ACA defenders don't need to "learn from" the Tea Party. They beat them in 2009-10

The fight to save the ACA is on, and all across the land, progressive groups large and small are mobilizing the law's supporters to let their senators and reps know the cost of dis-insuring 20 million people -- more, if Republicans block-grant Medicaid and/or collapse the individual market, less if they pass some poorly funded and designed facsimile of the ACA.

In reaction to the 35 "protect our care" rallies staged across the land on Sunday (Jan. 15), I keep seeing sentiments to the effect of  "progressives are learning from the Tea Party."  That's a half-truth at best, in that supporters of the ACA-in-progress fought protestors at least to a draw in 2009-2010 (proponents won in the sense that they got the ACA passed, but they did (briefly) have a 60-vote Senate majority and a large House majority). The ACA would never have got anywhere near the finish line without the most massive grass-roots advocacy ever achieved.

The Tea Party protests against the ACA-in-progress at Town Hall meetings in the long hot summer of 2009 have become part of American political lore. What’s less well known is that progressive groups supporting health reform fought back on the spot, often with equal or superior manpower and local impact. The media preferred the screamers, of course.

There was a massive coordinated effort led by Health Care for American Now (HCAN), an umbrella organization for groups committed to universal healthcare, formed in the runup to the 2008 election. Member groups’ ability to muster supporters provided vital support that kept many representatives and senators committed to passing the bill that became the ACA.

In which Obama feels the pain of the price tag he imposed on the ACA

In an interview with Jonathan Chait, President Obama rather casually ticked off his first priority for shoring up the ACA:

In my mind the [Affordable Care Act] has been a huge success, but it’s got real problems. They’re eminently fixable problems in terms of strengthening the marketplace, improving the subsidies so more folks can get it, making sure everybody has Medicaid who was qualified under the original legislation, doing more on the cost containment. But you hit a point where if Congress just is not willing to make any constructive modifications and it’s all political football, then you’re getting a suboptimal solution. 

By now, the imperative to enrich the marketplace subsidies is a matter of consensus among progressive healthcare scholars and officials. Out-of-pocket costs are just too high for prospective enrollees with incomes over 200% of the Federal Poverty Level (FPL)*, the cutoff for strong Cost Sharing Reduction (CSR) subsidies, and premium subsidies leave buyers paying too high a percentage of their income -- between 6.4% and 9.7% of income for those in the 200-400% FPL range. In August 2015, Urban Institute scholars Linda Blumberg and John Holahan put out a detailed proposal for subsidy enrichment that included raising the actuarial value of the benchmark plan to 80% from the current 70% , with richer CSR extending further up the income ladder, as well as capping premiums at 8.5% of income for all income levels. Hillary Clinton's rather vague proposal for subsidy enrichment is apparently based on Blumberg and Holahan's. ACA improvement proposals by Timothy Jost and Harold Pollack and Sabrina Corlette and Jack Hoadley also prominently feature subsidy boosts.

The inadequacy of marketplace subsidies was evident to progressives from the beginning. Complaints began when Max Baucus's Senate Finance Committee released its bill in fall 2009, with a subsidy schedule that was far skimpier than that of the House bill.** In his 2011 book about the battle to pass the ACA, Richard Kirsch, national campaign manager from 2008-12 for Health Care for America Now (HCAN), an  umbrella group formed by unions and progressive nonprofits to advocate for universal health care, pins responsibility for the skimpy subsidies primarily on Obama:

What if a public option were added to the ACA marketplace now?

Aetna's sudden sharp cutback in its participation in the ACA marketplace has renewed discussion of how the marketplace might be stabilized. The most obvious fix is to boost the subsidies and thus lower subsidized  enrollees' premiums and out-of-pocket costs. At present, Kaiser estimates that about 64% of people eligible for subsidies are enrolled in marketplace coverage. Many of the subsidy-eligible uninsured find the offered coverage unaffordable. If the marketplace were attracting 90% of those eligible the risk pools would be much deeper. That would in turn moderate the pending price hikes for the unsubsidized.

The premium hikes and large-insurer pullbacks have also renewed calls to create the public option -- a government-run plan competing on equal terms with private insurers in the marketplace. In the runup to the ACA's passage, progressives regarded the public option as a linchpin, an essential means of keeping private insurers from price-gouging. Its absence from the final bill was regarded as a major defeat.

What would be the likely effects of adding a national public option now, if it were politically possible? A few points:

1. Before risk adjustment and reinsurance are factored in, ACA-compliant plans were calculated to have paid out an average 110% of premiums collected in medical claims in 2014 and, for  the entire individual market 4th-largest health insurer HCSC* in 2015,, 117% .  Those negative loss ratios have driven average weighted average premium increases of 24% this year (though the increases will likely prove lower for the plans most people will buy). Those losses have led to exits and pullbacks that, according to Avalere Health, will leave 55% of rating areas nationally with two or fewer competitors (though that number disproportionately includes low-population areas, and so most buyers will probably have more choices).  In many regions, if a public option managed to significantly underprice the competition, it might well become the only option.

Yes We HCAN, sort of: Richard Kirsch's blow-by-blow account of the grassroots battle for health reform

I have been picking my Twitter-induced-ADHD-addled way through Richard Kirsch's Fighting for Our Health: The Epic Battle to Make Health Care a Right in the United States, published in 2012. Kirsch, a lifelong public action exec trained by Ralph Nader, was national campaign manager from 2008-12 for Health Care for America Now (HCAN), a massive umbrella group formed by unions and progressive nonprofits to advocate for universal health care. The book is a blow-by-blow account of the organizing and lobbying efforts that built support for the ACA and pushed it over the finsih line.

This is one of those blog-as-you-read posts, which you could make a case against, but which I enjoy doing as a book pulls me in various directions. I'm on vacation this week and will not trouble myself with excerpts. So far (I'm a bit more than halfway through), the two themes dominate:

o The ACA would not have been possible without massive, coordinated grassroots organizing -- meeting constantly with congressional reps, recruiting people who suffered for lack of health insurance access to tell their stories, raising large numbers of demonstrators to counter the Tea Party at Town Halls, calibrating support for and pressure on wavering reps, etc.

o Squishiness on the public option on the part of Obama and the Democratic Party as a whole was a self-inflicted wound that gravely weakened reform. I do not entirely buy into this, and I have much more yet to read about how that fight played out. That said, a few takeaways and preliminary thoughts:

1. The Tea Party's hysterical, misinformation-fueled, rage-filled hijackings of congressional reps' town hall meetings focused on health care in the summer of 2009 anticipate the Trump rallies of today -- with reps shouted down and drowned out by chants, disabled citizens testifying about their health care struggles booed off the stage, posters of Obama with a Hitler mustache, and equations of end-of-life counseling with genocide.  The funding of these oppo efforts by the Kochs' Americans for Prosperity trace a line from hardcore ideological libertarianism to Trumpian fascism, the common denominator being the sabotage of fact-based discourse.