Joe Biden’s Obamacare Gaffe Points to a Larger Truth

In Iowa just before the New Year, former Vice President Joe Biden had an interesting response to a voter’s concerns about Obamacare. The voter said his father had lost his coverage when the law’s major provisions took effect in 2014, and the “replacement” plans proved far more expensive. Asked to apologize for what PolitiFact dubbed its “Lie of the Year” for 2013—that “If you like your plan, you can keep it”—Biden demurred by claiming the following:

There’s two ways people know when something is important. One, when it’s so clear when it’s passed that everybody understands it. And no one did understand Obamacare, including the way it was rolled out. And the gentleman’s right—he said you could keep your doctor if you wanted to, and you couldn’t keep your doctor if you wanted to, necessarily. He’s dead right about that.

On its face, Biden’s comments initially resemble House Speaker Nancy Pelosi’s “We have to pass the bill so that you can find out what is in it” gaffe. But in reality, they hint at a larger truth: the federal government has gotten so big and sprawling, nobody really understands it.

Pelosi’s ‘Kinsley Gaffe’

Just before Obamacare’s passage in March 2010, Pelosi made comments that conservatives have parodied for most of the ten years since:

Upon closer inspection, though, her comments centered on the political messaging about the law, rather than the underlying policy. She prefaced her infamous quote by noting that “You’ve heard about the controversies within the bill, the process about the bill.”

But in Pelosi’s view, the American people had not heard about the substance of the bill itself: “I don’t know if you have heard that it is legislation for the future.” She went on to talk a bit about preventive care measures contained in Obamacare, which in her view would lower health-care costs. She then gave her infamous quote about passing the bill “so that you can find out what is in it, away from the fog of the controversy.”

Pelosi’s statement still seems extraordinary. She admitted that, even with Barack Obama—who won the presidency in fair measure through his rhetoric—in the White House, more than 250 Democrats in the House, and 60 Democrats in the Senate, Obamacare had proven a political failure. Democrats had lost the messaging battle in 2009 and 2010, and could only hope that enacting the legislation and allowing Americans to see its purported benefits could turn the dynamic around.

But Pelosi’s comments said “we have to pass the bill so that you can find out what is in it”—emphasis on the second person. She still claimed to know the contents of the legislation, contra the recent claims of the vice president at the time.

So Much for ‘Experts’

On one level, Biden’s comments echoed Pelosi’s. He talked about “the way it was rolled out”—a likely reference to the messaging battles of 2009-10, the “debacle” of the exchange launch in late 2013, or a combination of the two.

But unlike Pelosi—who said the public didn’t understand Obamacare—Biden said that “no one did understand Obamacare.” One wonders whether the statement meant to inoculate Obama from accepting blame for his “like your plan” rhetoric, even though Obama himself apologized for misleading the public on the issue in late 2013.

Regardless, Biden’s rhetoric echoes the example of Max Baucus, at the time the chairman of the Senate Finance Committee. Asked shortly after the legislation passed whether he had read Obamacare prior to its enactment, he responded that “I don’t think you want me to waste my time to read every single word of that health care bill,” because “we hire experts” who are the only people who “know what the heck it is:”

Except that four years later, one of those “experts” who worked on Baucus’ staff at the time, Yvette Fontenot, admitted that when drafting Obamacare’s employer mandate, “We didn’t have a very good handle on how difficult operationalizing the provision would be at that time.” So, to borrow Baucus’ own phrase, even one of his self-appointed “experts” didn’t “know what the heck it is” either.

Why Expand a Government You Can’t Even Understand?

Biden’s comments once again reveal that the federal government has become too big and sprawling for anyone to understand. Yet he and his Democratic colleagues continue to push massive, multi-trillion-dollar expansions of government as part of their presidential campaigns. Sen. Elizabeth Warren goes so far as to claim that “experts” can fix just about everything that’s wrong with the world, even though Biden’s admission shows that they need to start by fixing the problems they caused.

As the old saying goes, when you’re in a hole, stop digging. That axiom applies equally to Biden’s propensity to put his foot in his mouth and Democrats’ desire to expand a government they do not understand.

This post was originally published at The Federalist.

Christmas Eve Vote on Obamacare Showed Washington Still Has Shame

A decade ago this morning, 60 Senate Democrats cast their final votes approving the legislation that became Obamacare. The bill took a circuitous route to enactment after Scott Brown’s surprise victory in the Massachusetts Senate contest, which occurred a few weeks after the Senate vote, in January 2010.

