In “The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage,” journalist Jonathan Cohn writes about the battle over healthcare and takes readers into the impetus for, history of and current state of the Affordable Care Act. He joins to discuss what’s missing, inflection points, the role of bipartisanship and what the ACA means for Americans trying to navigate an increasingly complex system.
Note: This is a rough transcript — please excuse any typos.
Jonathan Cohn: We are still the only country in the developed world that doesn’t have truly universal health care. We have many millions of people who do not have insurance. We have many millions of people who have insurance, but they still can’t pay their medical bills, right, ’cause they got these high deductibles. The premiums are really eating into their wages. We have people who they have to, you know, they have to fight insurance bureaucracies to get treatments. They deal with a mind-boggling level of hassle.
Chris Hayes: Hello, and welcome to “Why Is This Happening?” with me, your host Chris Hayes. One of the weirdest things about the politics of the current moment to me is how the American right has evolved in such a way that it ceases to have anything to say about the major questions of political economy in our time.
What do I mean by that? Well, I came of age at a time when there was a certain kind of ascendant intellectual right. People call it neoliberalism. It was embodied in figures like Friedrich Hayek and then Milton Friedman and then in figures like Reagan and Thatcher that made these arguments about markets versus the state, about big government, and about the need for smaller government, and how markets were both better for human flourishing as a kind of moral and philosophical matter, and better for prosperity as a kind of efficiency question.
And that entire universe, it was dominant in the University of Chicago School of Economics, all sorts of think tanks, all sorts of writers, this huge kind of era of big government is over, as Bill Clinton famously said in one of his major speeches.
All of that has basically collapsed in on itself. Like, when you go to the American right today, like, they’ll get real worked up about certain things, like if you’re gonna make their child who’s unvaccinated wear a mask to help prevent on the margin the spread of an incredibly dangerous (LAUGH) and transmissible respiratory infection, like, they will get worked up on that.
They will get worked up about ten year olds showing up on the border, desperate, and afraid, and seeking asylum. They’ll get real worked up on that. They will get worked up about whether Twitter bans a Nazi, or someone Nazi-adjacent. That they’ll get very worked up about.
They don’t get worked up (LAUGH) about these big questions of political economy the way they used to. There’s a fascinating moment where Rick Scott of Florida did a big thing about inflation, and he was doing a press conference. He had these big billboards saying, “This is the price of milk now, and this is what these durable goods cost.”
And it was like, I had this weird thing of like, “Ah, that’s normal politics. That’s a recognizably conservative argument about the fact that if you’re spending too much money, that might have some deleterious effects on inflation, which could then hurt people.”
Like, that’s a recognizably intellectually coherent political argument to make. I don’t agree with it at this moment, but it was just like looking at the etchings of, like, a lost civilization (LAUGH) of, like, when conservatives used to make arguments about political economy.
And I think all of that has gone away. It’s very hard to find anymore. They’ll still talk about spending and deficits, but their heart is not in it. And I think the inflection point for this is Obamacare. I think the ACA was the last big fight about a fundamental aspect of political economy, and it was messy, and the outcome unclear still.
But they basically definitively lost it. And then Donald Trump kind of finished off whatever the remnants of Milton Friedman (LAUGH) version of conservatism might look like. And now they’re left with very little. And I think you can’t understand modern politics without understanding the fight over the ACA and the current ACA.
There’s a substantive aspect too, which we’ll get into, about how American health care works and doesn’t work, particularly during an era of pandemic. But there’s something about that fight that I really think is a turning point in a certain kind of question of the realignment and the big battles about political economy.
And so the best person to talk about that is probably the most dogged and informed chronicler of the ACA, Jonathan Cohn, who writes for HuffPo and has a great book out called The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage, which chronicles both how the law was passed and what’s happened after. And Jonathan, great to have you on the program.
Jonathan Cohn: Thank you for having me on the show.
Chris Hayes: First, what do you think of that thesis?
Jonathan Cohn: I think you’re right. I mean, I’ve been amazed just watching these last few weeks and months, right? Here we have the Democratic Party embarking on this incredibly ambitious effort, really to remake whole swaths of the welfare state, right?
I mean we’re talking about huge initiatives on childcare, on paid leave, college tuition, and then not to mention climate, right, and fighting poverty, any of which you can imagine being their own sort of knock down, drag out ideological substantive fight on the merits, right?
And I’ve sort of been bracing for it, ’cause you know, I’m a policy writer, right? So I’ve (LAUGH) spent the last, you know, so I’m reading CBO reports, right, and I’m like, going through conservative think tank reports. Like, “So where are we?”
You know, childcare for example, like, there is an argument to be had, right, I mean, you may or may not agree with it, but you know, if your a conservative, well, “Government shouldn’t be taking on this responsibility. There’s evidence that childcare programs don’t work,” et cetera, et cetera, et cetera. And we have just seen almost none of that.
Chris Hayes: Right. (LAUGH)
Jonathan Cohn: It’s all culture. It’s all tribal fights. It’s everything you listed. It’s vaccines, it’s immigrants. Sometimes there’s, like, an intersection, because a lot of these programs do have a kind of distributional component to them, right? They are about who gets the resources. And it’s not too hard to turn any sort of debate over a government spending program into a debate about, “Well, who’s getting the money and who’s giving it up?”
Chris Hayes: Correct.
Jonathan Cohn: Right? And that gets back to the stuff we’ve been seeing, you know, since the ’60s–
Chris Hayes: Right, and that’s Reagan’s, yeah, and Nixon and Reagan both understood that very well. Right.
Jonathan Cohn: Yeah. But I mean, it’s basically a policy-free party now. It’s just not where they’re interested anymore. I don’t even entirely know why. I mean, I sit and puzzle about this. I mean, is it just because at this point it’s the fight itself that they, you know, is it about that just everything is so fundamentally about identity politics to them that everything else comes secondary? Or is it, to some extent, the fact that they’ve become so extreme in their views when they do talk about substance that it becomes hard to engage? I mean–
Chris Hayes: I think it’s the opposite. I think they’ve moderated on substance, meaning they’ve moderated on questions of political economy. And I think these basic ideas of, like, big, bad government is gonna give you some benefit or do something no longer gets the base riled up the way it once did.
I think that has to do with a bunch of things about the different components of the base. The things they can racialize, obviously yes. And that’s really true about anything touching on immigrants. But I think partly because it’s become more of the party’s mass base is less economically affluent (LAUGH) than its old mass base used to be back during the era of Reagan that I think it’s harder to get them worked up about, like, the government sending them stuff.
