How ‘Hillarycare’ Did, and Didn’t, Lead to Obamacare

The real precursor was Mitt Romney’s plan, say people who wrote the president’s health care law.

Hillary Clinton is taking increasing credit for Obamacare, arguing that the 1993 health care overhaul effort she spearheaded was the foundation for President Barack Obama’s plan.

“It was called Hillarycare before it was called Obamacare,” the Democratic presidential candidate said in Vinton, Iowa, on Thursday, referring to her plan’s derisive nickname. “I don’t want to start over again, I don’t want to rip up this accomplishment and begin this contentious debate all over again.”

Her comments come as she wages war with liberal rival Bernie Sanders ahead of the Feb. 1 Iowa caucuses and Feb. 9 New Hampshire primary. Clinton says Sanders’s plan to replace most private health insurance with a government-run system, known as single-payer, is too disruptive and a potential threat to the Affordable Care Act. But does her claim—part of an attempt to position herself as Obama’s heir—hold up?

It’s an oversimplification, as Obama’s plan more closely resembles the Massachusetts overhaul signed into law in 2006 by the state’s then-governor, Mitt Romney, Obama’s Republican opponent in 2012. But people who helped write the Affordable Care Act give Clinton credit for laying the political groundwork that helped Obama succeed where her husband, former President Bill Clinton, failed.

“The Affordable Care Act was modeled after Romney’s Massachusetts plan, not the 1993 Bill Clinton plan,” said Timothy Jost, an expert on health care law. “The 1993 plan and the ACA are very different proposals.” 

Obama’s plan is a federal version of Romney’s in its basic structure: A regulated marketplace that prohibits insurers from refusing coverage for sick people, or charging them higher prices; requires most people to buy coverage; and provides subsidies to low-income people to help them afford coverage. The goal of both plans was to preserve most existing coverage while extending it to the uninsured.

Clinton’s plan, by contrast, was more ambitious in its scope and would have been more disruptive for the vast majority of Americans who receive insurance coverage through an employer or through Medicare or Medicaid, the government programs for the elderly and disabled and for the poor. The sprawling proposal sought to achieve universal health coverage by offering all Americans a standard minimum-benefits package and imposing limits on out-of-pocket expenses, along with a broad requirement that employers provide insurance.

“It did try to impose a fundamentally new system,” Jost said, arguing that many people would have seen their coverage—or the source of it—change.

“For all the criticism that the ACA has caused disruption, it’s remarkably incremental compared to what the Clinton administration proposed back in the 1990s,” said Larry Levitt, a health policy expert with the Kaiser Family Foundation who worked in the Clinton administration and helped develop the proposal. “The ACA leaves the current private insurance system largely unchanged for the majority of people who get coverage through their employers. The Clinton Health Security Act would have required most people to switch their health insurance coverage to new health insurance alliances, and it imposed caps on how fast premiums could rise.”

As a result, Republicans and the health insurance industry linked arms to vociferously oppose Clinton’s plan, and it died before even getting a vote in the Democratic-led Congress. A crucial lesson that the Obama White House learned from that endeavor was that health care change of that magnitude was nearly impossible to move through Congress, given that most Americans are satisfied with their coverage. As a result, Obamacare was aimed more narrowly at the uninsured.

Hillary Clinton adopted that lesson in her 2008 presidential campaign, proposing a health care plan that closely resembled Romney’s. It included an individual mandate to buy insurance, which Obama ironically argued against in the Democratic primary, only to embrace it later as president.

“The 2008 Hillary plan was basically Romneycare, and they were both much closer to the ACA than the early 1990s plan,” said Jonathan Gruber, a health care economist and MIT professor who advised both the Romney and Obama reform efforts.

“That said, I think the success of the ACA would not have been possible without some of the key lessons learned during the Clinton era debates,” Gruber said. “So she gets important credit for setting the political groundwork.”