Brown’s election meant Republicans gained a 41st Senate seat, giving them the necessary votes to filibuster a House-Senate conference report on Obamacare. Because Democrats lacked the 60 votes to overcome a filibuster, they eventually agreed to a process amending certain budgetary and fiscal elements of the Senate bill through the reconciliation process on a 51-vote threshold.

The grubby process leading up to Obamacare’s enactment, full of parochial politics and special interest pork, cost Democrats politically. But many Americans do not realize that such machinations occur all the time in Washington—indeed, occurred just last week. When one party participates in a corrupt process, it becomes a scandal; when both parties partake, few outside the Beltway bother to notice.

Backroom Deals

The process among Democrats leading up to the final health vote resembled an open market, with each Senator making “asks” of Majority Leader Harry Reid (D-NV). Reid needed all 60 Democrats to vote for Obamacare to break a Republican filibuster, and the parochial provisions included in the legislation showed the lengths he would go to enact it:

Cornhusker Kickback:” The most notorious of the backroom deals came after Sen. Ben Nelson (D-NE) requested a 100 percent Medicaid match rate for his home state of Nebraska. The final manager’s amendment introduced by Reid included this earmark—Nebraska would have its entire costs of Medicaid expansion paid for by the federal government forever. But the blowback from constituents and the press became so great that Nelson asked to have the provision removed; the reconciliation measure enacted in March 2010 gave Nebraska the same treatment as all other states.

Gator Aid:” This provision, inserted at the behest of Sen. Bill Nelson (D-FL), and later removed in the reconciliation bill, sought to exempt Florida seniors from much of the effects of the law’s Medicare Advantage cuts.

Louisiana Purchase:” This provision, included due to a request from Sen. Mary Landrieu (D-LA), adjusted the state’s Medicaid matching formula. Landrieu publicly defended the provision—which she said reflected the state’s circumstances after Hurricane Katrina—and it remained in law for several years, but was eventually phased out in legislation enacted February 2012.

While these three provisions captivated the public’s attention, other earmarks and pork provisions abounded inside Obamacare too—a Medicaid funding provision that helped Massachusetts; exemptions from the insurer tax for two Blue Cross carriers; a $100 million earmark for a Connecticut hospital, and health benefits for miners in Libby, Montana, courtesy of then-Senate Finance Committee Chairman Max Baucus (D-MT).

Not only did senators try to keep these corrupt deals in the legislation—notwithstanding the public outrage they engendered—but Reid defended both the earmarks and the horse-trading process that led to their inclusion:

I don’t know if there’s a senator who doesn’t have something in this bill that’s important to them. And if they don’t have something in it that’s important to them, then it doesn’t speak well for them.

It was a far cry from Barack Obama’s 2008 (broken) campaign promise to have all his health care negotiations televised on C-SPAN, “so we will know who is making arguments on behalf of their constituents, and who are making arguments on behalf of the drug companies or the insurance companies.” And it looked like Democrats didn’t really believe in the merits of the underlying legislation, but instead voted to restructure nearly one-fifth of the American economy because they got some comparatively minor pork project for their district back home.

Déjà Vu All Over Again

Democrats lost control of the House in the 2010 elections, and political scientists have attributed much of the loss to the impact of the Obamacare vote. One study found that Obamacare cost Democrats 6 percentage points of support in the 2010 midterm elections, and at least 13 seats in Congress.

But did the rebuke Democrats received for their behavior prompt them to change their ways? Only to the extent that, when they want to ram through a massive piece of legislation no one has bothered to read, they include Republicans in the taxpayer-funded largesse.

Consider last week’s $1.4 trillion spending package: Two bills totaling more than 2,300 pages, which lawmakers introduced on Monday and voted on in the House 24 hours later. Democrats wanted to repeal one set of Obamacare taxes—and in exchange, they agreed to repeal another set of taxes that Republicans (and their K Street lobbying friends) wanted gone. The Obamacare taxes went away, but the Obamacare spending remained, thus increasing the deficit by nearly $400 billion.

And both sides agreed to increase spending in defense and non-defense categories alike. Therein lies the true definition of bipartisanship in Washington: An agreement in which both sides get what they want—courtesy of taxpayers in the next generation, who get stuck with the bill.

It remains a sad commentary on the state of affairs in the nation’s capital that the Obamacare debacle remains an anomaly—the one time when the glare of the spotlight so seared Members seeking pork projects that they dared consider forsaking their ill-gotten gains. To paraphrase the axiom about casinos, in Washington, The Swamp (almost) always wins.

