them hope.
RK: Yeah. Well, they’re very scared of the disruption. You would hope that what they would do is just vociferously oppose the repeal, but of course they’re not doing that. Instead, what they’re doing is trying to figure out a way to get a replacement plan that allows them to make more money. The kind of plans they love are plans with very high deductibles, because that means that people are on the hook for most of the care and they don’t have to worry about the most expensive medical bills; those are the most profitable plans. So they’d be perfectly happy if a repeal weakens consumer protections, weakens the kind of benefits they have to provide, gives them more ability to deny people care and at the same time push the high deductible plans. Also, one of the things that they’re asking for, in order not to abandon the market in the kind of uncertainty Republicans are craving, is huge [corporate] subsidies. They’re worried about losing a lot of money if Republicans are going to make the market collapse. Insurers have said, “we can’t make any money in a situation where we have to cover people who can’t afford it, but we’ll stay in the market if you give us huge bailouts during the transition.” So if Republicans throw a huge amount of money at the insurance industry to bribe them to stay in, it would be ironic. Instead of providing insurance coverage for people, Republicans would be spending vast sums bailing out the insurance industry.
EC: Do you think that a mass mobilization on behalf of saving the Affordable Care Act could have the potential to start us moving in the direction of single payer health care again, or at least of a robust public option?
RK: Not so much single payer. I think as much as people on the left would love to hear that, you can’t tell 160 million people that they’re going to lose their employer-based health coverage. It’s just politically dead on arrival. But you can say that having a choice of Medicare, a plan that’s a huge national public insurance, is something that everybody should be offered alongside employer-based coverage, and that’s very popular. The bigger question is: Can we move towards a choice of Medicare for everyone in the country? As well as fighting against the Trump/Republican plan to dismantle health care and all the other awful things he’s doing, we need to be putting out a vision for the kind of big solutions that will address the real issues and problems of the day, not just offer Band-Aids. We need to do that because, first of all, people need to see that we have ideas and can give them hope. And second, if the reaction against the Trump administration leads to a turnabout in a more progressive era—and if you look at American history all progressive eras follow really conservative eras—we need to be putting out an agenda for the kind of changes we’ll make if we actually have the power to make big changes.
[*] Correction: An earlier version of this article misnamed the home state of Senator Max Baucus. He is from Montana.