James Capretta hits the main points of President Obama’s JAMA article on his health-care law. Here I want to write about a partisan talking point Obama’s people worked into this allegedly “scholarly” article.
The first lesson is that any change is difficult, but it is especially difficult in the face of hyperpartisanship. Republicans reversed course and rejected their own ideas once they appeared in the text of a bill that I supported. For example, they supported a fully funded risk-corridor program and a public plan fallback in the Medicare drug benefit in 2003 but opposed them in the ACA. They supported the individual mandate in Massachusetts in 2006 but opposed it in the ACA. They supported the employer mandate in California in 2007 but opposed it in the ACA—and then opposed the administration’s decision to delay it.
Obama writes as though it’s somehow unfair for most Republicans across the country to reject the national imposition of a policy that California Republicans and Massachusetts Republicans blessed for their states. It’s true that the balance of elite conservative opinion on the individual mandate shifted over time. That happens sometimes, especially among a large and changing collection of people. It even happens with individuals: Obama’s own opinion on the mandate shifted in the other direction. (Remember, his opposition to a mandate was one of the few issue distinctions between Hillary Clinton and him in the 2008 primary.)
The reference to the Medicare drug benefit is especially misleading. Republicans objected to the possibility that insurance companies would underprice their plans on the exchange in the expectation that taxpayers would bail them out. Given the difficulty the companies have faced with the exchanges, it was a real possibility. It was a more theoretical issue when it came to Medicare drug plans: Costs have been lower and profits higher than originally expected, so the risk corridors have taken money from the insurers rather than giving it to them. They would have been more controversial otherwise.
Differences in context, rather than Republicans’ partisanship or growing extremism, also explain why Republicans opposed a public option within Obamacare while accepting it for drug benefits. Prior to enactment of the drug benefit, Medicare already covered health bills for seniors other than medicine; no mainstream politician found this controversial; and both parties agreed that it made no sense to cover surgery but not medicine. The extent to which government should be involved in health care for working-age Americans was instead a live dispute, as Obama well knows. That fact helped to lead many Democrats, too, to oppose a public option, and to do so more effectually than Republicans. It was the opposition of key Democrats, not Republicans, that sank the public option, something Obama does not see fit to mention.