Healthcare: Fight on Obamacare credits fits a historic pattern

Carl P. Leubsdorf, Tribune News Service

It was hardly surprising when the Republican-controlled Congress adjourned for the year without extending the premium tax credits that have helped millions of Americans pay for their health insurance. After all, the current fight fits the pattern of congressional battles on health care coverage for nearly a century, from the Social Security Act of the mid-1930s to two more recent Biden-era bills: Democrats trying to expand the government’s role in protecting health; Republicans resisting. What was surprising was when four moderate Republicans, their seats endangered next November, joined House Democrats to force a vote in January on a three-year extension of the credits. But the Senate has already rejected that, so at least nine GOP senators would have to change their positions for it to have a chance.

It’s always possible that a flood of protests after the subsidies expire next week could persuade some hitherto resistant Republicans, or that a bipartisan compromise would emerge for a shorter extension than the Democrats are seeking. But that remains an unlikely outcome from a Congress with GOP majorities divided over the issue and a Republican president whose idea of leadership on health is to periodically denounce the Affordable Care Act and make vague, unfulfilled promises to present his own plan. In any case, millions of Obamacare participants will enter the new year with no relief for their vastly increased insurance premiums, hoping something positive might happen when Congress returns in January.

In interviewing voters over the years, they always said their top concern was the cost and accessibility of health care. But a brief history of key congressional actions over the years tells why it takes a more favorable political situation than exists now for Congress to act. One reason, as former Utah Sen. Mitt Romney noted the other day, is that writing health care legislation is just plain hard, because so many elements and interests need to be considered. But a more salient factor is that it’s even harder when almost everyone in one of the two major parties — starting with their leaders — consistently opposes meaningful action.

In the past, it’s taken large Democratic majorities — and a Democratic president — to produce significant action, something that is currently not even possible until 2029, if then. When the original Social Security Act passed Congress in 1935 during President Franklin D. Roosevelt’s first term, all but one House Republican and most Senate Republicans voted to kill its key provisions for old age assistance before backing them on final passage. When large Democratic majorities elected on President Lyndon B. Johnson’s coattails enacted Medicare in 1965, providing health care coverage for older Americans, all but 10 House Republicans voted to make participation voluntary.

When President Barack Obama persuaded a Democratic Congress to pass the Affordable Care Act in 2010, requiring all Americans to have health insurance, every House and Senate Republicans voted against it; later, House Republicans voted more than 60 times to repeal the measure that became known as Obamacare. And when Congress under President Joe Biden passed the tax credits to help Americans pay their Obamacare premiums, during the COVID pandemic, and extended them the next year, every Republican opposed the bills that included them, the American Rescue Plan Act of 2021 and the Inflation Reduction Act of 2022.

But the Dec. 31, 2025, cutoff in the 2022 extension meant Congress would face the issue again less than 12 months before the 2026 midterm elections. There was probably little expectation then that Republicans would control both branches – and the White House. Last summer, the Democrats spotted a political opening when it became clear that partisan disagreements over spending levels would force a government shutdown this fall. They quickly made support for extending the tax credits their price for helping to reopen the government. Confident the Democrats would pay a political price for the shutdown, Trump and the GOP refused to yield. After the Democrats scored in scattered off-year elections, they agreed to a guaranteed Senate vote on the Obamacare tax credits.

Republicans promptly offered a rival bill, providing funds for health savings accounts to pay insurance premiums. But shifting people to those accounts would have weakened a basic attribute of the Affordable Care Act, which depends on requiring insurance for relatively healthy people to offset the costs for the millions with preexisting medical conditions. With 60 votes required for Senate action, neither proposal passed, though four Republicans joined the Democrats because of concerns over the political impact of doing nothing.

Missouri Republican Sen. Josh Hawley, who warned against the political risk of major Medicaid cuts last spring before backing the bill that included them, once again sounded a warning.