Former Vice President Joe Biden likes to talk about the Affordable Care Act and how, at the 2010 White House signing ceremony, he was the one who famously called the law a “big fucking deal.”
Biden’s assessment was spot on. “Obamacare” turned out to be the administration’s most consequential domestic policy achievement. Biden felt genuine joy when it passed, former administration officials tell HuffPost, and during the legislative process he was instrumental in locking down wavering Democratic senators who threatened to sink the entire enterprise.
But one year earlier, according to several former officials, Biden was among the many advisers urging President Barack Obama not to pursue comprehensive health care reform right away ― either because it would distract from addressing the economic crisis, or because similar efforts had been disastrous for previous Democratic presidencies, or both.
Although memories of exactly what Biden said and why have grown fuzzy, one former official recalled a Roosevelt Room meeting in early 2009 in which Biden made a strident 10-minute argument. “It was very, very strongly phrased and very long, and I have heard very few things like it over the years,” the former official said, adding that it would be fair to call it a “tirade.”
At one point, the same official said, Biden directly addressed the few advisers who were more enthusiastic about the health care endeavor, warning them that they did not understand the dangers and likely tradeoffs: “It was just, ‘We shouldn’t do this. This will be terrible for us. I know politics, I know people, I’ve been doing this for 36 years. You are all well-intentioned, but you don’t get it.’”
The meaning and significance of these recollections are open to interpretation. Health care was not an issue on which Biden had particular expertise, and during the administration’s first year he was preoccupied with managing the 2009 economic stimulus package known as the Recovery Act, among other things.
Many Obama veterans don’t even remember what Biden said or thought in those internal deliberations, while Biden's advisers, past and present, say his determination to work towards universal coverage never wavered. “From day one ... Biden strongly advocated for action that would allow as many uninsured Americans as possible to gain access to health care,” a spokesman for his 2020 campaign told HuffPost.
Still, Biden had been wary of overreach on health care before he became vice president, just as he’s declined to endorse the most ambitious health reforms some Democrats are proposing today. Taken together, this history and rhetoric could be clues to how Biden would actually act as president, and not just on health care.
What The Health Care Debate Looked Like Back Then
The parameters of the health care debate looked a lot different a decade ago. Back then, Democrats still had deep scars from the Clinton administration’s failed effort at comprehensive reform in the 1990s. For years after that, they had focused on proposing more limited undertakings, like regulating managed care companies or helping seniors to pay for drugs.
By the time of the 2008 presidential campaign, “universal coverage” was back in the party lexicon, and the most ambitious idea getting serious attention was a proposed scheme of expanded Medicaid, tax credits and new insurance rules that advocates hoped would reach most of the uninsured. The three Democratic front-runners, Obama and then-Sens. Hillary Clinton and John Edwards, had called for versions of that approach. Biden had not.
Although Biden identified “universal coverage” as a priority should he become the president, the plan he put forward focused on insuring children, allowing near-seniors to buy into Medicare and opening the federal employee health insurance plan to outsiders. It was similar to what John Kerry, the former Massachusetts senator, had proposed when he was the Democratic nominee in 2004.
Biden’s proposal was “more like a collection of incremental measures,” Larry Levitt, senior vice president of the Henry J. Kaiser Family Foundation, said in a recent interview. “This set of proposals certainly could have accomplished a lot in providing health insurance to people, depending on the details,” Levitt said. “However, it’s fair to say that Biden did not have a comprehensive health reform plan like Obama, Clinton and Edwards.”
In a subsequent Kaiser Foundation forum, Biden laid out the strategy he intended to pursue as president ― securing quick passage of a measure for children and maybe one or two other elements of his plan, then bringing together stakeholders and Republicans to forge consensus on a plan to insure everybody else. He’d said something similar during an Iowa debate a few weeks earlier. Previously, in New Hampshire, he had suggested allowing states to take the lead until a national consensus on universal coverage had come together.
At one point in the Kaiser forum, a panelist asked Biden why he thought Republicans would negotiate on any legislation, given their hostility to Democrats and opposition to a children’s health proposal then before Congress. Biden predicted that with George W. Bush gone, he would be able to bring around some Republicans. “I’d be president and Bush wouldn’t be,” he quipped.
During the forum, Biden talked about health care as a “moral and practical imperative,” pointed to his long record of supporting government-led expansions of insurance and told stories about middle-class Americans struggling with their medical bills. But, Biden warned, passing comprehensive reform on a party-line vote wouldn’t work. “Anyone who thinks we’re going to take $2 trillion of the economy, with stakeholders in that $2 trillion, and by a single vote and move it from here to here [gesturing] is kidding themselves,” Biden said. “It’s not going to happen.”
“He doesn’t want to say chicken-in-every-pot on health care because he doesn’t think he can deliver that.”
- A former Obama administration official, describing Joe Biden
Within the Democratic Party, at least, the primaries settled the debate in favor of attempting more sweeping reforms. But not long after Obama became the nominee, the argument among Democrats shifted to a first-year agenda and how much emphasis to give health care in that time frame. During the transition, Obama heard from multiple advisers who wanted to wait on a major reform, and one of them was Biden, who thought the American people recognized that, with the economy in crisis, circumstances had changed since the campaign.
“They’ll give you a pass on this one,” Biden told Obama, according to Jonathan Alter’s book “The Promise.” Another account of the administration’s first year, Noam Scheiber’s “The Escape Artists,” confirmed the story, noting that at a January 2009 meeting, “the vice president begged Obama to make his early presidency about jobs.”