Elizabeth Warren’s Health Plan and the Limits of “Experts”

By one count, Sen. Elizabeth Warren used 9,275 words in her health care plan (that is, her original health care plan, not the one she released two weeks later, to overcome the political obstacles she created in the first version). Of that lengthy verbiage, one word stands out: “Expert” appears no fewer than 18 times in the document.

According to Warren, “the experts conclude” that her plan would cost $20.5 trillion over a decade; other “top experts…examine[d] options” to pay for that new federal spending. She cited experts in triplicate for emphasis, noting “the conclusions of expert after expert after expert” that a single-payer health care system can cover all Americans while lowering costs. Warren even pledged that “no for-profit insurance company should be able to stop anyone from seeing the expert…they need.”

Therein lies her biggest problem: In farming out every policy issue for “experts” to solve, Warren effectively insults the intelligence of American voters—telling them they’re not smart enough to solve their own problems, or even to understand the details of her proposed solutions.

‘Experts’ Couldn’t Even Build a Website

The Massachusetts senator’s reliance on experts jives with her campaign’s unofficial slogan. No matter the issue, Warren has a plan for that—blessed by the experts—to enact her agenda. But as Mike Tyson once said, “Everyone has a plan until they get punched in the mouth.” For reasons both practical and philosophical, Warren and her technocratic ilk might benefit from some humility as they seek to remake the health care system—and the nation.

Six years ago this fall, the failure of healthcare.gov provided a searing example of the limits of expertise. After years of planning and countless federal dollars, what Health and Human Services Secretary Kathleen Sebelius called a “debacle” played out in slow-motion on national television. Half a century on from Halberstam’s best and brightest, Barack Obama had to concede that government was “generally not very efficient” at procurement and technology.

Another politician who invoked “experts” regarding health policy, Max Baucus, did so in August 2010. Then the chairman of the Senate Finance Committee, Baucus said he did not bother to read the Obamacare legislation he helped to draft because “It takes a real expert to know what the heck it is. We hire experts.”

Nearly four years later, one of those experts—Yvette Fontenot, who worked on Baucus’ staff during the Obamacare debate—admitted that when drafting the law’s employer mandate, “we didn’t have a very good handle on how difficult operationalizing the provision would be at that time.” Here again, remaking a health system approaching $4 trillion in size brings unintended consequences lurking at every corner.

Yet Warren and her “experts” see no such reason for caution. One of the authors of her health care paper, former Obama administration official Donald Berwick, once said, “I want to see that in the city of San Diego or Seattle there are exactly as many MRI units as needed when operating at full capacity. Not less and not more.” Implicit in his statement: Federal officials, sitting at desks in Washington, or at Medicare’s headquarters in Baltimore, can quantify and assess the “right” number of machines, facilities, and personnel in every community across the land.

Liberals Act Like Voters Are Stupid

A belief that administrators should, let alone can, effectively micromanage an entire health system requires no small amount of hubris. Indeed, Berwick said in a 2008 speech that “I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.”

In this vein, Berwick echoed his Obama administration colleague Peter Orszag, who in advocating for an unelected board to make recommendations reducing health spending—a change included in Obamacare, but repealed by Congress last yearargued that “we might be a healthier democracy if we were slightly less democratic.”

From the 2004 work “What’s the Matter with Kansas?” to the post-mortems after the last presidential election, liberals continue to question why some households vote against their supposed financial interests. The “expert” mentality—as Orszag wrote, “relying more on…depoliticized commissions for certain policy decisions”—likely plays a role, as by its very nature and through its soft paternalism it disenfranchises Americans.

For instance, studies suggest most low-income individuals do not particularly value Medicaid coverage, yet neither Warren nor others on the left spend much time debating whether expanding health insurance represents the best way to help the poor. As Reagan would note, they’re from the government, and they’re here to help.

Warren thinks that to win the presidency, she must convince voters she has a plan for everything. In reality, her campaign’s hopes may rest instead on developing a plan to narrow the growing gap between the rulers—her beloved “experts”—and the ruled.

This post was originally published at The Federalist.

Antiquated Kidney Care System Shows Single Payer’s Poor Care

Earlier this month, President Trump signed another executive order on health care, this one related to the treatment of patients with kidney disease. The administration estimates the measures will ultimately save billions of taxpayer dollars, and up to 28,000 lives per year.

