Oral histories offer reflections on the Affordable Care Act

Today, Incite at Columbia University released 26 new oral history interviews (Opens in a new tab) on the legacy of the Affordable Care Act, which were conducted as part of a larger project first announced in 2019 that Columbia is leading to document President Obama’s years in office. 

These 26 interviews bring to life so many moments of triumph, impact, and compromise on the road to getting the bill passed and implemented. But taken together as a whole, they bring into focus the sheer amount of work over eight years that was necessary to remake the health care system – and the impact that effort has had on millions of Americans who were able to gain coverage for the first time or gain peace of mind from new protections.

14 years later the effects of the Affordable Care Act are well documented. More than 21 million Americans have health care due to the ACA. The country’s overall uninsured rate is at an all time low. Americans can no longer be denied coverage for pre-existing conditions, young people can stay on their parents insurance until they’re 26, and insurers can no longer charge women more than men for the same coverage.  It’s why President Obama fought to pass the ACA in the first place and has continued to champion the law since leaving office, so that policymakers can continue to build upon the ACA’s strong foundation and make it possible for more Americans to access health care. 

Below are some excerpts from their stories:

The interviews feature former White House and congressional staff sharing their behind the scenes perspective on what drove the President’s commitment to making health care a priority and the legislative process: 

“Listening to President Obama talking about healthcare on the campaign trail, what I did notice was how personally it affected him, and how it was often about individuals that he met. And that turned out to be not just talking points that his speechwriter wrote: it was him. That compassion animated the entire exhausting process of driving the Affordable Care Act to fruition. And it was those stories and those people that he would continually ask me about, and think about, and make sure the policy helped them.” – Nancy-Ann DeParle, Director of the Office of Health Reform & Deputy White House Chief of Staff for Policy

“President Obama knew policy to a level of detail that you wouldn’t expect the chief executive to know. He really understood the details, the impact. He understood the politics of each one, and who was going to be helped and who was going to be hurt. And in his mind, he had a view of what the right approach might be.” – Elizabeth Fowler, Chief Health Counsel to Sen. Baucus on Senate Finance & Deputy Director of the Office of Consumer Information and Oversight at HHS “The president was the negotiator in chief at every point along the way, cajoling, critical, encouraging. What was also really interesting—he wasn’t really imposing his views. There were a couple of times where he was very noticeably agitated around drug pricing. He really felt strongly that this was an opportunity to get some drug pricing framework into a bill, if the Democrats were going to pass a bill, if he was going to support a bill, Medicare negotiation, something. And there were people both in the House and the Senate who made it clear that if that issue, which had not been in either of the bills—if that issue came back in a conference report, they would lose what majority they had to pass the bill.” – Kathleen Sebilius, Former HHS Secretary

During the ACA debate, the President received a letter from Natoma Canfield, a woman in Ohio who could no longer afford coverage due to a pre-existing condition. The president would cite her story often and kept her letter hanging outside the Oval Office. In 2020, President Obama reflected on Natoma’s story and why the night the ACA passed meant more to him than the night he was elected president – take a look:

Natoma’s sister Connie reflected in her interview on the relationship that developed between the President and Natoma. 

“[Natoma] was a fighter and that was evident even before she got ill. But when all this started, she had been a cleaning lady and also as a midwife for cows. She did have a varied career. She had worked hard and she had had breast cancer sixteen years prior to all this. The insurance company, I think they paid out nine hundred dollars or something. It was a low amount. And then they raised her rate twenty-five percent. She could barely afford that. And then, later on, they raised it another forty percent. She had not had treatment for cancer, but she was rated, and now she was a pre-existing cancer person, so that’s why she kept getting rated. She could not afford it. She was worried about losing her home…

So she got mad and she wrote the president. And, of course, people around her, “Oh, yes, what’s that going to do?” blah, blah, blah, that type of thing. She wrote the letter and she didn’t think too much about it until one day, the phone rang. It was the White House, asking if they could share the letter with an executive meeting that the president was having. He recognized right away that this was a letter that had heart. It captured the feeling of what Americans were going through in similar situations. So, of course, she said that was fine. Again, she thought that was the end of it. Well, he read the letter.”

Former HHS Secretary Kathleen Sebelius reflected on what Natoma’s letter meant to the President: “I think the Canfield letter crystallized a bunch of things for him…Here was a woman who was saying, ‘I’m battling a disease and battling companies at the same time, and I don’t know what’s going to happen.’“

“He had gone through that situation when his mother was quite ill and watched her, as he talked about, battle insurance companies….it personalized a lot of the theory of why the rules of the insurance industry didn’t make a lot of sense. I think she became, for him, an example of why we needed to change this law, what was happening to people all over the country; because she was articulate and had a compelling issue, but also it wasn’t a uniquely—it wasn’t a mom with a child with a rare condition, which we certainly had. It wasn’t an out-of- the-box—this was a woman, and there were people like her all over the country who were battling their own battles. She just had the gumption to write to him and tell him about it.”

Natoma passed away in 2021, and her sister Connie reflected on her relationship with President Obama, who called to offer his condolences after her passing. 