How Biden Helped Make Obamacare Possible
Several former Biden staffers whom HuffPost interviewed said they did not recall him warning Obama to wait on major health care reform. They didn’t dispute the published accounts or recollections of other officials per se, but they argued that it would be wrong to interpret such episodes as anything more than Biden offering his candid advice on priorities in order to get the most out of Obama’s first term.
“During the transition, [Biden] pushed as hard as anyone for the administration’s proposal to achieve universal coverage,” said Mark Gitenstein, who was co-chair of Biden’s transition team and said he was in every health care meeting that Biden attended during that period. “We had a number of conversations about timing and how best to achieve our goal, but the vice president never wavered in his belief that everyone in this country deserves quality, affordable health care.”
T.J. Ducklo, national press secretary for the Biden campaign, offered HuffPost a similar statement: “Vice President Biden believes quality, affordable health care in America is a fundamental right that should be guaranteed to everyone. Full stop. He’s fought for those values his entire career, and he’ll do it again from the White House.”
One reason it’s difficult to be precise about Biden’s counsel on health care is that he was not among the advisers who made big impressions during White House deliberations on the issue. Biden typically reserved his strongest advice for private, one-on-one conversations with the president, former officials said, and he had his hands full with the rest of his portfolio, which included not just oversight of the Recovery Act but also scaling back the U.S. military presence in Afghanistan and Iraq.
Recollections of Biden’s contributions to the legislative effort are clearer, in part, because he had developed a reputation within the White House for his acumen as a dealmaker. Several former officials noted that Biden had played a pivotal role in convincing Sen. Arlen Specter of Pennsylvania to switch parties, without which Democrats would not have had the 60 votes they needed to overcome a filibuster and pass legislation.
“Nobody in the administration was more helpful in trying to move this through the process once the president was moving forward, using his instincts about what would and wouldn’t fly,” said Pete Rouse, former senior adviser to Obama. Phil Schiliro, who at the time was the White House director of legislative affairs, described Biden as “100% on board. There was nothing we asked him to do that he didn’t do.”
When the discussion turned to policy details, Biden paid particular attention to whether the final product would provide enough assistance to middle-class Americans, according to Jared Bernstein and Terrell McSweeny, who were policy advisers on his White House staff. Fighting for bigger subsidies inevitably meant fighting for a larger bill, which was something more conservative Democrats in Congress had resisted.
McSweeny, who worked for Biden from 2005 through 2012, said that was typical of his approach to governing, which she summed up using one of Biden’s favorite phrases: “Never die on a small cross.”
What It All Means About A Potential Biden Presidency
Today the health care debate inside the Democratic Party has shifted pretty dramatically. On one end are advocates for a single-payer, “Medicare for All” system. On the other end are those who prefer much narrower, more incremental measures. Biden has indicated he supports creating a new government-run plan and giving people a “choice” of whether to enroll in it, which could put him anywhere in between those poles, depending on the details of what (if anything) he ends up proposing.
Biden’s rejection of Medicare for All could reflect any number of factors, including a substantive preference for keeping a mix of private and public insurance. But one former Obama administration official thinks at least part of the explanation is that Biden tempers his enthusiasm for universal coverage with an acute sense of what’s not achievable in health care reform.
“He’s gone through so much with so many family members, he definitely believes it’s a moral imperative,” the official said, noting that Biden has extensive personal experience with medical crises and the U.S. health care system. “But he’s also somebody who doesn’t like to over-promise. He doesn’t want to say chicken-in-every-pot on health care because he doesn’t think he can deliver that and he thinks that’s not the way to go about this issue.”
“Nobody in the administration was more helpful in trying to move this through the process once the president was moving forward.”
- Pete Rouse, former White House senior advisor
All elected leaders have to make difficult strategic decisions and face political reality. On health care specifically, it’s entirely possible that Medicare for All is beyond the reach of even the most motivated president and energized grassroots right now ― because the entire health care industry would fight it, because people with employer insurance would be reluctant to give it up and because getting massive reforms through Congress is difficult under any circumstances. Some versions of the “public option” might be easier to pass and still have far-reaching effects.
But the debate in the Democratic Party isn’t simply about whether health care reform should require wiping out private insurance. It’s about whether the economic agenda should include some kind of job guarantee or a universal child allowance, whether government should guarantee access to high-quality child care, and whether the crisis of global warming requires something with the ambition of a Green New Deal. Behind each of these proposals are layers of substantive and strategic questions, among them whether to pursue bipartisan reform, even if that means settling for less sweeping measures, or whether to assume GOP intransigence and focus on maximizing what Democrats can accomplish on their own.
Biden has not yet said much specifically about policy and, following reports that he was crafting a climate change proposal that would appeal to Donald Trump voters, rejected suggestions that he was looking for a “middle road.” But Biden has also said he still believes in bipartisan reform, sounding an awful lot like the 2008 candidate who predicted Republicans would be more reasonable once Bush was out of office.
“With Donald Trump out of the White House — not a joke — you will see an epiphany occur among many of my Republican friends,” Biden said at a May 14 campaign stop in New Hampshire.
Biden, who would bring decades of legislative experience to the White House, prides himself on his political intuition. And insofar as he thought pursuing health care reform in 2009 and 2010 would have negative political repercussions, he was probably right. The effort soaked up resources the Obama administration could have spent elsewhere. The party-line vote made the law easier to attack. The backlash hurt Democrats in the midterms.
But it may have taken those kinds of trade-offs to pass what was arguably the most transformative domestic policy act since Lyndon B. Johnson’s Great Society, with gains the public now values so much that even Republicans claim to consider them sacrosanct.
The Affordable Care Act is law because Obama decided to test the boundaries of the politically possible for the sake of what he believed could be a once-in-a-generation achievement. A key question about Biden is whether, as a president facing similar circumstances, he would do the same.