Critics highlighted that Trump’s order relies upon authorities in Obamacare to reform the kidney care system, even as his administration argues that federal courts should strike down the entire law. But these critics omitted another, even greater irony: At a time the left wants to create a single-payer health care system, the deplorable condition of kidney care in this country—with high death rates, and patients unnecessarily suffering because they continue to receive outdated and inefficient treatments—illustrates perfectly all the flaws of government-run health care.

Health Care ‘Innovation,’ Circa 1973

  • Only 12 percent of American patients undergo dialysis at home, compared to 80 percent in Hong Kong. Even Guatemala has a 56 percent in-home dialysis rate.
  • A total of $114 billion in federal spending, just to treat this one condition.
  • Half of the patients who undergo dialysis die within five years.
  • We’re currently using “Decades-old models of care,” as described by one kidney care administrator: “The last 30 years as a country all we’ve done is wait for kidneys to fail and we put people on dialysis.”

As Health and Human Services Secretary Alex Azar, whose father received a transplanted kidney five years ago, noted in a speech in March: “One of the key reasons for our failing policies is that kidney care in particular has some of the worst incentives in American health care.”

Why does kidney care have some of the worst incentives in a health care system plagued with all sorts of perverse disincentives? Even Vox stumbled across the truth in an article on the issue: “Medicare has covered all end-stage kidney disease treatment since 1973.”

Because Medicare provides full coverage for most kidney care patients, providers have very little incentive to innovate. The two largest dialysis providers—DaVita and Fresenius—get paid more for providing care in clinics rather than at home. As a result, American patients (as opposed to patients in other countries) must endure the hardship of taking hours out of their day several times per week to go to dialysis clinics, rather than receiving the treatment in the comfort of their home while they sleep.

But because dialysis providers have little qualms charging the federal government beaucoup bucks for substandard care, and because the federal government does not adapt nearly as quickly to new care models as the private sector, kidney patients—and taxpayers—have suffered. It’s but another example of how government-run health care inflicts its greatest harms on the most vulnerable patients.

Health Care Run by Bureaucrats

The Trump administration’s executive order envisions new delivery models for kidney care proposed by the Center for Medicare and Medicaid Innovation (CMMI). As noted above, some pointed out that Obamacare created CMMI, meaning that if federal courts strike down all of the law, the authority to implement these changes would disappear. The critics ignore one key fact: Congress enacted Obamacare into law nearly a decade ago—yet neither Congress nor CMMI took action on kidney care issues until this point.

The fact that it took a self-proclaimed “innovation” center nearly a decade to propose reforms to kidney care reinforces the inability to change within the entire federal health care bureaucracy. Just before Obamacare’s enactment, Sen. Max Baucus (D-MT), then-chair of the Senate Finance Committee, called officials within the Centers for Medicare and Medicaid Services “hidebound, not very creative, a crank-turning bunch of folks.”

The lack of progress on kidney care for so many years reinforces the accuracy of Baucus’ assessment. Yet the left wants to empower these same “hidebound” bureaucrats with authority not just over Medicare, but all Americans’ health care treatments.

Note to American patients: If you want the best health care money could buy as of 1973—the year when Medicare began coverage of end-stage renal disease—then you’ll love single-payer health care. If, on the other hand, you prefer access to modern, 21st-century medicine, then you might want to stick with another type of health care system—one run by doctors and patients rather than government bureaucrats.

This post was originally published at The Federalist.

How Robert Francis O’Rourke Sabotaged Obamacare

On Monday night, the Wall Street Journal reported that former U.S. representative Robert Francis O’Rourke had underpaid his taxes for 2013 and 2014. When O’Rourke released his tax returns Monday night, the Journal contacted an accountant, who noticed the error:

O’Rourke and his wife, Amy, appear to have underpaid their 2013 and 2014 taxes by more than $4,000 combined because of an error in the way they reported their medical expenses, according to tax returns the couple released Monday evening.

They took deductions for those costs without regard to the limit that only allowed that break for medical and dental expenses above 10% of income for people their age. Had they not taken the nearly $16,000 in medical deductions, their taxable income would have been higher.

But why did they over-report their medical expense deduction? If you’re curious, go and fetch a copy of the Consolidated Print of the Patient Protection and Affordable Care Act. Why, lookie what we have here:

SEC. 9013. MODIFICATION OF ITEMIZED DEDUCTION FOR MEDICAL EXPENSES.

(a) IN GENERAL.—Subsection (a) of section 213 of the Internal Revenue Code of 1986 is amended by striking ‘7.5 percent’ and inserting ‘10 percent’.

