Before Tuesday night, Barack Obama was slated to become the most important American president since Ronald Reagan, a liberal icon in the mold of LBJ or FDR who deeply reshaped the federal government.
Just think about everything that changed during his presidency. He signed into law a comprehensive national health insurance bill, a goal that had eluded progressive presidents for a century. He got surprisingly tough reforms to Wall Street passed as well, not to mention a stimulus package that both blunted the recession and transformed education and energy policy.
He's put in place the toughest climate rules in American history and signed a major international climate accord. He opened the US to Cuba for the first time in more than half a century, and reached a peaceful settlement to the nuclear standoff with Iran. He opened the military to LGBTQ Americans and appointed Supreme Court justices who made same-sex marriage the law of the land.
And now, with the election of Donald Trump and Republican majorities in both houses of Congress, almost all of that legacy is imperiled. Trump has promised to repeal Obamacare, to dismantle the Dodd-Frank financial reforms, to reverse the deal with Iran, and to scrap all climate regulations. Much of that he could do with executive power alone. The rest could be done with a cooperative Congress, in some cases even without a filibuster-proof majority.
We don’t know yet how much Trump, Paul Ryan, and Mitch McConnell will actually be able to do. But if they do what they’ve promised, Obama’s ultimate legacy will be greatly diminished. Maybe his policies would be brought back by future presidents — but maybe they’ll be gone forever. Maybe, like Ulysses S. Grant, he will go down as a president who enacted a huge number of crucial, socially progressive policies that were abandoned as soon as he left office.
What Donald Trump can do to Obamacare, the president’s greatest achievement
Florida Residents Sign Up For Affordable Care Act On Deadline Day Joe Raedle/Getty Images
The Affordable Care Act will not survive in anything resembling its current form.
The Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 touched almost every aspect of American health care policy. They created massive new subsidies for insurance for people not poor enough to be covered by Medicaid. They greatly expanded Medicaid too. They also set new protections for women, people with preexisting conditions, and people 26 and younger to expand their access to health care.
But the most important thing those laws did, the thing that cemented Obama’s legacy as an expander of the American welfare state in the tradition of LBJ or FDR, was establish that it was the responsibility of the US government to provide its citizens with health care.
As Brian Steensland, a sociologist who studies American social policy at Indiana University–Purdue University Indianapolis, told me back in 2015, "The main thing it does, I think, is establish the expectation in the public’s mind that access to basic health care is a right. It’s going to be hard to go back to a time when access to health insurance, and the subsidies to help pay for it, wasn’t near universal."
We’re about to find out how hard. On paper, it’s clearly possible for Trump and his allies in Congress to dismantle some or all of Obamacare. Some things Trump can unilaterally change by executive fiat — like redefining “preventive health care for women” to not include birth control. Other things he can do through the budget reconciliation process, like ending Obamacare's insurance subsidies, Medicaid expansion, taxes, and individual mandate. Budget reconciliation bills are filibuster-proof, so assuming more moderate-leaning Republican senators like Susan Collins don’t defect, Trump and the Republican Congress could pass all of that.
Still more things, like the extension of health insurance to 26-year-olds, can’t go through budget reconciliation and would face a Democratic filibuster — unless Senate Majority Leader Mitch McConnell ends the filibuster altogether, which is very possible given that it was ended for most nominations just three years ago.
The question is: Will they actually follow through, and if so, what will they replace Obamacare with? On the first point, it’s telling that McConnell has refused to commit to using budget reconciliation to repeal Obamacare. That opens the door to letting Democrats filibuster repeal efforts. Given the enormous political pain that could await Republicans should they suddenly deny 22 million people health care, it’s easy to imagine savvy operators like McConnell eyeing repeal warily, and looking for ways to act like they want to repeal the law while letting Democrats prevent them from actually doing so.
It’s also worth keeping in mind that while Trump has been consistently anti-Obamacare this election, he has in the past expressed very different views on government-subsidized health care programs, and it’s hard to know how firmly he’ll stick to his campaign pledges.
One possibility is that McConnell and Trump insist on including a replacement package in any repeal — and then the question becomes what precisely is in that package. Trump has promised to replace it with “something terrific” with “much better healthcare”:
If that something is his stated replacement plan, which offers tax deductions for health insurance, the result will be a massive increase in the uninsured population. His stated approach effectively replaces the insurance subsidies and support of Obamacare with nothing at all.
I am going to repeal and replace ObamaCare. We will have MUCH less expensive and MUCH better healthcare. With Hillary, costs will triple!
— Donald J. Trump (@realDonaldTrump) November 2, 2016
But it doesn’t have to be that way. Avik Roy, a conservative health policy expert who has advised Rick Perry and Mitt Romney, has offered a right-leaning reform plan that repeals the Medicaid expansion, tax hikes, and individual mandate from Obamacare, but keeps insurance exchanges and preserves progressive, sliding-scale insurance subsidies for poor and middle-class Americans. Sens. Richard Burr (R-NC) and Orrin Hatch (R-UT), the latter of whom chairs the Senate Finance Committee, have offered a plan very similar to this. Paul Ryan's latest plan would preserve a refundable health care tax credit, albeit one that does not increase in size for poorer Americans.
These are not, to be very clear, Democratic proposals. They loosen insurance regulation on the exchanges considerably. Roy would abolish Medicaid for beneficiaries not needing long-term care, instead offering tax subsidies on the exchanges, while Burr and Hatch would block-grant Medicaid. These are not proposals that President Obama would have signed into law. But Roy asserts that his plan would increase health coverage by 9 million relative to Obamacare. Hatch and Burr would decrease it by 3 million, Ryan by 2 million.
I’m not sure I’m that optimistic about the plans’ effects. But even if they “only” reduce insurance by 5 million, that’s far, far better than outright repealing Obamacare and leaving 22 million people without insurance.
If the Roy plan, or the Hatch/Burr plan, becomes law, Obama’s health care legacy will survive in at least some form. Millions of people will continue to be insured who would not have been had he not pushed Obamacare through in 2010. But if Trump passes his current reform plan, then Obama’s greatest accomplishment, his pledge that the federal government will ensure near-universal coverage, will be
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http://www.vox.com/policy-and-politics/2016/11/11/13575668/barack-obama-legacy-donald-trump
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