“He called, and he said that he and Michelle were extending their condolences. He wanted our family to know how sorry he was, and how important Natoma had been to him personally, and also for the Affordable Care Act. He couldn’t have been nicer and kinder. And, believe me, even though she had been sick for a long time, it was still hard for me…but, it was special, and Natoma would have been very, very happy to know the president had called and sent his condolences.”

Recording the reflections of letter writers like Natoma who could speak to the real world effects of the ACA was a key part of this oral history project. John Meir, who wrote a letter to the White House sharing his experience with healthcare.gov, offered his reflections on the impact of the law on his family: 

“Basically we were on a collision course with bankruptcy because we were not going to be able to afford the insurance rates which were going to go up again the following year. So had we not had the ACA, we would’ve stopped insuring ourselves. My wife had to have an operation to remove tumors, mass, from her breast. That was four or five years ago. That would’ve put us under. We couldn’t have paid for it.”

Small business owner Jim Houser talked about what the law meant to his employees: 

“I don’t know if there was an obvious connection [for employees] made between what’s happened in DC [...] But what they did do is, they raised families; because we covered dependents. We had one year where three of our employees all had babies in one year. And people bought houses. They were able to have steady, good income. One of the biggest expenses, healthcare, was under control.”

The interviews also include Obama alumni, many of whom continue to advocate for health care reform today, talking about their work and the legacy of the law.  

Jeanne Lambrew, who was at the center of passing and implementing the ACA, now serves as Health and Human Services Commissioner for the state of Maine. 

“The Affordable Care Act was nothing but a team effort. It was nothing but a bunch of people putting their egos in check to try to do something bigger than their individual shelves, their own advocacy, their own representation. And that was something, I think, that we valued….we try to identify people who are talented, who have nascent abilities and skills, but put them with other people so they become better together…

A lot of the success we had was this kind of transfer of intellectual human relations and skill set from generation to generation. And I would say what President Obama did was, he brought that to a finer point, really bringing into the White House some of the lessons. I mean he created the job of deputy chief of staff for implementation. It never existed before. But guess what? It really really matters. In fact, I’m creating a deputy for implementation down the hallway from here for me in Maine, because it’s a brilliant idea and you need that.”

Advocates and policy makers also reflected on the legacy of the ACA in the years since:

“There are people who come up to me every day and say, ‘I have insurance because of you. My kid is covered because of you.’ I live in Lawrence, Kansas, and there’s a little diner downtown. The owner, Meg, said to me—one of the days I was visiting and having lunch in there, she said, “You know, this is your diner.” I said, “Really? That’s very cool. Why is this my diner?” She said, “I was a waitress for years, and I’m married to a carpenter who does beautiful work but he has no health insurance. I have preexisting conditions, and I always had to work for a restaurant company where I could get insurance and insure our kids, because that was important to all of us.” And she said, “When the Affordable Care Act passed, I could take my savings and finally open a diner, which I’ve always wanted to do. This is my life’s dream. But that would not have been possible without the bill that was passed.”

I hear those stories every day. And it wasn’t my work. It was the president’s total commitment and focus that this was one of the most important things he could do. I think that legacy will live on and on and on.” – Kathleen Sebelius, Former HHS Secretary

“I think the Obama presidency was simply consequential in our life, and as history goes on and you look at that and you look at some of the enduring values that I think he represented as a human being and as president, that will stay with you. And the people who worked with him and who trained in that ethos came away with that sort of idea of, how do you do something of value? So your situation may change, but that way of going about it, that kind of integrity, that kind of commitment, is really unchanged….I think the ACA was a game-changer. I think we’re still going to work on this issue, because we’re going to have to solve the problem as a nation of truly making healthcare accessible in whatever region of the country you get it, whether you’re rural or urban or up or down.”  – Dr. Carolyn Britton, Former President of the National Medical Association

“I was obsessed with having the three things we always talked about, and I didn’t care if they knew anything else about the Affordable Care Act. One, that it meant women could no longer be charged more for health insurance than men. Essentially gender rating ended. Of course, no one knew that. No one talked about that. Saved women so much money. Two, that we couldn’t be prevented from getting insurance because we had preexisting conditions, which were disproportionately a burden for women, particularly women who had children, women who had pregnancy…

And the third is that we didn’t have to pay for our preventive care anymore. There was, literally, no copay, including birth control. And, of course, the tagline for all this was, ‘Being a woman is no longer a preexisting condition.’ ” – Cecile Richards, Former President, Planned Parenthood

“One of my most proud things....the Affordable Care Act produced the National Prevention Council. That council was made up of, like, at the time, seventeen Cabinet-level agency heads, who sat around for the first time ever to talk about prevention….with the National Prevention Strategy, our goal was to, again, move into an area of wellness and prevention. And our goal was to make sure we increase the wellness and increase the condition of Americans at every stage of life.[...] It was just really a good feeling to be a part of that administration, the Obama administration, who wanted people to get healthy, stay strong, live long, and thrive.” – Dr. Regina Benjamin, 18th US Surgeon General