Jonathan Cohn: Oh yeah. No, I mean, so I think there’s this disconnect, right, between the sort of old, intellectual conservative class, which still kind of exists, right? I mean, it exists in some think tanks. It exerts lobbying influence. I mean, we still have the Koch brothers who are, to some extent, about very old fashioned, “We don’t want regulations. Don’t tax us.”
Chris Hayes: Yes.
Jonathan Cohn: But as you say, it’s a complete mismatch with their base, which is perfectly happy to have a generous welfare state as long as it’s for them, right–
Chris Hayes: That’s right.
Jonathan Cohn: And we see in European democracies there’s a kind of more coherent version of this, but we don’t really have that here at the moment. And the contradictions between those two I think do explain a lot of what happened in the Trump era and why they weren’t able to govern successfully, because those are two very different world views.
Chris Hayes: Right, and they tried to take a run at repealing the ACA, which we’ll talk about. Let’s talk about the Affordable Care Act and let’s start with this. Sometimes (LAUGH) I feel about the Affordable Care Act, there’s a very funny joke Obama once told at the White House Correspondents’ Dinner, where there’s some battle over whether NPR is gonna be defunded.
And he made some joke about, he’s like, “I see NPR has a table here, so I guess you guys are still funded. Where did we end up on that?” And I, (LAUGH) sometimes I think that about the ACA. It was so central to all of our lives who covered politics, those of us like myself who was in Washington during the big fights over it, the multiple challenges in the Supreme Court. I’ve covered it. Like, let’s start with the now. How is the ACA doing under the strain of a national pandemic? What is its status right now?
Jonathan Cohn: You know, its status depends very much on your baseline for comparison. I would say, on the one hand, on the negative ledger, right, we are still the only country in the developed world that doesn’t have truly universal health care. We have many millions of people who do not have insurance.
We have many millions of people who have insurance but they still can’t pay their medical bills, right, ’cause they got these high deductibles, the premiums are really eating into their wage. We have people who, you know, they have to fight insurance bureaucracies to get treatments.
They deal with just a mind-boggling level of hassle. And I always kind of mention, like, I don’t know how much time you’ve spent talking to people abroad about their health care systems, but it never fails, when I’m describing what it’s like to deal with a medical bill in this country, and you explain the hoops you have to go through and the fights, and they just get this quizzical look like, “What on earth are you talking about? Who deals with that?”
So these are all big problems. And I think they contribute to problems that made the pandemic worse, right? People not having access to health care regularly. And I think it actually is a big part of the reason we’re having some of the problems with vaccination.
It’s not just Trump voters who have a political statement, it’s a lotta people, a lotta African Americans who are genuinely fearful of the shots, and a lot of it has to do with lack of connection to the medical establishment. And kind of dig, well, why is that?
Well, a big part is a lotta these people don’t go to the doctor because they don’t have insurance. So that’s all on the negative side of the ledger. You know, on the positive side of the ledger, if you wind back the clock imagine we were in a position where we did not have the Affordable Care Act in place.
Every one of those problems I just described would be twice as worse, right? I mean, we did make a huge reduction in the number of people without health insurance. I mean, it is at its lowest number ever. And we’ve done enough academic work to know that it made a big difference.
I mean, people who couldn’t get to the doctor are getting to the doctor. People who were struggling financially are able to pay their bills. I mean, this is not perfect, it is flawed in all kinds of ways, and yet I think so much better than what we had before.
And politically it has, I think, changed the conversation. I mean, and I think the symbol of that is the way we talk about preexisting conditions today. You cannot get up in American politics today and say, your first line on any conversation about health care is, “I believe in protecting preexisting conditions.”
The Republicans, they all say it. Now, they don’t necessarily believe it. I think if you look at their policies they wouldn’t guarantee it, and they don’t. Many of them truly don’t believe it. But they say they believe it. And as you know, in American politics, that’s when things change, is when the premise of the conversation, when you have to check that box in order to win an election, something big has happened.
Chris Hayes: I just wanna talk about medical billing, which I think is, at least from the consumer-facing standpoint, one of the most maddening aspects of our current system. I just continue to find it, like, enraging and astounding. My daughter broke her arm playing kickball.
And it was a bad break, but it was fine. You know, we took her to urgent care, got an X-ray, transferred us to an actual ER, she got a cast, all fairly routine. Every week now I get something in the mail, just indecipherable piece of nonsense.
I mean, I can’t make heads or tails of it. It’s one of those, like, “This is not a bill, explanation of benefits,” and there’s all these numbers floating around. And then eventually I’ll get something that says, “Okay, now you owe this.”
And I have pretty good insurance. And, like, I have no control over it. I sure as heck couldn’t comparison shop at the moment that my nine year old had a broken wrist that was swelling. I wasn’t in a position to be a consumer in any normal sense of the word.
I mean, it wasn’t really even much of, (LAUGH) ’cause we weren’t in charge of choosing my insurance, there wasn’t a ton of choice. And so, like, they could send me a bill that says you owe $36,000, or $360,000, or $360. I have no clue. I don’t know.
There’s nothing about this interaction that resembles any other market interaction I participate in. I don’t go to the store and take a carton of milk, go home with it and drink it, and then they send me a bill for $750 two weeks later and they’re like, “By the way, that’s what the carton cost.” (LAUGH)
It doesn’t work that way. Nothing works that way. You don’t pay contractors that way. There is nothing in life, there is no market interaction that works the way this market interaction works. And it is enraging that that’s the way it works. Anyway, that’s my rant on that.
Jonathan Cohn: Well, and look, you are as equipped as anybody to be able to deal with this, right? I mean–
Chris Hayes: More. I think to myself all the time when I open a bill and it says, “Oh, you owe $700,” I think to myself, “God dammit, I am lucky that I can just write the check for $700.” There’s times in my life when if someone just sent me a bill for $700 I’d be like, “I don’t have $700. (LAUGH) What are you talking about? I can’t, what, just come up.” Like, and yet that’s the way the system works for everyone. And I’m, yes, I’m in the 99.99999% percentile of people equipped with it, and I still think it’s nuts.
Jonathan Cohn: Right. So this is one of those things that I think for a long time, even on the democratic side of the aisle, the experts and economists who are helping to craft policy, they kind of wave their hands and dismiss as not a big deal. They’re like, “Oh, yeah, it’s a hassle, but we’re not really gonna worry about that.”
And I think, and I actually probably writing about it ten, 15 years ago, I think I was probably one of those people, like, “Yeah, you know, fine, it’s bad, but whatever, we’ll move on.” And the more I think about it and the more evidence we’re seeing now, it actually is a significant factor, and it interferes with people’s ability to get health care.
It causes financial problems because a lot of the people, most of the people who are in this situation, they don’t have the kind of resources you or I do. They don’t have the wherewithal. They don’t have the knowledge. And what do they end up doing? They owe the money, they get bill collectors, or they don’t get the care they need and then they’re in trouble.
