Jonathan Bernstein makes a very good point on the Democratic coalitions of 2007/2008:
One key point that Lemieux doesn’t mention this time: in one sense, this really isn’t about 2009 at all. It’s about 2007 and 2008, when the three leading Democratic presidential candidates converged on essentially the same plan (with Obama famously omitting the individual mandate). That says a lot. It says that none of those three candidates believed that adopting single-payer would have given them a serious edge in a closely contested nomination fight — and that no other candidate was able to leap to the top tier by embracing single-payer. In other words, it tells us that in the world of 2007-2008, at least, the ACA was mainstream within the actual Democratic Party as it was, and single-payer was a fringe position in the actual Democratic Party as it was.
This is right. Presidents have agency, but they lead political coalitions. In a political universe where single payer (or, more plausibly, Swiss health care) was viable, at a minimum it would have to have such powerful support among the Democratic electorate that a major presidential candidate would endorse it. This wouldn’t be enough — given its structure, the median votes in the Senate are almost certain to be well to the right of the Democratic candidate for president, let alone the Democratic primary electorate — but it would be a minimum first step. In the politics of 2008 and 2009, anybody who became a Democratic president was going to pursue comprehensive health care reform of essentially similar shape unless they decided not to pursue it all (which was highly unlikely.) It’s worth noting that the comprehensive health care reform undertaken by a major state with a much more liberal electorate and collection of legislators took a simialr form as well.
And while nobody can prove the counterfactual, I also agree that President Clinton would have signed something virtually identical to the ACA. It’s true that in a context in which every single one of the maximum number of votes in the Senate available in a very narrow window was necessary, there’s far more risk of a catastrophic downside
The key thing to remember is 217-60-1-5 in the universe as it is was in 2009-2010. (would be 218 but there were vacancies in the House)
Those are the numbers of the minimal viable coalition. PPACA passed at 219-60-1-5.