It was the first week of March 2009, and inside the White House, the grand policy aspirations of the young Obama administration were colliding with stark economic reality. On Thursday, March 5, President Barack Obama hosted a summit to kick off his health reform push. On Friday, the S&P 500 hit its lowest point in a decade.

But in the Eisenhower Executive Office Building next door, for all the talk of expanding health coverage and striking bipartisan deals, aides wrestled over a deeper question: Should they push harder to control America’s runaway health spending, even if it killed jobs in the short term?

“We knew our economy spends more than it should on health care," says Bob Kocher, a venture capitalist who served as a special assistant to the president in 2009 and 2010 and helped shape the Affordable Care Act. “And we had good battles inside the White House" over whether to preserve health jobs — which were one of the biggest drivers of those costs, but kept Americans employed at a bleak economic time.

Health care experts like Kocher and colleague Zeke Emanuel wanted reforms that would increase efficiency and tamp down the sector's growth. But “people on the jobs team were saying we need more middle-class jobs and the best place to create them was in health care,” Kocher says. “And after we lost 7 million jobs [in the recession], that argument was winning."

The resulting law — born at the very moment the economy was bottoming out — ultimately came down on the side of saving jobs. It conceded many cost controls in favor of softer measures. And in that respect the decision paid off: The industry has gained nearly 2 million jobs since the ACA was signed into law in March 2010. More people — 15.5 million — now work in health care than live in the state of Ohio. Employment in the health insurance industry, which had fallen since the recession, jumped nearly 9 percent from 2012 to 2013 as millions of Americans became newly insured. Based on job numbers, no sector is healthier than health care.

But is that what the American economy needs? Experts say that many health care jobs are an explicit drag on growth, and the higher the cost of health care, the less money invested elsewhere. The rising cost of health care is a top-three issue for CEOs; it’s often cited as a reason for why U.S. manufacturers are less competitive with their overseas rivals.

Today, the jobs-driven political tradeoff that prevented Obamacare's authors from making hard cuts to health care costs is still bedeviling policymakers. Despite a recent slowdown in spending growth, which the White House has repeatedly touted, health costs continue to rise every year — and they’re increasingly hard for legislators to address because scaling back will turn off a jobs engine. If Congress doesn’t figure out a way to confront the industry's unchecked spread, economists believe, the decisions made in 2009 will have costs that linger years and even decades into the future — leaving the next administration with the kind of success story it would prefer not to inherit.

“OBAMACARE KILLS JOBS” is a Republican talking point so common it might as well be burned into a teleprompter. "It is the biggest job-killer in this country," Ted Cruz said at the final GOP primary debate — a position echoed by John Boehner, Mitch McConnell, Rick Scott and nearly every other Republican luminary. Donald Trump, in his 2011 book "Time to Get Tough: Make America Great Again!", put it more floridly: "Obamacare is a heat-seeking missile that will destroy jobs and small businesses."

That’s not how the law turned out. The private sector has grown every single month since the ACA passed in March 2010, a number that Obama often touts when he defends his signature law. And many of those jobs are, literally, in health care. More than 1 in 9 employed Americans now gets a paycheck directly from the health care industry, and that's not counting the millions more who work in associated fields, like tech companies that specialize in health care services or the consulting firms that gorge on the sector's inefficiency.

Health care leaders tell a simple story: That their industry helped cure America's economy, post-recession. It's already surpassed the manufacturing industry in terms of total jobs, and based on current hiring trends, health care will become the nation's largest industry by 2019, passing the entire retail sector.

But there's another truth: All those new jobs are hiding a poison pill. Health care's fast growth is actually a drag on the rest of the nation's economy. As it grows, it's setting up an ever-bigger health care bill that employers, patients and taxpayers ultimately shoulder. Many of those jobs are effectively waste. "For every doctor, there are now 16 FTEs that are non-doctors," Kocher said. "Nine of them are administrators — and it's jumped from six" in the past few years.

That means that efforts to slow or even reverse health care costs would be massively disruptive to millions of middle-class workers by reducing jobs in one of the nation’s largest industries. So as it grows, health care becomes the sacred cow that lawmakers can't — or won't — cut.

To understand the central role health care now plays in employment, it helps to look at the recession, and how the sector appeared to pull off a minor miracle during America's darkest economic cycle in decades. Even as the rest of the economy shed more than 9 million jobs from January 2008 to February 2010, health care delivery firms like hospitals, physicians and home health agencies collectively gained more than 550,000 jobs.

In fact, the health care sector added jobs every single month during the nation's historic downturn. On employment charts, it looks like a mistake — the only straight upward line as every other industry cratered. And the sector just kept growing through the recovery, adding net jobs at a historic pace. Meanwhile, industries like manufacturing and retail have stayed flat or even shrunk since Obama took office.

The health care industry has characteristics that make it a great job creator. Health care demand is largely recession-proof; while some elective surgeries can be postponed, heart attacks and cancer don’t wait for the economy, the way car purchases and house-building do. It's hard to outsource hands-on patient care, which means that there's need for local employees in communities across the country. And for many Americans, a job in a hospital or clinic — even as a janitor or cafeteria worker — is safer than working in manufacturing. It also offers more job security than retail or dining, where companies can quickly shutter.