Chris Hayes: So this is a huge thing that I think the Affordable Care Act did not address. The big things that it addressed were sort of regularizing and regulating what insurance was, getting rid of this differential institute of what’s called a community rating, which is you basically gotta charge everyone essentially the same.
There’s some exceptions for if you’re a smoker or not. And guaranteed issue, right? You can’t deny people. So everyone can get insurance if they want it, in fact, they’re required to. One of the big, most controversial aspects of the law was the individual mandate, the requirement, right? Tell us a little bit about the history of that and then what’s ended up happening. And I feel like the answer to the story is hilarious in that, like, it ended up not mattering that much. Am I wrong (LAUGH) about that?
Jonathan Cohn: You’re not. You’re not wrong. (LAUGH)
Chris Hayes: Jonathan, how much, seriously, I’m gonna ask you a question, you and me. How much of our lives in sheer hours did we devote to debates over the individual mandate? I mean, I’m not exaggerating when I say thousands of hours. You certainly more than me, thousands of hours of intellectual work, argumentation, debates between Hillary and Obama all about this thing that then got repealed and, like, didn’t actually matter.
Jonathan Cohn: Economic debates, political debates, legal debates. I mean, not one, but two of the Supreme Court cases, right, of the three big Supreme Court cases, two of them were all about the mandate. So the quick story here, to go way, way back, right, is that we used to have a conservative side of the debate that kinda, sort of was sympathetic to the idea of universal coverage, right.
And you had people like Stuart Butler who was at the Heritage Foundation, who was actually I think it was important to the story, he’s British, right? So he’s from a country that has universal health care, and he’s very into, like, privatizing services, right, ’cause he’s very much in that sort of Thatcher mode.
But like most people in the developed world, like, the idea that you wouldn’t be able to get health care seems kind of nonsensical to him. So he ants to construct a kind of alternative conservative version of universal coverage that doesn’t involve a big government program.
And he’s not the only one, but he’s sort of the most well known. And so there becomes this interest in a kind of conservative way to get to universal coverage. And the thing is, well, what if we reform the private insurance market putting in those rules you talked about?
Okay, great. But then the problem is if you make insurers cover everybody, then people will wait till they get sick, and we gotta get people to sign up. And so how do you do that? Well, you somehow, you force them or you penalize them if they don’t get coverage.
And that’s the genesis of the individual mandate, which actually pops up, you know, way back when around the time of the Clinton health care fight, as this sort of conservative alternative. And it takes various forms. And the Democratic Party at this point, right, is the Clinton plan.
I talk a lot about the Clinton plan in my book, ’cause I feel like you can’t understand the Affordable Care Act without understanding that failure. And you know about this, but that sort of psychic trauma that episode inflicted. Like, the entire intelligentsia and the political establishment of the Democratic Party was like, “Whatever we do, don’t do that again. Next time we try health care, just do the opposite of what we did last time.”
Chris Hayes: Right.
Jonathan Cohn: And so there was this desire to find some middle road. And we’re still in the throes of the end of big government era. We have to somehow breach some of those Reagan voters. And the Democrats are sort of like, “Well, how do we do this?” And then Mitt Romney, when he was governor of Massachusetts, kind of a throwback to an old-style Rockefeller, “Hey, I’m a conservative, but I’ll work with Democrats and we’ll try to solve problems together,” he basically creates a program like that in Massachusetts.
And it’s like this eureka moment. And it’s funny, when I went to sit down and write the book, I’ve always told the story, “Well, Massachusetts does this mandate, and then that becomes the model for the Affordable Care Act.” I never actually knew how important it was.
And it was amazing to me, reading the old memos, interviewing people, interviewing Obama about this, like, the first thing out of his mouth, I’m like, “So why did you?” And he’s like, “Well, we saw what worked in Massachusetts and we were all like, ‘Aha, we can do this’.”
And that becomes built into the Affordable Care Act. The funny thing is, and you reference this earlier, right, people forget that in the 2008 presidential campaign, Hillary Clinton, who was the front runner, who was like, all over health care ’cause she’d done the Clinton health care plan when her husband was president.
It was like, she had the mandate. And Obama was the one who instinctively said, “I’m actually not so sure that’s a good idea. I’m not so comfortable with the idea of telling people they have to get a product they might think is too expensive, and by the way, is it gonna work?”
And he gets eventually, once he’s in the White House, I think we can talk about Obama at some point. The great thing budget Obama and a sort of failing of Obama is he’s very much, you know, he’s a substance guy and he’s very much a part of the intellectual establishment, which was absolutely convinced you needed the mandate to make this thing work.
The Congressional Budget Office, whose projections were essential to passing the law, were convinced it worked. And so he ends up endorsing it. And meanwhile, of course, the second it becomes part of the Democratic plan, right all the Republicans who had, in some cases, like, weeks before, said, “We should have a mandate,” turn against it.
And it becomes the sort of symbol of everything that’s wrong with the Affordable Care Act. It becomes, you know, after it passes there’s the lawsuit challenging it. It barely survives because John Roberts, for reasons that only John Roberts will know, eventually decides he doesn’t wanna kill the whole law.
And meanwhile at the end of the day, as it happens, Republicans end up, when they can’t repeal under Trump, they fail to repeal the health care law as a whole, they decide to get rid of the mandate. And there’s lots of predictions that well, take away the mandate and the insurance markets will collapse.
And well, and they didn’t. In fact, it doesn’t seem like it had much impact at all. Now, there’s a really important asterisk. I don’t wanna talk about this forever, but like, there’s a very solid argument that if you hadn’t had the mandate in the first place, you know, you needed it at the beginning and then you don’t need it so much later. So we’ll see. But I definitely think at the end of the day, like, the amount of time we spent, clearly not as important as we all thought.
Chris Hayes: It was a central fight. It was a central fight in the debate, and then it was a central fight in the constructional plan, then the aftermath, then the lawsuits, then the tax repeal. And the whole argument, and like, every, this was, like, complete, like, this was wonk canon, okay?
You will get into a death spiral because here’s what will happen: young people, healthy people, won’t buy insurance because they’re not required to. They will be outside the risk pool. Their dollars of premiums won’t be going in to subsidize everyone else, which is the way insurance works.
The young and the healthy subsidize the old and the sick. You need the young and the healthy in the risk pool. If you don’t make them get into the risk pool then they’ll just not do it. And premiums will go up and you’ll enter a death spiral.
