Public Options and Death Panels: How the Health Care Debate Evolved

March 23, 2012 -- In October of the 2008 presidential campaign, Barack Obama and John McCain took a question at a town-hall debate on whether health care is a privilege, a right, or a responsibility for Americans.

Obama's answer foretold one of the most dominant conversations of the next four years of his life:"I think it should be a right for every American," Obama said.

After years of countless contentious town halls across the country, backroom negotiations, speeches, compromises, advertisements and spam emails, the Great Health Care Debate has split the United States along party lines and is likely to be one of the more important matters for voters on Election Day 2012.

Next week, the Supreme Court will hear oral arguments on the constitutionality of the health care law's "individual mandate," the provision that requires people to have health insurance or to pay a penalty.

So how did we get here?

The 2008 Campaign

Actually, go back further.

The Clinton Administration

Bill Clinton tried to pass health care "reform" in 1993, an effort tied closely to his wife, future senator/presidential candidate/Secretary of State Hillary Clinton. He famously used a prop before a joint session of Congress, holding up a card and saying that all Americans would get such a card to guarantee health benefits for life. (Kind of like the Social Security card.)

Teddy Roosevelt was actually the first president who tried to oversee national health reform. But like Clinton, he couldn't get his plan through Congress.

The 2008 Campaign

Barack Obama and Hillary Clinton both want to make health care more accessible for all Americans. John McCain does, too, but the Democrats say their plan is more realistic. Obama expresses support for what's called the "public option," basically government-sponsored health care. (He gives up on it later on.)

Health care becomes a big issue in both the primary and the general election. That's why Tom Brokaw asked Obama and McCain at that town hall whether health care is a privilege, a right or a responsibility. Obama's promise is basically that he'll try to make health care better, in general terms.

One hiccup for Obama that will return to haunt him is that while he campaigns, he opposes the "individual mandate" — the very provision in the current law that is at stake in the Supreme Court case.

The First Days

Obama wins and becomes president. His health care plan is essentially a collage of ideas that have been around for a while, all cobbled together. But because the plan has no key defining factor, it's hard to sell to the public. Republicans use this opportunity as a chance to say it's a government takeover of health care.

"It's still the case that, not surprisingly, the majority of the public has no clue about what the bill actually did," says Mark Schlesinger, a professor at the Yale School of Public Health.

A few parts of the plan are really popular – like getting rid of "pre-existing conditions," clauses and letting young people stay on their parents' plans for a few more years. When polled, people generally say they like those things, and some bigger parts of the bill, too. But when they're asked if they like the bill as a whole, many say no. This upsets the White House.

The Death Panels

Sarah Palin proved in the 2008 campaign that she can make a slogan stick — that pitbull and lipstick comment, and "palling around with terrorists" — and she returns in August 2009 to write on her Facebook page that Obama's health care plan includes a "death panel" (which she puts in quotes for some reason) that will determine who lives and who doesn't. There was no death panel but it didn't matter.

"It was hard to answer because it was hard to simply explain," Schlesinger says. "It was easy to raise people's fears about what might be lurking in this complicated and hard-to-define piece of legislation."

Palin reshaped the debate, mostly by raising the temperature and making health care a do-or-die issue. It was already a partisan debate, and now there was less hope for Democrats that they would be able to get Republicans on board.

A Long and Mostly Boring Meeting

In February 2010, Obama opened up the White House to members of Congress from both parties so they could sit around and talk about the health care plan. The idea was to share ideas, but really the idea was to show that Obama was a mediator, not a demagogue.

For seven hours, Obama and the Democrats debated health care reform with the Republicans. It produced a few fiery exchanges but nothing essential changed.

One thing that Obama learned from Bill Clinton's failure in the 1990s was to be wary of what the Democrats call "GOP scare tactics," be they death panels or government takeovers or raised debts. Afraid that the public would think that the new plan would change their health care coverage drastically, Obama repeated variations of the line, "If you've got a health care plan that you like, you can keep it."

"This was not a masterpiece of democratic debate," said Michael Tanner, a senior fellow at the conservative Cato Institute. "It was a pretty horrible political debate on all sides of this thing."

Smoke-Filled Rooms and Locked Doors

Republicans became upset that Democrats were making deals behind closed doors, after Obama had promised during the campaign that health care negotiations would be televised on C-Span. The Democrats were meeting secretly in the first place because they needed enough votes to pass the thing, but some — like Nebraska's conservative Sen. Ben Nelson and Louisiana's Mary Landrieu — needed some sweetening in the legislation.

The GOP started tossing around the term "Cornhusker Kickback" (there's corn in Nebraska) to characterize the deal-making. Obama told ABC News, "I didn't make a bunch of deals." Either way, it didn't look good.

This whole time, Democrats were unable to get a single Republican to vote for the bill — not even those liberally ladies from Maine. And things got complicated when ...

Republican Named Scott Brown Takes Ted Kennedy's Seat

Ted Kennedy had been a liberal hallmark of the Senate, crusading for health care reform and brandishing a righteous legislative history of brokering disputes between the parties. When he died, a special election was held for his seat, and instead of another Democrat winning, Scott Brown won the open Massachusetts seat.

The Democrats needed 60 votes in the Senate to avoid a Republican filibuster, and now they had only 59. They whined for a while about how the GOP was being obstructionist, that they had a clear majority, that the rules are a little weird anyway, aren't they?

To get around the snag, the Democrats pulled what some thought of as pretty hefty trickery by not bringing the legislation back to the Senate, even though the two chambers had passed different bills, then they used the Senate's bill as the core for a "reconciliation vote" and passed it in March 2010.

A few days later, Joe Biden called it a big deal.

Not So Fast!

Some newly-elected Republican governors weren't happy with ObamaCare (a term, by the way, that Obama has embraced), so they decided not to "implement" it in their states. Also, a bunch of Republican attorneys general from typically conservative states have taken issue with the "individual mandate" in the law, and they've taken the issue to court.

The question is whether the "mandate" is constitutional. The law's supporters say it's not a mandate at all — instead it's a choice: either buy insurance or pay a tax. Critics say that means it's a mandate, and mandates aren't allowed in the Constitution.

The Supreme Court is going to determine who is right.

"In order for the challengers to win, they would have to show that it is not a tax," says Jack Balkin, a constitutional law professor at Yale. "Most people think that the law will be upheld, but the Supreme Court will decide."

Looking Back

The monster that is the health care debate has ravaged the political scene for four years. Every Republican presidential candidate says he would repeal ObamaCare as soon as possible. And the public still doesn't know if the law is good or bad, because it won't take effect for years.

Obama gave a big speech to a joint session of Congress, just as Bill Clinton did, in which he laid out his promises for his health care plan. "Now that we're basically at the 2-year anniversary," said Kate Nix, a policy analyst at the conservative Heritage Foundation, "a lot of those promises aren't going to come true."

One reason that the health care debate was so acrimonious is that it erupted during a period of heightened government control. The Bush administration had just bailed out the banks, and Americans were confused why the jobs of the people who had caused the financial crisis were saved, while the rest of the country spun into unemployment.

Obama also wanted to bail out another industry — car makers. And on top of all of that, he passed a massive spending program called the "stimulus plan" that critics then said would do nothing and now say didn't do much.

Health care sponsored by the government wasn't exactly what most Americans wanted in their personal lives.

"The timing of it stirred up the emotions around it a lot," Tanner said. "I think people looked at it and said, 'Whoa — where are we going?' "