As we enter the implementation phase of the Affordable Care Act, aka “Obamacare”, some are reviewing how we got here.
Politico recently examined how Barack Obama, whose rise to political stardom owed nothing to the issue, nevertheless made the cause of universal health care his own. It’s a worthwhile read, but it makes Sen. and later President Obama’s path to the Affordable Care Act, the reform that may be his greatest legacy, seem highly contingent, if not coincidental.
This is misleading. While not every twist and turn in the ACA’s tortured path was fated, Obama’s embrace of health care reform can be explained simply; it is the longstanding policy of the Democratic Party he sought to lead. Democratic constituencies have long wanted health care reform and Democratic presidents have fought for it, with varying degrees of commitment and success, since the time of Harry Truman.
Given Democratic control over the White House and Capitol Hill for the first time in 14 years, a push for health reform was predictable. Politico reports much evidence consistent with this explanation, but resists connecting these dots. Call it the Donkey in the Room syndrome.
Media coverage often focuses on the maneuvering of individual politicians and downplays structural factors like the preferences of party coalitions. Political scientists focus on durable structural factors more than journalists do, even when we realize that individuals matter in history. Their boring stability and impersonal quality means structural factors are seldom the stuff of journalistic narratives. Instead, too often coverage of the president as personality trumps coverage of the president as partisan, even where the party’s role is clearly central.
Obama first took up the health care issue in response to his Democratic rivals. Hillary Clinton was strongly associated with the issue due to her unsuccessful reform advocacy during the first Clinton Administration. John Edwards had announced an ambitious plan. In 2007 Edwards was courting core constituencies of his party, what Paul Wellstone termed “The Democratic Wing of the Democratic Party.” (This phrase won more fame when uttered by Howard Dean, who initially built his 2004 Presidential bid around health care reform.) Clinton and Edwards would be speaking along with Obama at a 2007 Families USA Event and the Illinois senator’s team reportedly decided he needed to have something to say about health care.
All the aspirants for the Democratic nomination knew their party wanted health care reform. Families USA was founded by longtime Democratic donor Philippe Villers. The group was a prominent backer of the Clinton Administration’s failed health care reform initiative, which occurred before Barack Obama had won any elections outside of the Harvard Law Review. Moreover, labor unions, long the central constituency of the Democratic Party, have supported health care reform for decades (albeit with some controversy over details). Similarly, Ted Kennedy, another onetime Democratic presidential contender, reportedly conditioned his endorsement of Obama on the latter’s embrace of the health care reform cause that had long been the Massachusetts Senator’s signature issue.
Initially, Obama wanted to address the health care issue without duplicating the plans of his party rivals. Yet once he won the nomination and needed to represent his party broadly rather than distinguish himself from other Democratic candidates, the key feature separating Obama’s plan from those of Edwards and Clinton, an avoidance of the controversial “individual mandate”, soon disappeared.
What’s more, Obama’s eventual plan resembled not only those of his 2008 Democratic rivals, but John Kerry’s 2004 health care plan as well. Both plans reduced the ranks of the uninsured via employer subsidies and Medicaid expansion. The proposals were not identical — Kerry’s was more modest — but it’s no accident that a Democratic candidate whose background could not have been more different from Obama’s promoted a similar plan four years earlier. Nor is it an accident that another health care reform plan was the leading initiative of the previous Democratic president in 1993 and 1994. Politico’s reporters even acknowledge that for Obama, health care reform was a more attractive first term agenda leader than immigration reform or climate change policy because the latter topics were more divisive among Democrats.
The real story here is the durable preferences of key groups in the Democratic Party rather than the “conversion” of Barack Obama, the individual politician. To understand the maneuverings of candidates we need to appreciate the partisan context in which they operate. Recent scholarship on parties, both my own book and co-authored work emphasizes the role of “intense policy demanders” in political parties. Politicians take stands to appeal to party constituencies. Obama’s behavior is the rule, not the exception.
None of this is to deny that individuals matter in history or to that Obama made a difference in the politics of health care. Obama, working with Democratic Congressional leaders, managed to win the votes needed to pass the Affordable Care Act. The eventual unity of Senate Democrats was not preordained. In early 2010 advisers urged the President to back down or to settle for a more modest reform. Another Democratic chief executive might have followed that advice. Obama chose instead to forge ahead, a fateful decision that may prove the most important one in his presidency. To understand why Obama did so one must learn about him as an individual.
Yet to understand why Sen. Obama chose to embrace the health care issue in the first place, we really just need to turn the spotlight on political parties. Candidates come and go, but the parties and their coalitions remain. If we want to learn why elected officials do what they do sometimes the answer is staring us in the face.