With the United States in the grips of a pandemic that will surely test our health care system, it’s worth reflecting on how the law that is now deeply woven into the fabric of American health care came to be.
It took a monumental effort to pass the Affordable Care Act, or Obamacare, which turns 10 years old this month. But because of it, no American can be denied health insurance for having a preexisting medical condition. And 20 million people who previously lacked coverage now have it.
On the latest episode of The Dose, the Commonwealth Fund’s Elizabeth Fowler – one of the key architects of Obamacare – talks about the behind-the-scenes effort it took to get the law passed.
LIZ FOWLER: A president that chooses to take up health reform and go forward with a major overhaul, again, that is the major issue. And it’s probably to the exclusion of working on climate change and affordable housing and income inequality and other issues that you might choose to take up.
SHANOOR SEERVAI: Hi everyone. Welcome to The Dose. I’m Shanoor Seervai, and today we’re going to be talking about the law that changed the health care system in America, the Affordable Care Act or Obamacare as it’s usually called. Obamacare turns 10 years old this week, and so I invited someone to be on the show who spent countless hours, days, weeks, months getting that law passed. Liz Fowler, she was the chief health counsel to Senator Max Baucus when he was the chair of the Senate Finance Committee, and she’s now the executive vice president for programs at the Commonwealth Fund. Whenever I go into her office for a meeting, the first thing I notice on the wall is the roll call vote from the night when the Senate passed the bill. And I look at that piece of paper with those check marks and that signature and I wonder, what did it actually take to make that happen? So Liz is going to talk about that today.
Liz, welcome to the show.
LIZ FOWLER: Thanks. Thanks for having me. And I might add that it was actually a monumental effort on a lot of people’s behalf. I just happened to be in the right place at the right time to work on it, but there was a very large team involved. So I really can’t take all that credit.
SHANOOR SEERVAI: Of course. And part of the reason I wanted to have this conversation with you is because there were so many people, so many different pieces involved in passing the law. So let’s dive right in. Tell me about some of the different things that had to happen.
LIZ FOWLER: Sure. Well, first of all, I think what you have to realize is Congress responds to a public need when there’s a public policy crisis. So I think the first thing to keep in mind is that our health care system was really broken. It’s not that it’s 100 percent fixed now, but the first thing that we had to do, and I think that was present, was a real evidence base for what the problems were in the health care system. We had 50 million people without health care coverage. We had evidence that the health care system wasn’t delivering always at the highest quality. We had a study that showed that if you had diabetes, you only got recommended care about 50 percent of the time. We were spending more than any other country in the world. We still are by almost double. So we did a lot of work building an evidence base for what the problems were and what the actual consequences were to people’s health and people’s pocketbook. And we can talk about whether that’s still the case because I think there’s still issues, but it was definitely the case in the 2008 election. This was a big issue.
SHANOOR SEERVAI: I wonder, is there anything that personally motivated you to work on health care, to be involved in this issue?
LIZ FOWLER: Well, I took a class when I was a sophomore in college and I thought I wanted to be a doctor. But then I took a policy class and they said the U.S. was the only industrialized country in the world without a national health system. And actually that spurred me to want to work on that issue. So I think I was 18 or 19 years old when I decided I wanted to work on health reform. And as an adult, this issue affected me personally.
As my parents retired, my father was a physician, my mother was an accountant. They moved to a state that was sort of outside the zone of their retiree health benefits. My father was eligible for Medicare, but my mom who wasn’t eligible for Medicare, had a preexisting health condition and couldn’t find affordable coverage. Really could not find an insurance company that would sell her a policy based on her health condition. And so she ended up going back to work. And at 62 years old, or thereabout, became a gate agent for an airline in Las Vegas working the night shift. And there’s my mother, who wanted to be retired, and is instead working the midnight shift for people taking red eye flights back to wherever they came from after their vacation. And all that was to get health benefits. And it was a real lesson in the struggles that people must be having with our system. So not only is it now just about the numbers and the averages, but it was, for me, a real personal story.
SHANOOR SEERVAI: I mean, I can’t even imagine how that must’ve felt. Like, here’s your mom who wants to retire, and not only does she have to go back to work, but it sounds like it was . . . I wouldn’t want to work the midnight shift at an airport. That sounds grueling.
LIZ FOWLER: It was, and listening to her coming back and she’d tell stories of coming back at two o’clock or three o’clock in the morning. And all of this is just to get health benefits, and frankly she’s lucky she found a job where she could work part time and get health benefits. Not everyone can do that. And so she was lucky that that was the case for her. But I think it drove home for my family, certainly in me personally, what a struggle it is to get affordable health coverage in this country.
SHANOOR SEERVAI: And before we get into what it actually took to pass the law, it’s worth mentioning that now if you have a preexisting condition, you are able to get insurance, right?
LIZ FOWLER: Exactly. So now she would be able to buy coverage on a health exchange, whether that be in a state that runs its own exchange or through HealthCare.gov. And I think that’s really the most important change since the Affordable Care Act that maybe people haven’t really focused on. And certainly, it’s something that is not out of the question that we could lose it if a court case goes the wrong way, or if Congress decides they want to take up repeal and replace. I think it’s something we can’t take for granted.