(b) TEMPORARY WAIVER OF INCREASE FOR CERTAIN SENIORS.— Section 213 of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection:

‘(f) SPECIAL RULE FOR 2013, 2014, 2015, AND 2016.—In the case of any taxable year beginning after December 31, 2012, and ending before January 1, 2017, subsection (a) shall be applied with respect to a taxpayer by substituting ‘7.5 percent’ for ‘10 percent’ if such taxpayer or such taxpayer’s spouse has attained age 65 be- fore the close of such taxable year.’

However, seniors could report at the lower 7.5 percent level for 2013 through 2016. In 2013 and 2014, Robert Francis reported at the lower 7.5 percent level, even though he and his wife aren’t seniors. Oops.

Several things come to mind upon reading this news, the first being one word: SABOTAGE. Democrats frequently like to claim that the Trump administration is “sabotaging” Obamacare. But by failing to pay an Obamacare-related tax increase, Robert Francis quite literally did just that—he sabotaged the law, failing to fund its entitlements by failing to pay his newly increased tax bill.

Second, did Robert Francis ever bother to READ Obamacare? Sure, he wasn’t a congressman when the bill passed, because he wasn’t a congressman for long, but one would think a member of Congress would bother to educate himself about such an important, and visible, piece of legislation. I talked several times with my mother, a senior who uses the medical expense deduction, about the import of this provision on her taxes. But then again, I actually bothered to read the bill.

More to the point, this episode once again reveals how Democrats want to bequeath to the nation laws that they do not understand. Recall that Max Baucus (D-MT), then the chairman of the Senate Finance Committee and a main author of Obamacare, said he didn’t need to bother reading the bill because he hired “experts” to do it for him. Except that one of those supposed “experts” admitted four years later that, on the law’s employer mandate, “we didn’t have a very good handle on how difficult operationalizing that provision would be at that time.” A government too big to manage—that’s liberals’ greatest legacy.

As James Madison reminded us in Federalist 51, “In framing a government which is to be administered by men over men, the great difficulty lies in this: You must first enable the government to control the governed, and in the next place oblige it to control itself.” Maybe Robert Francis should think about that the next time he’s out on the campaign trail—or writing that check for back taxes to the IRS.

This post was originally published at The Federalist.

Obamacare, The Constitution, and “Sabotage”

Donald Trump:           Nancy, Chuck, so good to see you. I wanted to bring you some good news: We’re starting construction on the border wall tomorrow.

Nancy Pelosi and Chuck Schumer:             What? Congress hasn’t appropriated money for the wall. And Congress has the “power of the purse,” not you. How can you say you’ll build the wall when we haven’t signed off on the funding?

Trump:            Because Barack Obama did it for years. What about his actions on Obamacare?

Pelosi:              What do you mean, what about Obamacare? It’s the law of the land—and you should stop sabotaging it!

Trump:            By “sabotaging Obamacare,” you mean failing to spend money on the cost-sharing subsidies to lower deductibles and co-payments…

Pelosi and Schumer: Right!

Trump:            …even though the text of Obamacare itself nowhere includes an appropriation for those subsidies…?

Pelosi and Schumer: Ummm…

Trump:            Let me get this straight: You’re accusing ME of sabotage, because YOU “forgot” to include an appropriation in Obamacare for more than $10 billion per year in spending?

Pelosi:              But “everyone understood” the law provided an appropriation…

Trump:            Even though you couldn’t be bothered to write it down?

Pelosi and Schumer: Ummm…

Trump:            Did either one of you—or for that matter, any Democrat—actually read the bill before voting for it?

Schumer:         I meant to, I swear! But Max Baucus said he hired the best experts, so we didn’t think we needed to.

Trump:            Didn’t those experts read the bill?

Schumer:         They spent all their time cutting deals to get the bill passed. Those Cornhusker Kickbacks don’t write themselves, y’know!

Trump:            Well, your loss is my gain. I’ve read some of the documents in the lawsuit over the cost-sharing subsidies. Do you know that the Obama Administration argued that the structure of the bill implied an appropriation, even though one doesn’t exist…?

Pelosi and Schumer: Yes…

Trump:            And Nancy, you remember the amicus brief you filed in the case right before my election, which said that the courts are “certainly not” the venue for litigating cases when the executive invents an appropriation, as it did with the cost-sharing subsidies…?

Pelosi:              But…but…but…

Trump:            That means I can argue that there’s an appropriation behind any law Congress has passed—like the bill you voted for, Chuck, authorizing construction of the border fence…

Schumer:         What?

Trump:            …And you can’t go to court to stop me!

