Betsy and Zeke

Republicans knew the death-panel smear against Obamacare was a lie. They used it anyway.

Jonathan Cohn is a senior national correspondent at HuffPost and a former senior editor at the New Republic. This is excerpted from The Ten Year War: Obamacare and the Unfinished Crusade for Universal Coverage (St. Martin’s Press).

In 1994 the New Republic published an article by Elizabeth McCaughey, a fellow at the conservative Manhattan Institute, that demolished the policy rationale for Hillary Clinton’s ambitious health care plan. The piece was hugely influential, and it went on to win a National Magazine Award. Along with a related article that she published on the Wall Street Journal editorial page, McCaughey parlayed her Hillarycare piece into a spot with George Pataki on New York’s Republican gubernatorial ticket. When Pataki won, she became the state’s lieutenant governor.

McCaughey’s article was wrong in so many particulars that journalists were still documenting them a year later. McCaughey had no background writing about health policy; her only qualification was a doctorate in American constitutional history. Among her arguments was the patently false claim that the Clinton plan prohibited doctors from accepting private payments for services. 

Devastating takedowns of McCaughey’s analysis were published in the Atlantic and even in the New Republic, but by then Newsweek columnist George Will and talk radio host Rush Limbaugh had conveyed her arguments to millions. Hillarycare died in the Senate, Republicans regained the House for the first time in 40 years, and for the next decade Democratic politicians avoided even discussing any framework for a national health care plan.

That changed in January 2007, when candidate Barack Obama boldly promised “universal health care for every single American.” Two years later, Obama was president and the Democrats were putting together a health care bill.

Then McCaughey re-emerged.

McCaughey’s political career had not gone well. She and Pataki didn’t get along, and Pataki dropped her from the ticket in 1998. McCaughey then switched parties to run as a Democrat against Pataki, bankrolled by her husband, the financier Wilbur Ross (who would later be Donald Trump’s Commerce secretary). She lost the primary race, divorced Ross, then filed a $40 million lawsuit alleging that Ross broke a promise to her by not funding her candidacy unconditionally. 

McCaughey told a talk radio audience in June 2009 that the Democratic health bill “would make mandatory—absolutely require—that every five years people in Medicare have a required counseling session that will tell them how to end their life sooner.” This was just as wildly inaccurate as her earlier claims about Hillarycare had been. All the Democrats were proposing was to have Medicare reimburse doctors for time they spent advising patients who wanted to write advance directives. The hope was that, with the reimbursement, doctors would give patients their undivided attention for more than just a few minutes, to make the process of writing those instructions easier.

Once again, fact-checkers pointed out that McCaughey was quite wrong. Once again, it didn’t stop the attack from spreading—especially on Fox News. In short order Sarah Palin, Sen. John McCain’s running mate against Obama the previous year, coined the phrase “death panels” that came to describe this mythical feature of the health care bill.

Among those outraged by the distortions was Sen. Johnny Isakson (R.-Ga.), who wrote the provision on end-of-life counseling that had ended up in the bill. “It’s to protect children or a spouse from being put into a situation where they have to make a terrible decision,” Isakson told journalist Ezra Klein, “as well as physicians from being put into a position where they have to practice defensive medicine because of the trial lawyers.” But most Republicans said nothing, and quite a few repeated versions of the argument. House Republican leader John Boehner sent out an official statement warning that the end-of-life counseling provision “may start us down a treacherous path toward government-encouraged euthanasia if enacted into law.”

For the White House and its allies, the death panel nonsense was a politically damaging distraction. For Zeke Emanuel, the principal health policy adviser to White House budget chief Peter Orszag, it was a personal attack. 

Zeke was the oldest of the three high-achieving Emanuel brothers, whom more than one person had likened to a modern-day version of the Kennedys, only Jewish and less focused on politics. In addition to Rahm, who was serving as Obama’s chief of staff, there was Ari, the Hollywood talent representative who had built one of the entertainment industry’s biggest and most powerful agencies. Growing up, the three boys were energetic, outspoken, and highly competitive with one another. As grown-ups, they were pretty much the same. Of the three, Zeke was the most academically accomplished. He had a medical degree and a doctorate from Harvard, where he also won the annual Toppan Prize for the government department’s best dissertation.