SHANOOR SEERVAI: And as you were debating the preexisting condition issue and other policy issues, what did it take to get the President, Congress, other stakeholders, on board again and pass this law 10 years ago?
LIZ FOWLER: So, it’s hard to explain how difficult it is to get such major legislation passed through the House and Senate and signed by the President, and legislation that’s complicated and has vast impacts. I mean, if you think about the fact that 18 percent of our GDP or close to 18 percent of our GDP, and it was a little less than that at the time, but that’s a significant portion of our economy. So, to come up with a far-reaching legislation and to be able to get all the pieces aligned, the policy, the budget impacts, the stakeholder impacts, the sort of the votes lined up, it’s a pretty monumental undertaking.
SHANOOR SEERVAI: So let’s talk about policy. Now, we had a blueprint if I may, in Massachusetts, which had already passed its own health reform.
LIZ FOWLER: Exactly. So the 2006 Massachusetts reform, which was bipartisan, a Republican governor, Mitt Romney at the time, and Senator Kennedy and the Democrats in Massachusetts came on board and passed this law that built on the current health care system to achieve a higher rate of coverage. And that really became the model for the federal policy.
SHANOOR SEERVAI: It’s interesting that that was bipartisan, and then the health law that ultimately passed all the elements off it did not receive bipartisan support.
LIZ FOWLER: Yeah, there’s a lot that goes into the politics of an issue. So it’s not just getting the policy and the numbers, but it’s also the politics.
SHANOOR SEERVAI: Mm-hmm. Okay. So we have Senate committees and House committees, and they all have perhaps different priorities, but they’re all working on this issue and trying to figure out how they’re going to get health reform passed. We have an example in Massachusetts, as you say, a policy that was trying to raise the level of coverage. And then we have this evidence base that we discussed earlier, which is just that 50 million people, that’s almost one in six Americans, don’t have health insurance. People like your own mother are being denied coverage. So what else did it take to move this along? How was President Obama involved?
LIZ FOWLER: So, that’s exactly where I would start is, presidential leadership is absolutely critical. You have to have a president who says, “I’m going to make this my priority. This is the number one thing for my administration. This is the domestic policy that I’m going to take on and try to fix.” And you had that in President Obama. He took up health care reform. I’m sure there were probably a lot of advisors who said, “This is a hornet’s nest. Maybe you ought to go in a different direction,” but President Obama took this up and said, “This is something I want to get done.” And it’s hard to understate how critical that that leadership is. I’d say his leadership was important, not just because he made it a priority, but also because he helped sort through some of the controversies and some of the policy issues that might’ve tripped us up working on legislation and trying to get that through.
So the president’s role, not only in setting the policy direction and setting the policy priorities, but also helping to help Congress sort through some of the controversial issues when there’s disagreements. Making sure that members stayed on board and everyone’s oars were in the boat rowing in the same direction. I know that’s not a great phrase, but . . .
SHANOOR SEERVAI: I get what you mean.
LIZ FOWLER: So I think, the other aspect that I would say was really important about President Obama’s leadership was really giving Congress enough space to be able to write legislation. I think if you compared the 2009 effort with what happened in 1993, ‘94 where there was a task force of 500 people who were writing policy and then sending it to Capitol Hill and saying, “This is what we want you to pass.” That’s really not how our government is constructed.
I mean, Congress has a role in writing the law. Clearly we need direction from the president and help sorting through some of the controversial issues. But you got to give Congress enough space to work on the legislation. And that’s something that President Obama was really good at.
SHANOOR SEERVAI: So you’re saying he sort of struck a balance where he would weigh in where he felt he was needed, but he also gave people the freedom and the agency to figure out what they needed to do.
LIZ FOWLER: Exactly. To work through the legislative process as was intended by the Constitution.
SHANOOR SEERVAI: And I mean everyone, all the members of the House and the Senate, they all have constituents. They all have stakeholders they’re responsible for. So I imagine that there’s so many different things that even each individual member of the Senate or the House has to think about as they’re working on this.
LIZ FOWLER: Absolutely. I mean, you’ve got to think about how this legislation might impact hospitals and health insurance industry and physicians. I mean, first and foremost patients, but as well as a number of other stakeholders who you know are going to be at your door. And if policy starts to impact them very negatively, you can bet that every member of Congress is going to hear from them. For example, you think about the fact that the hospital is probably, in many communities, the largest employer.
SHANOOR SEERVAI: Right.
LIZ FOWLER: So, whatever policy you do that’s going to impact hospitals, you’re going to hear about it as a legislator.
SHANOOR SEERVAI: Do you have any stories or reflections on how, especially looking back, on how President Obama was able to help build bridges over a controversial issue or help get people in the room in a way that moved the legislation forward?
LIZ FOWLER: I think part of what he did was through public statements, his joint address of Congress, emphasizing how important this issue was, but also behind the scenes, calling members, calling members down to the Oval Office, making sure folks stayed in line. Also, a really critical issue, he and his staff who I have great admiration for, really delving into the details and understanding the stakeholder concerns and when presidential meetings might be helpful and when do you use his heft and his weight appropriately. So all of that came into play.