I mean, I can give you, I can cite chapter and verse of this. It was like the Our Father. Like, this was (LAUGH) taught to me. And it was total consensus. I mean, complete, just was not right. Like, it’s just amazing to me that the Republicans tried twice to repeal the popular parts of the ACA, which they cannot do because it would be so brutally terrible. They then repealed the least popular part in their tax bill. And, like, the ACA is fine. The insurance markets are fine, right?
Jonathan Cohn: Yup.
Chris Hayes: I mean, it didn’t actually have the, like, catastrophic consequences that were predicted for, like, ten years.
Jonathan Cohn: No, no, it didn’t. And, you know, it’s funny, you talk about, like, the sort of canon. You can go back and read my articles from then, I definitely was part of that canon, right? I mean, I wrote those articles.
Chris Hayes: Yes. Everyone was just, like–
Jonathan Cohn: We all were.
Chris Hayes: –I would tell people, like, with like, complete assured expertise, like, “Well, you see, the understand, the death spiral, and the.”
Jonathan Cohn: Well, and it’s funny, so I have thought a lot about this, and this is, like, a kind of meta media commentary. But like, the thinking, like, I tried, and writing the book, I tried to do a lot of self, “What did I get wrong? I got a lotta things wrong.”
But just in general how we cover policy, and I think actually this gets a little bit into some pandemic issues, I think it’s important, we need expertise. We need research. We want to listen to the research rather than just having people spout off.
But I think the right way to do that is to recognize that experts can be wrong. And especially when there’s an overwhelming expert consensus, you want to be able to kind of step outside that and say, “Are we missing something? Is this too simplistic?”
And I definitely think with all kinds of things associated with the Academic, and many other issues as well, there is a consensus sometimes that maybe is a little stronger than it ought to be. And we want reasonable questioning of it without going full to the other side of just saying, “Eh, expertise doesn’t matter. Science doesn’t matter.”
Chris Hayes: Well, yes. And this is terrain that I’m obsessed with, so I’ll just linger on this for a second. But I think that’s exactly right, that expert consensus is as much a sociological as an epistemic phenomenon. (LAUGH) And so you need to sort of look at it through both of those lenses.
And in things where there’s new data happening, and that’s why, like, I hate this sort of sledgehammer, like, trust the science or listen to the science. It’s like, science doesn’t tell us what policy should be. And experts can’t tell. Like, policy and politics is a human endeavor that involves value judgments and trade offs and different people’s estimations of what they value and what they do, and how to make the best of the compromises that life imposes on us.
And so it’s not enough to say, “Trust the experts,” because sometimes they’re wrong. It’s also, like, this nihilistic, “I’m gonna look for any COVID treatment that isn’t (LAUGH) being recommended by the experts, because then that has to be right,” is also obviously a road to madness. So threading that is difficult, but I just, I’m glad we lingered on this mandate question, because it’s a fascinating case study, I think, in expertise and in policy making consensus.
Jonathan Cohn: Yeah, yeah, no, I’ve thought a lot about this too, but like, I don’t know how to solve this problem. We’re in this very weird world where we do get an expert consensus that needs questioning. And yet at the same time we’re also awash, we’re in a weird world where because of social media everyone can find an expert to say almost anything–
Chris Hayes: Exactly.
Jonathan Cohn: And, like–
Chris Hayes: Yes, there are people in lab coats running around on YouTube saying, “Don’t take the vaccine.”
Jonathan Cohn: Yeah. I don’t know about you, but I find, like, if I follow any of these debates in the pandemic, or on any policy that happens on social media, there’s a sort of, everybody can cite arguments now, right? Everyone’s got their studies.
Chris Hayes: Yup, yup.
Jonathan Cohn: And it’s really hard if you’re not paying very close attention to be able to, like, tell–
Chris Hayes: Even if you’re paying (LAUGH) the closest attention. I mean, to me what it all comes down to, and this I think in some ways gets us back to Obama and the ACA is that I, and I said this before in the podcast, the quality that I used to think was most valuable when I was younger, when I was 15 years younger, was intelligence.
I was like, “Oh, so and so’s so smart.” And now I think that’s basically, like, neither here nor there. It’s probably necessary, but not sufficient. And what really matters more than anything is judgment and good judgment. And judgment is much rarer than intelligence, A, and B, not correlated with it.
There’s people who I don’t think necessarily would, like, get great grades or, like, bear out in traditional ways of measuring, quote unquote, “intelligence,” which again, is like, a super-contested term, but have great judgment. And there are incredibly smart people with wildly terrible judgment.
Those, in some ways, are the most dangerous (LAUGH) people in politics. Like, people who are super smart with bad judgment are just, like, a bomb waiting to go off. All of this to say that, like, judgment ends up being what matters a lot. And I think to go back to the sort of passage of the bill, there was a lot of judgment calls being made all the time that are different trade offs that are happening. And I’m curious, as you think about it now, particularly as we’re looking at this possible reconciliation bill and this really big, ambitious social welfare agenda, like, what the big lessons you have from that ACA fight are.
Jonathan Cohn: Yeah. So there were a lotta judgment calls. And I always sort of premise this by saying I think they got a lot wrong. I also think they got a lot right. I mean, I think any discussion of the ACA has to start with the fact that Democrats are trying to pass something like this for decades.
And the fact that they got anything done suggests just on its face they made a lot of right calls. They made a lot of wrong calls, but at the end of the day that was really hard to pull off. And we don’t need to go into stories, but you know, like, I just think you were talking about judgment, there was some very good judgment by a bunch of seasoned people in Congress and the White House who, at the end of the day, got it over the line.
Obviously time matters. This is, interestingly enough, a lesson that Republicans learned maybe a little too well. But you don’t want to linger. And this was a thing they knew going in, right? I mean, one of the ongoing narratives of the ACA fight is Rahm Emanuel pushing faster and faster, we can’t wait, we can’t wait, this has to get done.
And the negotiations are just dragging out constantly through the Senate Finance Committee, and something that they had hoped to get done by the fall is no dragging into January. And uh oh, we lost the Senate seat from Ted Kennedy. So time obviously matters.
The flip side is it’s hard to imagine a scenario where that works, where given the Congress they had, and for various reasons, they could’ve gone that much faster. So, I mean, but speed helps if you can do it. I do feel like, at the same time, it also shows the importance of actually taking policy seriously.
Democrats spent ten years preparing for that moment, right? I mean, they had done all the sort of really un-glamorous, quiet policy organizing work to get, you know, to get the coalitions built, to work out the policies so that when Obama got elected and they had the majority, they were ready to go.
I think the failure to do that is a huge reason why Republicans failed in 2017. They hadn’t done any of that work. You know, they just figured they could kind of one off it ’cause they didn’t take it seriously. They hadn’t done it. You know, I tell the story of Jeanne Lambrew, who was, like, one of the key Obama advisors who predicted the day Trump was elected, she was one of the few people who said, “They will not succeed in repealing this because they don’t know what they’re getting into. They haven’t prepared for it.”