Pelosi and Schumer: But you requested funding from Congress—and we refused to grant it!

Trump:            You mean, like Congress refused to appropriate funds for the Obamacare cost-sharing reductions, after President Obama requested them…?

Pelosi and Schumer: Ummm…

Trump:            The Obama Administration testified before Congress that it had the authority to spend money on the cost-sharing reductions because Congress didn’t explicitly stop them from spending it, correct?

Schumer:         Yes…

Trump:            And Nancy, your brief said the same thing: That unless Congress explicitly prohibits a President from spending money, the President has free rein to do so…

Pelosi:              But I was trying to protect Obamacare from sabotage!

Trump:            Did you take an oath to support and defend the Constitution, or to support and defend Obamacare?

Pelosi and Schumer: There’s a difference?

Trump:            Yes—and here it is. Thanks to President Obama’s precedent, I can make up whatever appropriations I want—and by your own admission, you can’t go to court to stop me. You could in theory enact a bill prohibiting me from spending money on these phantom appropriations. But because I have a veto pen, you’ll need a 2/3rds majority in each chamber to override me. You don’t have a 2/3rds majority, do you?

Pelosi and Schumer: No, Mr. President.

Trump:            Didn’t think so. So I’ll get my funding for the border wall—and increased defense funding to boot. And maybe I’ll find some other appropriations too. I think the structure of Michelle Obama’s school lunch program implies an appropriation for a new chef at Mar-A-Lago…

Pelosi:              You know, Mr. President, maybe we need to re-think our position on these phantom appropriations. I signed that legal brief the week before the election, not knowing who the next President would be. I thought that power would be safe in her hands…

Trump:            WRONG!

Pelosi:              But executive power has its limits—and Congress should jealously guard its “power of the purse,” regardless of which party holds power at the other end of Pennsylvania Avenue. Otherwise, we could see all sorts of unintended consequences from legislation…

Trump:            You mean, we had to pass the bill so that you could find out what is in it…?

Pelosi:              Well played, Mr. President.

Hillarycare Redux? A Review of “The System”

A young president promising hope and change takes over the White House. Immediately embarking upon a major health-care initiative, he becomes trapped amidst warring factions in his party in Congress, bickering interest groups, and an angry public, all laying the groundwork for a resounding electoral defeat.

Barack Obama, circa 2009-10? Most definitely. But the same story also applies to Bill Clinton’s first two years in office, a period marked by a health-care debate in 1993-94 that paved the way for the Republican takeover of both houses of Congress.

In their seminal work “The System,” Haynes Johnson and David Broder recount the events of 1993-94 in detail—explaining not just how the Clinton health initiative failed, but also why. Anyone following the debate on Obamacare repeal should take time over the holidays to read “The System” to better understand what may await Congress and Washington next year. After all, why spend time arguing with your in-laws at the holiday table when you can read about people arguing in Congress two decades ago?

Echoes of History

For those following events of the past few years, the Clinton health debate as profiled in “The System” provides interesting echoes between past and present. Here is Karen Ignani of the AFL-CIO, viewed as a single-payer supporter and complaining that insurance companies could still “game the system” under some proposed reforms. Ironic sentiments indeed, as Ignani went on to chair the health insurance industry’s trade association during the Obamacare debate.

There are references to health care becoming a president’s Waterloo—Johnson and Broder attribute that quote to Grover Norquist, years before Sen. Jim DeMint uttered it in 2009. Max Baucus makes an appearance—he opposed in 1994 the employer mandate he included in Obamacare in 2009—as do raucous rallies in the summer of 1994, presaging the Obamacare town halls 15 years later.

Then there are the bigger lessons and themes that helped define the larger debate:

“Events, Dear Boy, Events:” The axiom attributed to Harold Macmillan about leaders being cast adrift by crises out of their control applied to the Clintons’ health-care debate. Foreign crises in Somalia (see “Black Hawk Down”) and Haiti sapped time on the presidential calendar and press attention, and distracted messaging. During the second half of 2009, Obama spent most of his time and energy focused on health care, leading some to conclude he had turned away from solving the economic crisis.

Old Bulls and Power Centers: “The System” spends much more time profiling the chairs of the respective congressional committees—including Dan Rostenkowski at House Ways and Means, John Dingell at House Energy and Commerce, and Patrick Moynihan at Senate Finance—than would have been warranted in 2009-10. While committee chairs held great power in the early 1990s, 15 years later House Speaker Nancy Pelosi and Senate Majority Leader Harry Reid called most of the legislative shots from their leadership offices.

