What’s a prez to do? Obamacare

“Do what you can, with what you've got, where you are.”

Theodore Roosevelt liked to repeat this saying, which he credited to “Squire Bill" Widener of Virginia. It's good advice, applicable to people in all stations of life. Presidents have more to work with than most folks, and so can expect to do more. But even they have constraints on what they can do.

Barack Obama might or might not have been familiar with this saying, but he acted on its essence. When Obama entered the White House in 2009, health care had been a federal responsibility for almost half a century. But the federal role was patchy. It applied to seniors, through Medicare, and to some of the poor, through Medicaid. For most Americans, health care was an adjunct to employment. Which meant that if you weren't employed or a dependent of someone who was employed, you probably didn't have health care.

This had striking consequences. First, tens of millions of Americans had no medical insurance. They were an accident or a bad illness away from bankruptcy. Second, even those Americans who had insurance often felt locked into their jobs. Employers had no obligation to provide health insurance, and especially if prospective employees had expensive pre-existing conditions, such as cancer or depression, an employee who switched jobs risked losing coverage. So such employees stayed put.

Obama wanted to patch the holes in the system. He wanted to provide coverage for people without it. He wanted to bar insurers from excluding people with pre-existing conditions. He wanted to raise the age at which children were booted off their parents' coverage.

And he wanted to do it in a way that would make the changes stick. In American politics to that point, all the major reforms had been approved by Congress with bipartisan majorities. The Reconstruction amendments received bipartisan super majorities in the 1860s. The progressive reforms of the early 20th century got votes from both Republicans and Democrats. The New Deal was a predominantly Democratic package, but it too garnered Republican votes. Democrat Lyndon Johnson sponsored civil rights reforms in the 1960s, but on the Civil Rights Act of 1964, a greater majority of Republicans in Congress than Democrats voted in favor. 

Obama knew this. And he wanted a similar bipartisan seal of approval on his health care package. He understood that the Republicans as a party wouldn't be enthusiastic, but he hoped to find a few who could get behind the reforms he had in mind. He met with Republicans and asked how his ideas could be modified to make them acceptable. He engaged in the log-rolling—you help me with my bill and I’ll help you with yours—that had been a feature of American politics from the start. More than once he thought he had succeeded. But the Republicans would meet among themselves and would end up rejecting the very compromises they had suggested.

Obama had a choice. He could try again at the next session of Congress and hope to be more persuasive then. Or he could push health care through Congress on a straight party line vote. The Democrats controlled both houses, making the reform he wanted doable.

The downside of delay was suggested by precedent. Most important reforms occur early in a presidency. The political capital a president wins in a successful campaign begins to dwindle on inauguration day. If he can't get his good ideas through Congress in his first term, his chances go down. If Obama didn't take what he could get now, he might get nothing at all.

But relying solely on Democratic votes had its own significant downside. Whatever passed would be an irresistible target to Republicans at the next election and far into the future. If none of them voted for it, they didn't own it. As soon as they gained a majority, they’d claim a mandate to overturn it.

Voters forced Obama's hand. In the congressional elections in November 2010, the Republicans dealt the Democrats a stunning blow. They gained 63 seats in the House and 6 in the Senate. They gained control of the House.

Which meant that as of January 2011, when the newly elected Congress met, Obama would lose all hope of health care reform.

He decided to take what he could get. He crafted a bill that would hold the Democrats together, and persuaded them to approve it. Not a single Republican in either house voted for the Affordable Care Act, colloquially Obamacare.

Immediately Republicans denounced it as more Democratic overreach, more profligacy, more government regulation, more disregard for the interests of Americans. At every opportunity they vowed to repeal Obamacare as soon as they had the opportunity.

But a funny thing happened before then. As the provisions of Obamacare kicked in, Americans discovered they liked it. Parents liked being able to keep their kids on their health insurance policies longer. People with pre-existing conditions liked being released from employment prison. People who hadn't had health insurance really liked being able to get it at a reasonable cost. 

Obama's reelection in 2012 bought Obamacare a four-year lease on life. Even if Republicans forced repeal through Congress, he’d veto it. Any existing program has an enormous advantage over any prospective program, in that repeal of an existing program typically requires that the repealers control both Congress and the presidency. 

Obama's 2010 decision to accept Obamacare on a strictly Democratic vote paid off. By the time the Republicans controlled both Congress and the presidency, after the 2016 elections, enough Americans liked Obamacare that Republicans had no choice but to leave it alone. They tweaked it, to save face, but its essentials remained.