And I think you see the virtues of that now in the reconciliation bill, because all these different pieces of legislation that they’re trying to move very quickly, and we’ll see how quickly they can actually move them, similar process.
I mean, you know, the childcare bill was the result of years of organizing and discussions among people who focus on this. There’s a bill that I’ve been writing a lot about to improve home and community-based care, which is basically the things that let people who are disabled or elderly stay at home and not in institutions.
They’ve been working on that for years. And so they’re ready to go. I do feel like, I mean, I’ve said before I think in some ways I feel like the story of the Affordable Care Act, and hopefully my book captures this, is a case study in the country becoming ungovernable.
Chris Hayes: Right.
Jonathan Cohn: And a really big part of that is the institutional problems of the United States Senate and the filibuster. To me, I don’t see how you come out of the ACA experience not absolutely convinced that the very first thing you do when you get into office is you get rid of the filibuster.
Democrats have not done that yet. Obviously I know why. I mean, that’s because you need them all to agree with it. They only have 50 votes. But to me, that is a lesson that was not learned because the filibuster is still there, and we see that right now, the effects of that, what they are able to do, what they are not able to do. And I feel like as long as the filibuster is in place, Democrats, and I’ll use your analogy, are fighting with one arm tied behind their back, carrying around a weight. Just, it is this huge obstacle to change, and it is still there.
Chris Hayes: Yeah, and I think that the thing that you capture really well in the book is that the ACA represents a sort of new form of legislating and legislative combat in the era of sort of increasing polarization, with our old institutions.
Whereas, you know, in previous big, domestic battles, like, which is not to say that there was ever anything other than politics and partisan politics, go back and read about, (LAUGH) you know, I mean, even the New Deal. Like, go back and read the newspaper at the time.
Like, there’s Republicans saying that FDR’s a socialist and they hate the alphabet soup of agencies and the government bureaucrats. But the way that Congress worked, and legislating worked, and regular order worked, and committee systems worked meant that there were institutional prerogatives that dominated partisan ones at various points of the legislative process.
And I think the ACA was the first one of these where we saw those all fall to the gravity of the partisan polarization strength. And they went into it thinking they were dealing with the old model, and coming out the other side of the other model.
So it was like, “We’re gonna go through regular order and we’re gonna have these committee hearings and we’re gonna make these deals in the committee.” And you saw this. You know, another great example is the January 6th Commission, where they did that (LAUGH) on the January 6th Commission where the Homeland Security, Benny Thompson and John Katko, who’s the ranking member, they worked out this old school deal where they traded horses and came up with compromises.
And then it was like, “No, we’re not doing that. Like, we’re Republicans, go eff yourself, we’re (LAUGH) not voting for that.” And so that, to me, is the really interesting thing about the ACA from a kind of, like, institutional legislative history standpoint, is that they went in thinking they were dealing with one kind of legislating model and they came out on the other end basically having to, like, run it on a party line vote.
And now everyone understands that that’s how these things are gonna work. Republicans, when they were gonna repeal the ACA, never had any illusion that they were gonna get any Democratic votes for it. And I think on reconciliation you’re seeing that. Like, they understand that we’re gonna do it, it’s gonna be 50 Democratic votes plus Kamala Harris.
Jonathan Cohn: Yup, yup. No, I mean, I’ve actually been, I do think to my surprise, Democrats, even Joe Manchin seem to get that.
Chris Hayes: Yes, that would be my point, exactly. He has his own predilections about the institutional structure, but I don’t think he has, like, they did the bipartisan bill, which is great. But I don’t think he has any illusions about the reconciliation part of it. Like, that’s just gonna be 50 Democratic votes if it passes at whatever size it does.
Jonathan Cohn: Yeah, yeah, no, I mean, they get that. And I think there was genuine shock. I mean, Obama, his advisors, you know, Phil Schiliro, people like that who was one of his legislative counselors, Harry Reid, Nancy Pelosi, none of them thought they were gonna be getting a ton. I mean, you know, I don’t think any of them ever thought they were gonna pass something with, like, 80 votes and 20 Republicans signing on–
Chris Hayes: Right, right.
Jonathan Cohn: They thought they’d get two or three. And originally they had to, right, because they were doing regular order and they only had 58 Democrats. And there was genuine shock that they could not do that. And I do feel like the sort of learning process of 2009 was oh, this world is not the world we thought we had.
We are operating in a whole different set of premises now. And I think even some Republicans were surprised by that. I mean, I do think, and this is where I feel like the sort of toxic mix of social media and right wing money really kind of contributed to sort of sending the Republican Party in particular off the rails.
But I continued, I was struck a lot talking to Republicans, I’m very happy a lot of Republicans talked to me for the book. And I think even among the Republicans who fought the ACA when it was being debated, I think a lotta them, the older ones, thought okay, we had the fight, we’ll gin up the base for a little while with it, but two or three years, we’ll move on to something else.
And of course they didn’t. And part of that was, and they thought that because they figured, well, we’re gonna wanna get back to our normal governing, doing pork for our districts or whatever, doing our projects that we care about and cutting taxes when we wanna cut taxes.
And they figured there was still some of that old school style of governing going on. And they figured that because that’s who was in charge of the party. But it quickly became apparent that they were no longer in control, right, and that the Michele Bachmanns of the world and the Jim DeMints of the world. And it was just so striking to me that the people who were defining where the Republican Party stood were these very new, very junior members of Congress who, 20-30 years ago, no one would’ve ever heard of.
Chris Hayes: Yeah, right, exactly.
Jonathan Cohn: And now they’re driving the debate because they know how to work the system. They know how to work social media. They understand the currency now. It isn’t get dollars for your district, it’s getting donations, getting you on Hannity, getting the big retweets and all that. I feel like that world changed, even in ways that surprised a lot of Republicans.
Chris Hayes: I wanna talk about repeal and why repeal failed, because that I think is also a really crucial lesson, right after we take this break.
Chris Hayes: So they try to repeal Obamacare twice, failed both times. And what I always think about is so insane when people make these arguments against the filibuster, like Sinema, Manchin, it’s like, “Well, how would you like it if the Republicans just came in and tried to undo this stuff?”
