Would the Affordable Care Act Have Been Bipartisan in 1993?

Historians typically shy away from counterfactuals, because they like to explain what happened, not what might have happened if A,B and C were different. But today I'll make an exception because I think looking at a counterfactual from the past will help us to understand the present. 

I've long believed that if President Clinton had proposed something like the Affordable Care Act in 1993, a version of the bill would have passed with overwhelming bipartisan margins. 

The impetus for this blog was a Kaiser Health News article mentioning the similarity between the Affordable Care Act and John Chafee (R-RI)'s health care proposal in 1993, which was the main Republican alternative offered in the Senate to President Clinton's healthcare bill. Chafee's bill had twenty-one co-sponsors, including Republican Leader Robert Dole (R-KA) and 2 Democrats.

I won't go through the specific similarities between the two bills, but suffice to say, people who view the Affordable Care Act as some sort of massive statist, leftist boondoggle might be surprised how similar it is to the Republican proposal from 1993. 

It actually makes sense that the Affordable Care Act approaches the Republican proposal from 1993, because Democrats learned from the searing experience of failing to pass health care reform in 1994.

When they got the opportunity to pursue the goal of universal healthcare again in 2009, they wanted to ensure that they did not fail again by trying to pass something politically unpalatable that drew the opposition of the key industries who helped to shape the public's perceptions about the 1993 Clinton proposal. 

The cynic might say, well, if the Affordable Care Act mimicked the 1993 Republican plan, why did it draw a grand total of 0 Republican votes on final passage? 

The answer is that the Republican Party moved substantially to the right between 1993 and 2009. 

My research reveals that 11 Republican senators in 1993 (Cohen, Kassebaum, Durenberger, Danforth, Specter, Packwood, Hatfield, Chafee, Jeffords, Gorton, and Stevens) had either lifetime American Conservative Union ratings of 65 or below as of 1996 (100 is the most conservative), or average ACU scores of below 65 between 1981 and 1996 (Gorton had an average of 65.71, but a lifetime score of 62). 

Additionally, other pragmatic conservatives served in the Republican caucus in 1993, including Senator Larry Pressler (R-SD), who had accumulated moderate scores early in his career, but became more conservative over time (this year Pressler ran unsuccessfully for Senate as an independent, because of disagreements with the Republican Party), Senator John Warner (R-VA), and Senator Richard Lugar (R-IN). 

Eight of the ten other moderate Republicans were among the 19 Republican cosponsors of Chafee's bill. That leaves a pool of roughly 21 Republicans who likely would have been amenable to some sort of moderate health care overhaul in 1993 that achieved universal coverage. 

Given that Democrats controlled 56 Senate seats (57 before Senator Kay Bailey Hutchinson (R-TX) won a special election in June 1993), the pool of senators who might have gone along with this sort of proposal would have been 78, far beyond the 60 needed to cut off a filibuster. 

That cushion of 18 senators would have allowed the bill to adapt in order to appease liberal senators, who, undoubtedly, disliked elements of Chafee's proposal. 

For example, the Chafee bill required universal coverage by 2005. Liberals would have opposed the 12 year lag in achieving what had been a goal dating back to FDR's presidency (see the work of David Blumenthal and James Morone for some of this history). 

Many of the moderate and liberal Republican senators also cared deeply about the federal deficit and balancing the budget. As such, there likely would have been substantial haggling over how to help people afford health care coverage without busting the budget (indeed, as Paul Starr noted in 1995, one flaw in the Chafee plan was its lack of a revenue source to finance subsidies). 

Nonetheless, the general framework of the proposal likely would have allowed for the necessary legislative give and take that could have achieved a satisfactory outcome. 

Some might wonder, why, if a bill hailed as a liberal achievement 17 years later could have passed, did President Clinton not achieve health care reform in 1993? A complete answer would take a book or long article—but I aim to offer an explanation in the next 7 paragraphs. 

This 1994 Newsweek reconstruction offers an explanation. Many scholarly explanations also exist, such as Theda Skocpol's Boomerang. Starr's account provides an insider explanation

In brief, Clinton believed that healthcare reform had been one of the main mandates with which he had emerged from the 1992 election. He campaigned on the issue, and likely did not feel the need to do much compromising given the large Democratic majorities in Congress and this perceived mandate.