Whereas the House marked up three very different versions of health-care legislation in 1993-94, all three committees started from the same chairman’s mark in 2009. With Speaker Paul Ryan, like John Boehner before him, running a much more diffuse leadership operation than Pelosi’s tightly controlled ship, it remains to be seen whether congressional leaders can drive consensus on both policy strategy and legislative tactics.

The Filibuster: At the beginning of the legislative debate in 1993, Robert Byrd—a guardian of Senate rules and procedures—pleaded for Democrats not to try and enact their health agenda using budget reconciliation procedures to avoid a filibuster. Democrats (begrudgingly) followed his advice in 1993, only to ignore his pleadings 16 years later, using reconciliation to ram through changes to Obamacare. Likewise, what and how Republicans use reconciliation, and Democrats use the filibuster, on health care will doubtless define next year’s Senate debate.

Many Obama White House operatives such as Rahm Emanuel, having lived through the Clinton debate, followed the exact opposite playbook to pass Obamacare.

They used the time between 1993 and 2009 to narrow their policy differences as a party. Rather than debating between a single-payer system and managed competition, most of the political wrangling focused on the narrower issue of a government-run “public option.” Rather than writing a massive, 1,300-page bill and dropping it on Capitol Hill’s lap, they deferred to congressional leaders early on. Rather than bashing special interest groups publicly, they cut “rock-solid deals” behind closed doors to win industry support. While their strategy ultimately led to legislative success, the electoral consequences proved eerily similar.

Lack of Institutional Knowledge

The example of Team Obama aside, Washington and Washingtonians sometimes have short memories. Recently a reporter e-mailed asking me if I knew of someone who used to work on health care issues for Vice President-elect Mike Pence. (Um, have you read my bio…?) Likewise, reporters consider “longtime advisers” those who have worked the issue since the last presidential election. While there is no substitute for experience itself, a robust knowledge of history would come in a close second.

Those who underestimate the task facing congressional Republicans would do well to read “The System.” Having read it for the first time the week of President Obama’s 2009 inauguration, I was less surprised by how that year played out on Capitol Hill than I was surprised by the eerie similarities.

George Santayana’s saying that “Those who cannot remember the past are condemned to repeat it” bears more than a grain of truth. History may not repeat itself exactly, but it does run in cycles. Those who read “The System” now will better understand the cycle about to unfold before us in the year ahead.

This post was originally published at The Federalist.

When CMS Director’s Post Opens–Again–Will Obama Step Up?

When Marilyn Tavenner steps down as head of the Centers for Medicare and Medicaid Services this month, one of the federal government’s most powerful positions will once again come open. History and President Barack Obama’s actions toward the post suggest that finding a replacement might prove difficult.

Before Ms. Tavenner was confirmed in May 2013, CMS had gone without a permanent, Senate-confirmed administrator for nearly seven years—since Mark McClellan left the agency in the fall of 2006. The Bush administration nominated Kerry Weems, a career civil servant, to replace Mr. McClellan; Mr. Weems received a polite hearing from the Senate Finance Committee in July 2007, but a CMS policy memo issued shortly afterward regarding the Children’s Health Insurance Program angered Senate Democrats. The committee’s chairman, Max Baucus (D., Mont.), refused to bring the nomination to a vote, and Mr. Weems served as acting administrator for the rest of the Bush administration.

Upon taking office, President Obama waited nearly 15 months—until his health-care legislation was passed—to nominate Don Berwick to run the agency that would oversee much of the law’s implementation. Mr. Berwick’s history of writings proved so inflammatory that Democrats, despite having an overwhelming Senate majority, refused to advance his nomination. Mr. Berwick received a controversial recess appointment from President Obama in July 2010 but was forced to leave CMS in December 2011 when his temporary appointment expired because the Senate had not voted on his confirmation.

While serving in the Senate in 2007-08, Mr. Obama stood by as Sen. Baucus and Majority Leader Harry Reid (D., Nev.) put Mr. Weems’s confirmation on ice. And as president, Mr. Obama failed to demand a vote from his fellow Democrats when they decided not to advance Mr. Berwick’s nomination, likely seeking to spare vulnerable incumbents from taking a position on a nominee with a controversial record. Given the president’s history of remaining quiet about a Democratic Senate not confirming CMS nominees, he has little standing to complain should the Republican-controlled Senate choose not to advance his choice to succeed Ms. Tavenner.