Chris Hayes: It’s like, we literally just lived through that. Like, what are you talking about? Like, am I high? Am I losing my mind? I think I covered that. They tried to repeal the ACA with 50 votes. What kind of universe is it where you need 60 votes to pass the ACA but only 50 to repeal it? How is that (LAUGH) a friend of progress? And yet, even though they went through reconciliation, even though they only had to get 50 votes and they had a few votes to spare, they failed. Why did they fail–
Jonathan Cohn: Yeah. So, I mean, there’s a lot of reasons that they failed. I think among the reasons they failed, number one as we said before, policy’s hard. Legislation is hard. It inevitably involves taking your big ideals, your big slogans, and translating them into actual legislative language and then modifying that language to deal with the bazillion people who have a stake in it who are gonna wanna change it, right?
I mean, that is a difficult process to do. It takes years of work. Democrats had done that work. Republicans never did. They are not a policy party anymore. You know, in the book I quote a bunch of Republicans on the record saying, “Yeah, we don’t care about policy anymore. We just don’t do that.” (LAUGH)
Regrettably, because I was talking mostly to the ones, the narrow, the small few who actually did care about policy. So that’s one part of it. Second, though, I think fundamentally if they had done that work, right, if they had done the homework, they would have quickly discovered that the idea of repeal, which was driven very much by this Koch brothers, right wing, government is bad, let the market, was just fundamentally unpopular.
That actually, for all of the problems of Obamacare, and there are lots of problems, and lots of people were not happy with the insurance they ended up with afterwards. But for all of that, there were many parts of the law that people valued.
And there were a lotta people getting coverage. And I think this is an important point. I think the Republicans in Congress who were so enthusiastic, who thought this would be so easy, were high on their own supply. They watched Fox News. They read, right?
And you go back through the clips. You go back through the articles. There is almost nothing in the right wing media about people who were happy, who were benefiting from the ACA. I mean, I remember, you know, with the fiasco when the website crashed. And that was bad, right? I mean, I actually think that’s as close as it came, along with the Supreme Court case, to really unraveling.
And they came back, they fixed it, and they got these very big sign ups. And, like, Fox News didn’t even cover it, right? I mean, it’s just not a news item. You know, uninsured rate plummets to the lowest level ever. And so I think, I mean, you talked to these conservative members of Congress, they genuinely had no idea there were people out there who cared about this, (LAUGH) who– benefiting from it.
And so when they go out to their town hall meetings in 2017, and they get hit in the face with these protests, which are this kind of mirror, bizarro image of the Tea Party protests of 2010, only now it’s, like, people with disabilities coming out and saying, “Hey, you know, you’re gonna take away my Medicaid. You know, you’re gonna take away my guarantee of health insurance.
And people were angry about this. They were genuinely shocked. They had no idea people were gonna care about this. And the reality was that the law had done a lot of good, for all of its problems, and Republicans, you remember, this is really important. Donald Trump didn’t say, “I’m gonna take away the ACA and leave you with nothing.” His line was, “I’m gonna take away the ACA and give you great health care in return. Everyone’s gonna have insurance.”
Chris Hayes: Yes. (LAUGH)
Jonathan Cohn: And the thing is they did not have a better idea. They had no ideas. And it came back to haunt them.
Chris Hayes: So the big question for me now is there was a huge debate about single payer, Medicare for all in the Democratic primary. There is zero appetite (LAUGH) among the Democratic establishment, the sort of professional class of Democrats, even people that believe in single payer, for that fight.
And I don’t think it’s crazy. I mean, I might disagree with them, but I also think that, like, political capital’s fairly fixed, and there’s a lotta things, and I think in the end I would prioritize climate to spend that political capital, just because there’s a time ticking on that.
But I do wonder, like, okay, let’s say that we’re not going to in the near future pass a big, sweeping bill that says the age of Medicare eligibility is now zero, you know, one day old, and everyone is in Medicare. What are the ways to make the ACA better that both make it better but also move us towards something that is closer to single payer? Like, that to me seems the reform sweet spot. And I’m curious if you could talk about what that space looks like.
Jonathan Cohn: Yeah, yeah. Oh, I think that’s exactly right. I think it makes sense to think of Medicare for all, at least for purposes of this discussion, right, not as a single idea but a sort of set of tools or a set of principles. And you wanna move closer to that any way you can.
So anything you do should move you closer to one of those principles. So what are, like, the defining characteristics of a Medicare for all system? Well, health care is almost free at the point of service, by which I mean when you go to the doctor or you get a prescription, you are either paying nothing or just a really token amount.
Like, maybe you pay a little couple bucks extra to the pharmacist if you want a brand name drug than a generic drug. Maybe not even that, I don’t know. So that’s one thing. So the insurance should be very generous. The payment for this insurance, whether it’s taxes or premiums, should be structured in a way that everybody can afford it easily.
So that’s some kind of progressive structure. And it should be simple. It should not be this complicated. It should be simple to use. It should be simple for the patient. It should be simple for the providers. I mean, providers, we can have a whole conversation about what’s good and bad about the medical profession, whatever.
But the reality is our providers spend way too much time on the phone with insurance company bureaucrats. I just think that’s true. So you want it to be simpler, and you need cost control, right? You need some kind of, and I feel like this is one of the big lessons and a case where there was an expert consensus, that actually now the consensus is starting to change, which was for the longest time not just conservatives, but really the kind of center-left economists who drove democratic party thinking were like, “We can’t control prices. We can’t have government setting prices. We’re just gonna have the market competition. That will get the cost of medicine down.”
And you even now hear people who are still I would consider the center-left economist types, who are pretty much like, “Yeah, you know what? Every other country they basically either set an overall budget or they fix the prices for procedures and equipment, and maybe we should do the same.”
Chris Hayes: It’s interesting you say that, because that, to me, I think prices have this sort of totemic power under the old ideology, (LAUGH) right, that like, prices are how you ration scarce goods. And when you take microeconomics in college it’s often just called Price Theory.
The price is the signal point of information that matches supply to demand, and it rations the scarce goods in the maximally efficient way. That’s what a price does, right? It gives the people information. And the bad old system was government setting prices. You don’t want wage and price control, that’s all this nonsense that we’ve left behind in the dark ages.
Jonathan Cohn: When Nixon was doing it.
Chris Hayes: That’s right, yes, of course. I totally (LAUGH) agree that that has lost its taboo stigma. And you do see more people saying, “Well wait, in the Netherlands or whatever they just say, like, this is what a knee replacement (LAUGH) costs.” It’s not like, you know, you’re not at a bazaar figuring out, like, what different people are charging for copper. You just, you set the price.
Jonathan Cohn: Yeah, yeah, and it’s not like everyone’s walking around unable to walk in the Netherlands, right? They get good health care– (LAUGH)
Chris Hayes: Right, yeah.
Jonathan Cohn: –in the Netherlands. They get really good health care. Yeah, so to me you wanna be finding ways that move you along those dimensions, right, that move you forward, and ideally while delivering immediate benefit. So how do you do that? Well, pretty much everything on the Democratic agenda right now, not coincidentally, and there’s a bunch of different health care ideas in this reconciliation bill.
