Those were the critical numbers for the Affordable Care Act to assemble a minimal winning coalition in 2010.
The actual winning coalition was 219-60-1-5 on everything except mandatory Medicaid expansion.
I am of the opinion that Nancy Pelosi probably had a few extra votes in her back pocket if she needed them, but this is pure specualtion that caps the spare votes out at five or six votes. I am of the opinion that President Obama would be willing to sign something significantly more liberal. That leads the binding constraints on a changed PPACA minimal winning coalition to be both the Senate as any defector from the aye to the nays could kill the bill, or Chief Justice Roberts.
When I think of PPACA within this framework, my analysis quickly leads me to assume that there were very few tweaks that could have been passed with a sufficient minimal winning coalition that were not already included in the bill. So when I see Senator Harkin say the following, I want to pull my hair out:
He wonders in hindsight whether the law was made overly complicated to satisfy the political concerns of a few Democratic centrists who have since left Congress.
“We had the power to do it in a way that would have simplified healthcare, made it more efficient and made it less costly and we didn’t do it,” Harkin told The Hill. “So I look back and say we should have either done it the correct way or not done anything at all.
“What we did is we muddle through and we got a system that is complex, convoluted, needs probably some corrections and still rewards the insurance companies extensively,” he added….
“We had the votes in ’09. We had a huge majority in the House, we had 60 votes in the Senate,” he said.
He believes Congress should have enacted “single-payer right from the get go or at least put a public option would have simplified a lot.”
“We had the votes to do that and we blew it,” he said.
There were never the votes for Medicare for All in 2009 if we assume the minimal winning coalition is 217-60-1-5. I agree with Senator Harkin that it would have been better, more efficient and much smoother implementation to go for Medicare for All. However, as we saw with the proposal to drop the Medicare buy-in age to 55, there were multiple veto players (Sen. Lieberman of CT) who were not even willing to extend a successful single payer system at all to a logical target population.
The choice was not Single Payer or PPACA in 2010, the minimal winning coalition for PPACA included multiple veto players who would have vetoed Single Payer in the Senate and the House. The choice was PPACA or something extremely close to PPACA (you can convince me about a tweak here or there plus drafting fixes would have passed with the same coalition) versus nothing. And since we only had PPACA instead of a fine tooth combed revised PPACA, the actual choice was PPACA or nothing given the minimal winning coalition built.
Is PPACA perfect. Fuck no. Is it a massive improvement over the status quo. Fuck yeah.
Was single payer a passable option in 2010 — fuck no. So let’s take a good win when we can and celebrate it.