SHANOOR SEERVAI: So we talked a little bit about the committees that were involved and you were working with Senator Baucus who was chair of the Finance Committee at the time, and he was a moderate. And I think really my understanding is that he wanted to have the law pass with bipartisan support. Can you talk about that experience?
LIZ FOWLER: Sure, so I worked for Senator Baucus from Montana. He believed strongly that health care reform should pass with a bipartisan majority. As he saw it, he looked back historically, his view was that every major social legislation in the country had passed with major bipartisan support. Social Security, Medicare, Medicaid, Americans with Disabilities Act, the Civil Rights Act, and he would give examples and he would quote how many votes it took to pass all of those things. And it was large bipartisan majorities, and he really felt like health reform should also be passed with bipartisan majorities, but unfortunately that just wasn’t in the cards.
I think he tried. He had a real interest in getting Republicans on board. Unfortunately, politics took over.
And I think that’s led to a lot of the problems that we see today where people are sort of still not sure about the direction of the Affordable Care Act. With some segment on the left feeling like it should have gone much further. Some on the right who’d like to repeal the whole thing. And what I do think we have now is at the very least, and what is a change from 2009, is that a majority of the U.S. population now agrees that we should protect people with preexisting conditions. And I think we’ve also seen that affordability remains a challenge, that premiums and out-of-pocket costs are still a real challenge for people.
So, as much progress as we made with the Affordable Care Act in covering 20 million people, we still have almost 30 million who don’t have coverage. And those with coverage I think are seeing really large out-of-pocket costs. So I think we’re at a point now where we need to look and hopefully decide together what direction we want to go to continue to make progress on this road to universal coverage. With the ultimate goal, getting people covered with something they can afford that gives them the care that they need at the time they need it.
SHANOOR SEERVAI: So Liz, we’ve talked about Americans needing to be able to get health care when they need it, and as you said, being able to afford it in a way that doesn’t bankrupt them. And one of the issues, I think that there is some consensus of out among the public is that drugs cost too much money. Prescription drugs are just too expensive, but we haven’t seen a law that does anything about that.
LIZ FOWLER: Yeah, I mean drug pricing is an issue where 85 to 90 percent of Americans think that Congress and the administration ought to take action. And yet we’ve not seen the ability to pass legislation. I think the House has one approach that looks at government negotiation. The Senate has an approach that’s bipartisan with Senator Grassley and Senator Wyden that looks at curbing some of the price increases among other things. And we’ve still not seen legislation come out of the Congress that the president’s able to sign. And I think that’s a lesson in how hard it is, even when there is broad consensus that action should be taken to actually address the problem. And I think it’s something to keep in mind in this campaign season when we’re talking about a massive overhaul again of the health care system. Which, I think we ought to be talking about health reform, we ought to be talking about ways we can get to universal coverage, but we also need to keep in mind just how difficult it is to actually get things passed.
SHANOOR SEERVAI: And so as the election nears, Liz, do you have any thoughts or reflections from this very complicated process that you went through passing major health legislation to candidates who have a very wide range of big ideas for how they want to change the health care system all over again?
LIZ FOWLER: Well first of all, I think we still have many issues in our health system that need to be addressed. So I am pleased that candidates are still talking about health care and the need to make changes. In terms of taking up big, major monumental reforms, I think maybe one thing to think about is that a president that chooses to take up health reform and go forward with a major overhaul again, that is the major issue. And it’s probably to the exclusion of working on climate change, and affordable housing, and income inequality, and other issues that you might choose to take up, education. That if you choose to take this up, you’re going forward with something that’s going to take all of your time and effort, and all of the time and attention of Congress, and will probably take months and months. And it’s not saying it’s not worth it, or that it can’t be done, but just reflecting back on that and what it took to get that passed, I think probably there’s some lessons in there for how much you want to bite off again.
SHANOOR SEERVAI: Well, as we look back on the 10 years and the fact that this law passed 10 years ago, I do want to ask, if you had to name one thing that you’re most proud of, something that the Affordable Care Act has achieved that you really are most proud of when you look back.
LIZ FOWLER: I think the thing that makes me most pleased is hearing the stories of people who have health coverage now, or it saved their child or their father or their spouse, or they would have reached a maximum out-of-pocket limit and they would have been kicked off of their coverage. Those personal stories and hearing how it’s helped individual people who needed care and maybe wouldn’t have gotten it, or wouldn’t have been able to afford it, I think that’s really satisfying. Thinking about 20 million people who have coverage now that wouldn’t have had coverage otherwise.
SHANOOR SEERVAI: Yeah, 20 million is a big number, but there is an individual behind each of those. And as you say, it’s really important to think about them.
LIZ FOWLER: Absolutely.
SHANOOR SEERVAI: Well, thanks for joining me, Liz.
LIZ FOWLER: Thanks, Shanoor.
Guest bio: Elizabeth Fowler
Illustration by Rose Wong.