A lot of it, right, it’s a pretty big package, does that one way or another. So what are we talking about? So I mean one thing we’re talking about doing, as part of the COVID relief package they made the ACA more generous, which frankly was basically making up for the compromises they made to pass the bill back in 2009 and 2010. I mean, the biggest single problem with the ACA was it was underfunded, right? Is that it–
Chris Hayes: Yes. This is something people don’t understand. In order to make the bill more centrist and to get the CBO score, they reduced the subsidies, which meant that it just was more expensive for families than it ever should’ve been. And a lot of the things that people didn’t like about the ACA was that they were paying a lotta money for not great insurance, which could’ve been fixed (LAUGH) by just making the subsidies bigger.
Jonathan Cohn: Single biggest thing they could have changed that would have made a difference, in my mind. And that was all political. That was all about the getting the votes they needed to get to pass it.
Chris Hayes: But weirdly, let me just say, political in an interesting sense. It was political in the sense that the thing they needed for the votes was a CBO score about the budget. But it was the opposite of political in a deeper sense, which is if you just, like, again, you come from Mars, (LAUGH) okay, and you say, “Do you think people will like this program more if they pay more money for health insurance or less money for health insurance?” Like, that’s not a hard political question, guys, at all.
Jonathan Cohn: No, no, no, it’s not–
Chris Hayes: The answer is less. And yet the political adjustments they made (LAUGH) was to make it more expensive to get the votes to bring the moderates on board.
Jonathan Cohn: And I think that gets to, kind of we’re seeing a little bit of that with the reconciliation debate now. It’s a very similar debate of what you just described as the debate, right, that the debate should be what makes health care less expensive for the consumer.
Clearly to those of us who, like, you know, think about this, right, that’s obviously what you should be focused on. But in 2009-2010, for a variety of reasons, there was all this concern the bill was too big, the number was too high, it had to stay under $1 trillion.
And getting that thing under $1 trillion required pulling back on things that would’ve made health care more affordable. And I say, it should echo now, right, because here we are, debating this reconciliation bill. And what is it that we’re hearing from Joe Manchin and Kyrsten Sinema and some others, “The bill’s too big. $3.5 trillion is too big.”
And actually Manchin’s, like, relatively speaking if you’re a Democratic leader, much easier to work with than, say, Joe Lieberman was. But still, that’s the thing we’re dealing with. So, you know, adding, making those subsidies more generous so that the insurance is more affordable to me is an example of something where you are making the ACA work better.
Coverage is more affordable. More people got insurance. We’re seeing the sign up numbers go up. And yet at the same time, if the baseline of coverage is assumed to be more generous, then it’s that much closer to the ideal of Medicare for all.
Chris Hayes: But it’s also, like, then there’s also the cost question, right, which to me remains the crazy thing, right? Like, we’re still just spending, we’re just devoting a percentage of our GDP to health care that no other OECD country does, not for better outcome.
So it’s like we’ve taken the system, we’ve extended it, we’re putting more money into it to make it more accessible for folks. Medicaid expansion is coming to state after state. There’s still some holdouts. I think ultimately they will fall.
But at the end of the day, you’ve got a system that’s better, it’s more comprehensive, it’s more standardized, and it’s more regulated, and yet it’s still doing this thing that makes us this insane outlier. It’s like a much more humane version of this Rube Goldberg machine, but it’s still (LAUGH) this Rube Goldberg machine that just doesn’t scan. We spend so much more than any other country for basically either roughly the same or inferior outcomes at a population level. And what do we do about that?
Jonathan Cohn: So, I mean, I think the obvious answer is you go back to what we used to dismiss for a long, long time, this old fashioned idea of the government setting budgets, the government controlling the cost by brute force, which is exactly what every other country does.
Japan, Germany, France the Netherlands, Sweden, pick the country, every one of their health care systems has their pluses and minuses, but in general they spend a lot less than we do, they get results that are comparable, better in some ways, worse in other ways.
So that is where you wanna get. Now, look, I mean, politically how do we do that? That’s hard. I mean, that’s what was hard about the Affordable Care Act. I mean, I’ve been thinking a lot about comparing the Affordable Care Act to the reconciliation bill, and how you compare the two in terms of their impact and the challenge.
And you look at the numbers involved, right? The reconciliation bill is bigger, right? Just dollar size. And if everything in that bill becomes, it’s bigger than the Affordable Care Act. But one reason that I think they might be able to do that and they weren’t before is that it’s not, like, trying to tear down anything. It’s not trying to take money out of anyone’s pockets, except rich people who would have to pay more taxes, and that is a limiting factor.
Chris Hayes: But it’s not nothing. (LAUGH)
Jonathan Cohn: It’s not nothing, as we’re seeing. It’s a big thing. But controlling costs inevitably involves taking money away from the health care industry. The health care industry is super powerful. And it’s not just the drug industry which, by the way, is probably the easiest.
I would actually say ironically, because they’re sort of, people are used to sort of demonizing drug companies, like, you can build a political argument polling ideas on controlling drug costs. That always polls really well. Where it gets hard is, like, so much of the money is in hospitals.
You know, it’s like we pay too much for hospitals. The thing is, hospitals don’t push back by saying, “Don’t take our income away.” Hospitals push back by putting on stories, “Hey, we’re gonna have to close the trauma room in your neighborhood.” The board of every hospital is, like, the brother or neighbor or close friend of a member of Congress. And they’re huge employers.
Chris Hayes: Hospitals are like car dealerships. Everyone’s (LAUGH) got one in their district, or multiple ones.
Jonathan Cohn: Yup. Every one–
Chris Hayes: Like, and just hospitals have a lotta power on–
Jonathan Cohn: Yeah–
Chris Hayes: –Capitol Hill.
Jonathan Cohn: Yeah. I don’t have a magic bullet on this. I will say this, I do think that it’s a long-term process like these things often are. I think all the publicity we’ve gotten about surprise billing, inconsistent billing, and I’m thinking a lot of this is in the media.
So people like Sarah Kliff at the New York Times, Elisabeth Rosenthal, who runs Kaiser Health News, used to be at the Times, wrote a great book on this. I mean, Steven Brill’s book. All this sort of attention, the more people realize that our pricing system is crazy, which it is, the harder it becomes for the hospital industry to defend that.
And it’s a similar story, I mean, there’s different versions of that for every part of the health care industry. I just think it’s a difficult thing to do in one shot. Maybe it could happen. Maybe Bernie Sanders or AOC becomes president in eight years on a campaign to do Medicare for all, and the Democratic majorities, and they push it through, and it just happens. But I do think it’s just, it’s gonna take time because that is the hardest part of health care, because you’re taking money out of the pockets of industries that have a whole lot of influence and a whole lotta power.
