Why Health Care Drives Presidents Insane

I can’t prove this happened, but it wouldn’t surprise me at all if Bill Clinton and Barack Obama placed a conference call to President Trump, where they began by proclaiming: “Welcome to the club!”

Once again, a new American president has received a significant shock by daring to touch what is now the reigning third rail of American politics: health care. Do I exaggerate? Let’s take a trip down memory lane.

In 1993, Clinton entered the presidency with a Congress firmly in the grip of the Democratic Party—57 seats in the Senate and 258 seats in the House, which had been Democratic for some 35 years. He proposed a sweeping plan to provide universal health care. It called for employer mandates, regional health alliances, subsidies for the poor and a National Health Board to measure the quality of health care. Fatefully, he put his wife in charge of the effort, saying, “she’s better at organizing and leading people from a complex beginning to a certain end than anybody I’ve ever worked with in my life.”

It was a miserable failure. After withering criticism from conservatives, the health-care industry (with its “Harry and Louise” ads) and prominent Democrats—Sen. Pat Moynihan said, “anyone who thinks [the plan] can work in the real world as presently written isn’t living in it” —the bill died in 1994 without even coming to a vote. That fall, Democrats lost both the House and the Senate in an historic midterm landslide directly linked to the health-care debacle.

In 2009, Barack Obama, fresh off a decisive drubbing of Arizona Sen. John McCain, entered the presidency with Congress firmly in the grip of the Democratic Party—59 seats in the Senate, which would grow to 60 by the summer, and 256 seats in the House. He proposed a sweeping plan to expand health care; it called for individual and employer mandates, subsidies for the poor, the expansion of Medicaid and exchanges to provide a choice of plans for consumers. The eventual bill was subjected to withering criticism from conservatives, and from enough Democrats in the Senate—where every one of the 60 votes would be need to block a filibuster—and after significant compromises, the Affordable Care Act passed with just enough votes to become law.

It immediately garnered poor public approval ratings, and that unpopularity was one big reason why the Democrats lost the House in the 2010 midterms, dropping 63 seats and losing 5 Senate seats and thus its filibuster-proof majority. Four years later, with “Obamacare” still underwater in public opinion polls, Democrats lost 9 Senate seats, thus giving Obama the distinction of being the only president in memory to suffer two midterm disasters. That Senate loss, of course, also cost him a crucial Supreme Court appointment.

In 2017, Donald Trump came to the White House with a middling electoral majority (and a popular vote loss). But he had a solidly Republican House—240 seats and a narrow 52 vote majority in the Senate. Having embraced the seven year long Republican promise to “repeal and replace Obamacare,” he essentially took to the sidelines, while congressional leaders tried to hammer together a bill that would win majorities. After prevailing with two votes to spare in the House (on the second try!), Republicans tossed the bill into the circular file and cobbled together a piece of legislation in the Senate that achieved record-low public approval ratings, ultimately dying an unmourned death of a thousand cuts. Most intriguing, the more the pubic looked at the “repeal and replace” argument, the more they embraced the once-scorned Obamacare. Surveys say it is twice as popular as the now-dead replacement.

So what does this tell us? A few useful facts.

First, most Americans are reasonably happy with their health care. With elders covered by Medicare, most working people covered by their employers’ insurance, and Medicaid at least minimally protecting the poor, most people are more inclined to be wary of any change that could threaten what they have than they are welcoming about change. (This is in sharp contrast to the last genuinely popular health care change: Medicare threatened nothing, but only offered older people an easily understandable, highly significant benefit.)

Second, the popularity of a health-care measure falls when people see it as a gift to “them,” paid for by “us.” There are clear racial and class undertones to this belief—another reason why Medicare, enjoyed by everyone over 65, never suffered from that attack. It was the Republicans’ misfortune to assume that Obamacare would continue to be viewed through this us vs. them prism.

What happened instead was that millions of people, including millions of white working class people, came to realize that the Affordable Care Act actually provides them with benefits—or to put it inelegantly, “them” was “us”—and that the various Republican “repeal and replace” proposals threatened their health and their finances.

Third, if past is prologue, congressional Republicans are in for a rough ride. Like Clinton and Obama, Trump and the GOP tried to pass a significant health care bill with no pretense of bipartisanship—a move that should now be put into the “DO NOT TRY THIS AGAIN!” file.

Unlike Clinton and Obama, President Trump may not suffer personal political blowback, and for an odd reason: It is abundantly clear that, to put it politely, he is not deeply engaged in the particulars of the bill. To put it less politely, he had no clue about what was in wither the House or Senate bill, which is why is was able to celebrate the House passage and then denounce the bill as “mean,” and go on to declare that he would sign whatever he was sent.

This may however, be cold comfort. Trump’s most fervent supporters have little love lost for the GOP leadership in Congress, and the Drudge Reports and Hannitys of this world have shown every inclination of coming down hard on Paul Ryan and Mitch McConnell for their fecklessness. If Trump voters stay home a year from November, or engage in internecine primary wars, the president’s party will suffer even if his most loyal supporters do not hold him personally responsible for Obamacare’s survival.

If you’re an optimist, you will hope that the congressional leadership of the two parties will sit down and see what kind of common ground they could plow. If you’re a pessimist, you will put your chips on a civil war within Republican ranks, a barely concealed outbreak of schadenfreude within Democratic ranks, and a serious argument in the White House about whether to strengthen Obamacare or strangle it and try to blame Democrats for its death.

And if you’re a future U.S. president, you will likely answer the call for health-care reform by saying: “Let me try something easier—like permanent peace in the Middle East.”

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