As a medical student and future oncologist, Emanuel watched families struggle with difficult choices about treatment for dying patients no longer able to make their own decisions. Drawing on his background in philosophy, he and his then wife, Linda, created a basic form they called “The Medical Directive” designed to let patients think through and specify, in some detail, their preferences for four medical scenarios in which they could not consciously make decisions for themselves. The Emanuels published it in The Journal of the American Medical Associationand made copies available, for a dollar plus a self-addressed stamped envelope, by request. Their Medical Directive became a widely used template for living wills. Later, Emanuel joined the National Institutes of Health, where he launched its bioethics division. 

Emanuel’s primary focus in the White House Office of Management and Budget was on eliminating waste in the health care system. He worked closely with Bob Kocher, a fellow physician, and met with various groups from the health care industry to persuade them that reforms like bundled payments (as opposed to fee-for-service) were less threatening than they might seem. 

Emanuel didn’t watch television or follow social media, so it took him a few days to realize that the controversy about death panels had become a controversy about him. McCaughey went through Emanuel’s past work and wrote in the New York Post that he believed “medical care should be reserved for the non-disabled…. Translation: Don’t give much care to a grandmother with Parkinson’s or a child with cerebral palsy.”

On the House floor, Michele Bachmann, a hard-right junior Republican, read excerpts from the McCaughey article and then recounted the care her late father-in-law had received in his final weeks: “Apparently, under the Democrats’ health care plan, my father-in-law would not have received the high quality of care that he received in his last two months of life.” 

Emanuel seemed to his friends genuinely shocked, not least because he had spent so much of his career trying to improve end-of-life care. The quotes McCaughey pulled out came from academic papers about truly scarce resources, like organs for transplant, and the ethical questions that different criteria for allocating them would raise. In other publications, Emanuel had written whole articles against doctor-assisted suicide, and in a book on end-of-life care he criticized a high-profile court case in which a judge allowed doctors to discontinue treatments of an incapacitated patient because of the parents’ wishes.

“I’m an oncologist who has cared for scores, if not hundreds, of dying patients,” Emanuel told The Wall Street Journal after the McCaughey op-ed started to get attention. “It’s a perversion of everything I’ve done to take one or two quotes completely out of context, without any of the qualifiers I’ve added, and distort them.”

The White House mounted a full defense. So did Emanuel’s network of contacts and supporters, including high-profile conservatives like Stuart Butler, a scholar at the Heritage Foundation who had been involved in GOP politics since Reagan’s day. “These personal attacks on good people like Zeke are outrageous,” Butler said. “There are real policy issues that should be debated vigorously, but slandering a good person’s name is beyond the pale.” Gail Wilensky, another longtime Republican adviser who was by then a senior fellow at the global health organization Project Hope, said she was “shocked by the comments about Zeke.”

Wilensky’s voice was the kind that, at an earlier time, would have carried a great deal of weight in Republican circles. She was among the most formidable health policy experts in the country, a University of Michigan-trained economist who had run Medicare and Medicaid under President George H.W. Bush. When she said government programs were prone to waste and inefficiency, she spoke as somebody who had seen that waste and inefficiency up close. She was an early critic of the legislation that eventually became the Affordable Care Act, because she thought it was trying to do too much too quickly—and relied too heavily on the wisdom of government agencies that, in her experience, were not really that wise.

But Wilensky’s critiques of Democratic legislation were conspicuous for what they did not include. She did not attack the individual mandate on philosophical grounds, because, as a health economist, she believed it took that kind of incentive to make private insurance markets work properly. “I’m not against requiring insurance, in principle,” Wilensky explained to me in an interview two years later. “We’ve already made the commitment to not having people die in the streets.” And although she was no fan of government spending, she conceded that “if we’re going to fix the problems of the uninsured . . . we have to put money on the table initially.” That kind of nuance was no longer consistent with GOP rhetoric. 

Around the same time that McCaughey effectively called Emanuel a granny-killer in the New York Post, Sen. Jim DeMint (R.-S.C.), participated in a phone conversation with conservative activists. As recently as 2007, DeMint had praised the Massachusetts reforms that would provide the basic model for Obamacare. They were, after all, the handiwork of a fellow Republican, Gov. Mitt Romney. But now DeMint was attacking the Democratic bill as a “government takeover.” On the phone call, DeMint made his motive clear.

“If we’re able to stop Obama on this,” he said, “it will be his Waterloo. It will break him.”