Chris Hayes: Do you think this is now the way that we’re gonna legislate in the sort of near-medium term? I mean, reconciliation in some ways is fascinating because it’s a sort of apotheosis of this, which is like, I increasingly think that basically what will happen now is if you get a trifecta, (LAUGH) you’re gonna just pass one or two reconciliation bills.
And they will be these sorta placeholders for everything that you can get in there, whatever your priorities are. I think Republicans it’ll basically be tax cuts. It’s harder to do some of the other things they wanna do, but that’s really all they care about.
And that’s what the post-ACA process looks like. Everything else is kind of dead now because of these institutional bottlenecks. And so we’re gonna have increasingly this, like, narrow, partisan votes on big priorities under unified government that don’t even try to go through the pretend period of the negotiation.
Jonathan Cohn: Yeah, I think so. And I have very mixed feelings about that. I have mixed feelings about it. Like, I don’t think that’s a particularly–
Chris Hayes: Yeah, me too.
Jonathan Cohn: –good way to govern. I mean–
Chris Hayes: No, it’s not a great way to legislate. No, I agree–
Jonathan Cohn: It’s not. I mean, I always sorta say, like, the long committee process at the ACA had a lot of virtue to it. I mean, some of it was politically necessary, but also just working through the arguments, I mean, there’s value to that. It has its pluses and minuses.
I don’t think it’s ideal to be doing this all the way that we’re doing it right now. I mean, there’s so much we’re gonna try to do in the next few weeks. It’s just, it’s a lotta policy. I think Democrats, to their credit, as we were discussing before, they’ve spent a lotta time figuring this out.
And the reality is we do have bipartisan government now. We have a bipartisan government that’s the liberal wing of the Democratic Party and the conservative wing of the Democratic Party. Because the Republican Party doesn’t care about policy, right? So I mean, that’s–
Chris Hayes: Right. (LAUGH)
Jonathan Cohn: –bipartisanship. But this is not ideal, and it’s the way it has to be because the system is so fundamentally broken. But it shouldn’t be broken like this. There’s a reason we have a committee structure, right? There’s expertise. There’s a value to having hearings and working through these things.
I think also the more there’s this expectation that this one bill has to do everything that kind of things get loaded up on it. I just don’t feel like this is a particularly good way to govern. But as long as the filibuster’s in place I don’t know that there’s gonna be an alternative.
And frankly, the filibuster is harder on Democrats because of the way the Senate distributes its seats and the way political geography looks today. And that’s a whole other conversation. That’s another institutional factor that needs to be addressed.
Chris Hayes: You talked to Obama for this book, and he appears in the book on the record. I’m just curious what that conversation was like and what you feel like came through in terms of how he sees it.
Jonathan Cohn: Yeah. So I mean, sort of stylistically, and I’m sure you’ve observed this too, right, I’m always struck by the fact that the man speaks in the longest sentences I’ve ever heard in my life. Like, he stuffs more dependent clauses into one period.
Chris Hayes: They’re also so insanely hedged and calibrated.
Jonathan Cohn: Yes.
Chris Hayes: He doesn’t wanna make news, and he’s sort of one step ahead of you and his critics by then, like, anticipating and rebutting a critical interjection in the middle of a sentence (LAUGH) kinda thing–
Jonathan Cohn: Right, right, right, right. And right, it’s both, like, sort of his strength and his weakness. It’s what’s good and bad. You like that he’s so thoughtful and you hate that it’s, like, so hedged, and whatever. So it struck me that he had certainly learned the lessons of the ACA, right? I mean, he was fairly candid about that, I thought.
Chris Hayes: Yeah, he has, yeah–
Jonathan Cohn: It struck me that number one, I think he is someone who’s sort of being, his whole existence, like, his premise on the idea that you can have an adult conversation, and that there are reasonable people even who you disagree with who basically share your values and will be committed to some notion of the public interest.
And I think it still shocks him that that didn’t turn out to be the case. You know, it’s funny, whenever I’ve heard him talk about the ACA, and when we talked about it, the thing that bothers him the most, right, is that Republican governors and Republican state officials not expanding Medicaid.
And that’s just, like, it’s like it doesn’t compute. He’s like, “I don’t get that. Like, this is easy for them. They can say they’re doing it for their business community. And it’s just, it’s basically almost free money to help their people, and they won’t do it.”
And I think that just, like, it upsets him in a way that I get. And I think he’s learned that lesson. And I think he has come around. He will tell you, “We don’t live in the world we used to live in.” And he also, I think, made a very important point was that how the process of reform, he realizes, much more than he did, doesn’t stop when you sign the bill, right, that so much hinges on what happens afterwards. And then in the past, no matter how intense that fight was, you could count on some measure of good faith implementation from the other side–
Chris Hayes: Yes.
Jonathan Cohn: And he had this quote, and I don’t remember it word for word, you’re never gonna get this thing right on the first draft. There’s always gonna be things you need to modify. There’s always gonna be things you need to tinker with. And the inability to do that makes it so much harder.
But they couldn’t do that. There was no peace to be had. Even Republicans, I mean, the Republicans, you know, you talk to people who work around, like, Charles Grassley who’s who’s been around for a long time and had a lotta sorta senior health staffers, who kind of they were throwbacks to the age when, like, some Democrats supported the Medicare drug benefit, and they did HIPAA together, and CHIP.
And they were surprised that when they tried to bring up things that had nothing to do with politics, just routine fixes to make the system work better, the Republican Party would not go there. And that process makes it really hard to govern. And again, I think this gets back to the government is broken, and this is a problem.
Chris Hayes: Jonathan Cohn covers health care, policy, and politics at Huffington Post. He’s author of a great new book, The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage. Jonathan, that was great. Thanks so much.
Jonathan Cohn: Thank you.
Chris Hayes: Once again, great thanks to Jonathan Cohn. You should definitely check out the book The Ten Year War. You can tweet us with the hashtag #WITHpod, email WITHpod@gmail.com. “Why Is This Happening?” is presented by MSNBC and NBC News, produced by the All In team and features music by Eddie Cooper. You can see more of our work, including links to things we mentioned here, by going to NBCnews.com/WhyIsThisHappening.
Tweet us with the hashtag #WITHpod, email WITHpod@gmail.com. “Why Is This Happening?” is presented by MSNBC and NBC News, produced by the “All In” team and features music by Eddie Cooper. You can see more of our work, including links to things we mentioned here, by going to nbcnews.com/whyisthishappening.