First Lady Hillary Clinton, who helped design the Clinton proposal, reinforced any desire not to compromise, and not to work to mollify concerns from business executives about aspects of the plan (such as its employer mandate). 

The timing of the Clinton's healthcare push (he waited until September 22, 1993 to unveil a proposal, after several bruising political fights), the secretive process that shaped his proposal, its substance (especially the amount of bureaucracy), and Clinton's unwillingness to yield on certain provisions doomed the bill (the President held up a pen during a nationally televised address and threatened to use it to veto any bill that did not provide universal coverage, which boxed him in during subsequent negotiations). 

Clinton's chances of achieving universal coverage and a smashing political victory evaporated during the course of 1994. In December 1993, conservative strategist William Kristol famously urged Republicans not to compromise with the president, and instead to kill his bill for both policy and political reasons. 

Kristol's reasoning, opposition from small businessmen (and their trade groups, such as the National Federation of Independent Business), Republicans' improving electoral prospects as 1994 progressed, and Clinton's intransigence all combined to make Republicans less willing to engage in negotiations before it became too late to pass any sort of healthcare bill in an election year. 

As usual, luck, personalities, and institutional culture also played a role in closing the potential policy window for passing healthcare reform in 1993-1994. For example, formidable House Ways and Means Committee Chairman Dan Rostenkowksi (D-IL) abdicated his post after being indicted on May 31st, 1994. This left the far less formidable Sam Gibbons (D-FL) leading the committee, and trying to pass a healthcare bill. 

These blunders prevented a universal health care bill from passing in 1994, but a window existed in 1993 during which a more moderate proposal, similar to the Chafee plan, or the Affordable Care Act, could have passed with bipartisan support. 

Flash forward fifteen years to 2009, and President Obama faced a far different Congress. Although he had more Democrats in the Senate (60), he faced a Republican caucus that had far fewer moderates with whom to negotiate. Only two Republican senators (Snowe and Collins (ME)), had lifetime ACU scores below 65 after Senator Specter switched parties in April, 2009. 

The substantial pool of moderates who might have been amenable to the Affordable Care Act in 1993 simply did not exist in Congress in 2009. Not only did this make it more difficult for a bipartisan bill to develop, but it also placed enormous pressure on the few Republican moderates and pragmatists to hew to the party line, in order to avoid providing the bill with the imprimatur of bipartisanship.

Even as Senate Finance Committee Chairman Max Baucus (D-MT) labored to negotiate with three committee Republicans (including Snowe), his task verged on being impossible, because of ideological differences. The natural ideological partners who existed sixteen years earlier simply did not exist in 2009. 

Additionally, the rise of conservative media between 1988 and 2009 created a force that did not exist to the same degree in 1993 (talk radio really emerged as a political force in 1994, and Fox News and the blogosphere did not exist in 1993). 

The four Republican senators who had cosponsored the Chafee bill in 1993 and still served in 2009 (Bennett, Grassley, Lugar, and Hatch) had to worry far more about primary elections than general elections, which was not necessarily the case in 1994. Indeed, Bennett would not lose his bid for renomination at a 2010 state party convention in 2010, and Lugar would lose a 2012 Republican primary.

Supporting something along the lines of the Affordable Care Act would have been politically toxic for this group of senators after conservative media got done destroying them for their heresy. 

This exploration offers us hints as to why things that were routine legislatively for decades (such as correcting drafting errors in major reform legislation, or passing a farm or highway bill) have now become so difficult. The Republican Party has moved substantially to the right. This shift makes compromise far harder to achieve, even on the occasions that Democrats offered proposals, like the Affordable Care Act, that might have been considered centrist policy proposals in previous decades. 

This example also offers support for the notion of asymmetric polarization. Thomas Mann and Norman Ornstein have offered a persuasive case for asymmetric polarization in multiple venues (such as here and here). Yet, many in the center do not like the way that this argument places more blame on Republicans than Democrats.  

But the healthcare case shows that Democrats proposed a bill in 2009 that had as many similarities with the Republican proposal from 1993 as it did with President Clinton's 1993 proposal (if not more). Thus, it's hard to argue that they had moved far to the left on healthcare. 

The Republicans, by contrast, had become substantially more conservative— moderates had gone from 20% of their Senate caucus to a mere 5%. Thus, while Democrats deserve their fair share of blame for the current gridlock, it's easy to see why Republicans probably deserve more of the blame.