How Can Hillary Make Obamacare Her Own?

During the first Clinton White House, First Lady Hillary Clinton became the public face of the administration’s push for health care reform. She testified at public hearings, headed a task force, and the policies coalesced under the moniker “Hillarycare.” When those proposals died in 1993, it arguably set comprehensive health care reform back for more than a decade.

Then in 2008, the political environment was ripe for reform for the first time since. Then-Sen. Hillary Clinton, now running for president, laid out her plan, which per the Washington Post, would have sought “to build on the existing health-care system, but … make it easier for adults without health insurance to buy it through tax credits.” But she lost the Democratic primary to a senator from Illinois and, six years later, those policies have a different name ascribed to them: Obamacare.

More than 10 million have gained health coverage because of that law, the Affordable Care Act, with the second enrollment period set to start later this week. So if, as is almost universally expected, Clinton decides to seek for the White House again, what will there be left for her to do?

A lot actually, according to one of her closest former advisers: Center for American Progress president Neera Tanden, who was policy director for the 2008 Clinton campaign, worked in the Clinton White House and worked for the Obama administration on health care reform.

Like most people close to the former secretary of state and first lady, Tanden refused to entertain any direct questions about Clinton’s 2016 plans. But in an interview with TPM, she did talk about the role that health care might play in the coming presidential campaign and how potential Democratic candidates, and Clinton in particular, might approach it.

New England Summit on Health Care Reform at the World Trade Center in Boston, Dec. 7, 1993. (AP Photo/Jon Chase).

Early hints at Clinton’s 2016 message, themes that have been repeated throughout her recent public speaking appearances, signal that it will focus heavily on income inequality, the middle class, and growing wages. That could then be her opening for health care, too: Obamacare initially addressed insurance coverage, but its cost containment provisions were more back-loaded and how effective they ultimately will be is still an open question.

With all the controversy over Obamacare, people forget that expanding insurance coverage was the easy part. It’s good politics, people got a tangible benefit, and the health care industry received a boon of new paying customers. Cost containment — even the term makes eyes sag — is the heavier lift. The obvious political attack is “rationing” and “death panels.” Consumers see no immediate benefits and industry has to grapple with less revenue and begins squabbling over exactly whose costs should be contained.

“I think that health care is an issue that she cares deeply about. There are still issues that remain, not coverage issues,” Tanden said, “but there are still issues around health care costs that remain and those are important issues to voters.”

“Health care expenditures have gone down, but people’s individual costs are rising because out-of-pocket costs are going up because employers are shifting costs to employees, which was a long-term trend that started way before the ACA,” she continued. “So I think the issues around costs are an area for her.”

The problem is that there isn’t a lot of consensus about what the next steps in cost containment should be. In May 2007, during her last campaign, Clinton gave a speech at George Washington University that outlined her vision for health care. The first priority was lowering costs. Insuring everyone was third. But a lot of the ideas that she proposed for cost control were adopted into Obamacare. Free preventive care, electronic health records, increased competition through bigger insurance pools (i.e. exchanges) were all part of her plan and are now being tackled through the law.

Tanden specifically cited medical-loss ratios — which require insurance companies to spend a minimal percentage of premiums on health care costs — as something that Clinton proposed during the 2008 campaign but Obama didn’t that made its way into the ACA.

“It’s really quite remarkable how many of the elements of the ACA can be traced back to what she and President Obama and the other candidates were saying back in the 2008 campaign,” Larry Levitt, vice president at the Kaiser Family Foundation, told TPM of the 2007 speech. “The ACA contains some of almost all of what she talked about.”

That leads to the dilemma, though: Nobody is sure what comes next. Health care costs have grown more slowly since the law took effect, but experts expect as the economy improves and more people get coverage through Obamacare, cost growth will pick back up.

“If health costs do start to accelerate and enter the political debate, it’s hard to say where that debate might go,” Levitt said, “since there’s very little consensus about what approach to take.”

Democrats might propose policies like adding a public option or a regulated system for setting payment rates for all health care payers like Maryland has, Levitt theorized, but each comes with political risk. And Clinton hasn’t spent the last six years building a detailed domestic policy agenda.

So while health care costs might be opening, she’ll also be starting largely from scratch in finding solutions in what could be politically treacherous territory.

“It is my view that health care costs will be a big issue for everybody,” Tanden said. “But I don’t know where Hillary is going to land on that or where Biden’s going to land,” ticking off some of the presumed presidential contenders.

Then there is the open question of whether Republicans will still try to wield Obamacare against Democrats as they have for the last three election cycles. The new GOP Congress seems intent on taking symbolic votes for repeal and then chipping away at the law in a more piecemeal fashion over the next two years. Conservative legal challenges are also still active against the law, and one is soon heading to the Supreme Court.

The Congressional Budget Office projected earlier this year that 36 million people will be covered under the law by private insurance and Medicaid in 2016. There were already signs in 2014 that Obamacare, while still a favored topic for the GOP on the campaign trail, was no longer viewed as the silver bullet that it might have been in 2010. Whether that political trend accelerates heading into 2016 is one of the major outstanding questions for Clinton and other Democrats.

“The big driver of the change in views on gay marriage is people came out and people knew someone. Knowing someone’s who’s gay is the big difference between supporting gay marriage or not, right?” Tanden said. “If we get to 20 million people who have health care, people are going to know somebody who got health care through the exchange.”

“Two years from now,” she concluded, “it could be a positive thing.”