Even before Obamacare, the Centers for Medicare and Medicaid Services had a budget larger than that of the Pentagon; since the law passed, its subsidies, regulations, or both affect the insurance of basically every American with health coverage. The CMS administrator’s job is critical. But President Obama’s actions have contributed to a lack of permanent leadership in CMS for most of the past eight years. We’ll see whether that pattern persists after Ms. Tavenner departs.

This post was originally published at the Wall Street Journal Think Tank blog.

Obamacare and the Pitfalls of Congressional Legislating

Weeks before Congress embarked on its final push to put Obamacare on the statute books, then-House Speaker Nancy Pelosi infamously stated that Congress had to pass the bill “so that you can find out what’s in it.” But last week, a staffer at the heart of drafting the legislation admitted that Congress itself failed to comprehend the implications of the provisions it imposed upon the American people.

On Friday, a Capitol Hill newspaper published a story outlining the history of Obamacare’s employer mandate and whether the administration might delay its implementation still further. In the article, Yvette Fontenot—a lobbyist who helped write the bill for then-Senate Finance Committee Chairman Max Baucus and later worked on implementing the legislation at the White House—admitted that when Mr. Baucus’s staff drafted the employer mandate, “we didn’t have a very good handle on how difficult operationalizing the provision would be at that time.”

Indeed, the employer mandate has proved difficult to implement. Defining who counts as a full-time employee across a variety of industries and creating databases to track employees’ hours have taxed regulators and companies alike. While the administration has cited these difficulties in twice delaying the mandate’s implementation, the law’s critics take a different view—believing the administration postponed the mandate to avoid potential stories about job losses prior to the 2014 elections.

Likewise, the import of Ms. Fontenot’s admission. Liberals and supporters of a strong executive might argue that her comments highlight the need for agency rulemaking, rather than placing final authority in the hands of inexpert legislators and overtaxed congressional staff—essentially saving Congress from itself. House Speaker John Boehner obviously disagrees. The Ohio Republican views the impending House vote exploring legal action against the administration as one way for the legislature to regain its authority.

But more broadly, conservatives would argue that Ms. Fontenot’s comments highlight the need for a more deliberative—and more humble—Congress, one quicker to acknowledge its own flaws, and change its processes accordingly. Recall that Max Baucus—the prime congressional author of Obamacare—said four years ago that he didn’t want to “waste my time” reading the legislation, because “we hire experts.” But one of those “experts” now says she didn’t understand how one of the major portions of the bill would work. It makes a very compelling argument that Congress, rather than relying on agency employees to resolve its self-imposed problems, should instead revert to the Hippocratic oath, and focus first and foremost on doing no legislative harm.

This post was originally published at the Wall Street Journal Think Tank blog.

Flush with Cash, Obamacare Supporters Spending Money on…Porta-Potties

Rafael Ben-Ari/Chameleons Eye/Newscom

Rafael Ben-Ari/Chameleons Eye/Newscom

Even among the law’s supporters, Obamacare is in the toilet. Quite literally.

As The Washington Post reports, states implementing Obamacare’s exchanges are considering all kinds of methods to promote Obamacare. Reporter Sarah Kliff spoke with Michael Marchand, the head of Washington State’s exchange:

Marchand has been thinking up all sorts of ways to make sure young people hear about the new health program. Perhaps in music-heavy Washington state, it’s no surprise that his thoughts have gravitated toward outreach at concerts and music festivals.

“We’ve talked about everything we could use, even whether we could do some branding on porta-potties,” he said. “I want to sponsor charging stations, too. Talk about a captive audience. They’re standing there, charging their iPhones.”

Kliff reports on other states’ plans to “educate” their citizens about Obamacare, all using federal dollars provided through exchange grants. For instance, “Oregon may reel in hipsters with branded coffee cups for their lattes.” And Connecticut’s exchange “plans to head to the beach this summer” to promote Obamacare:

Officials will hand out sunscreen customized with a “get covered” slogan and hire an airplane to fly over beaches with a banner that advertises the new agency.

No word yet on whether Senator Max Baucus (D-MT) has suggested state exchanges partner with Amtrak, given his recent comments about the state of Obamacare implementation.

Jokes aside, the gusher of federal spending on exchange grants and related promotional activities demonstrates the problem with Obamacare. At a time when our nation’s debt is approaching $17 trillion, using taxpayer funds to buy latte cups, sunscreen, and portable toilets represents a massive amount of waste. It’s yet another reason why Congress should act to defund Obamacare and refuse to spend a single dime on such frivolous expenditures.

This post was originally published at The Daily Signal.