Although it’s hard to draw the line directly, Obamacare most likely accelerated that job growth itself. The White House says the ACA has led to 20 million people gaining health insurance — and that's led to greater demand for health care and need for workers to provide it. Hospitals have hired more people in the past 18 months — nearly 270,000 new employees — than in the previous six years before that combined.

When health care jobs grow, health care spending tends to rise, too; national health spending topped $3 trillion for the first time in 2014. Labor represents more than half of health costs, which often get passed along to employers and patients in the form of ever-higher health premiums, which outpace inflation. There's a clear negative effect: About 90 percent of surveyed executives blame their company's growing health costs for stifling investments and holding down employee wages.

For health economists, it's the ultimate conundrum. Health care jobs helped carry the nation out of recession — but too many health care jobs might keep the economy from reaching its full potential. And they're still wrestling with figuring out the right balance, while trying to persuade lawmakers to tackle the challenge too.

"Health care jobs are relatively high-paying jobs," said Ani Turner of the Altarum Institute, which issues monthly reports on health care employment and spending. "For the benefit of the broad economy, it's not bad to be growing health care jobs — they're good jobs." Our government expects health care's boom times to continue. The Bureau of Labor Statistics projects that as America ages, about 25 percent of all newly created jobs in the next decade will be in health care and social services, and there will be nearly 350,000 new home health aides alone. (Overall, the BLS projects that nine of the 12 fastest-growing occupations in the next decade will be in health care.) But devoting more resources to health care runs the risk of crowding out other industries, Turner added. "There are real trade-offs."

"Having more employment in the health care sector means spending more on health care," agreed Katherine Baicker, a Harvard health policy professor, who co-authored a widely shared 2012 paper, "The Health Care Jobs Fallacy," which rebuked policymakers for preserving health care jobs rather than prioritizing health system efficiency. "And whether that's a good thing or not hinges on whether it's producing health or not."

THE DANGER DOESN’T seem to resonate on Capitol Hill, where all jobs are good jobs. That’s the message that multiple staffers in both parties stressed in interviews: In a still-recovering economy, with the recession's scars still fresh, the imperative is to see as much employment growth as possible — even though reducing health care costs is a top priority of many voters.

Lawmakers have especially strong incentives to preserve the status quo in health care or even build on it — even as they call for “bending the curve” and spending less. Every congressional district has at least one hospital; it’s often the largest employer. Overall, health care and social assistance employs the most people in 56 percent of congressional districts.

Industry officials have gotten especially savvy about touting the halo effect of all those jobs, too. Take Johns Hopkins Hospital, which directly employed nearly 25,000 people in Maryland and Washington, D.C., in 2014. The hospital system determined that those jobs led to about $1.4 billion in direct economic output. But when factoring in purchasing, construction and other indirect effects, including patients who travel in for care, Johns Hopkins concluded that its total economic impact was worth more than $3.6 billion to Maryland and D.C. per year.

What it all means: There aren’t easy answers if lawmakers want to shift spending priorities without killing jobs. A specialist in arcane health care billing codes or revenue cycle can't become a nurse or doctor overnight. Democratic presidential candidate Bernie Sanders confronted this reality during his campaign. His proposed single-payer plan — which would have radically reshaped the health insurance industry by replacing it with Medicare-for-all — could have led to as many as 2 million Americans needing to find new work, according to an economic analysis. One retired health care worker plaintively asked Sanders at a CNN town hall earlier this year what would happen to them.

"There's hundreds of thousands of middle-class jobs in the health insurance industry all across this country that could be adversely affected," she said — prompting a vague, implausible promise from Sanders that all of those workers could be retrained.

It would seem that one big target might be waste: It's no secret that America's health system is wildly inefficient, and could theoretically shed many jobs without having much of an impact on patients. Some estimates have suggested that America's unnecessary health care spending and care tops 30 percent. The United States was ranked 11th out of 11 nations on health care efficiency by the Commonwealth Fund, and peer countries like Switzerland spend one-third less on health care as a share of GDP and 50 percent more on social services — like disability benefits and supportive housing — that experts increasingly say are linked with good health.

Yet it's still hard to pry wasted money out of our system, if that money helps keep people employed. "Every dollar of health care spending is someone else’s health care income," says Princeton economist Uwe Reinhardt. "Even when it's fraud, waste or abuse."

TO ACHIEVE THE larger goals of health reform — more affordable care for more people — America's health system needs to get more efficient, improving results and lowering costs the way other industries do. The White House likes to trumpet its success “bending the cost curve,” but this only means that the rate of growth has slowed — costs are still going up every year, faster than inflation. Truly bending the cost curve, or at least ensuring that costs lag inflation, might even require negative cost growth. And that's hard when the single biggest driver of health costs is labor, and when many of the new jobs are administrative.

Having studied the sector, Kocher concluded that recent health job growth is mostly in non-clinical positions, like overseeing billing and collections, which doesn't help patients or improve care. "Hospitals are especially bad," he said. "They have big office buildings full of people who aren't seeing patients."

Kocher believes that venture capitalists — like him — are free to do what D.C. has not. Namely, he thinks Silicon Valley can play an outsized role by funding new software and technologies like telemedicine that he believes will eliminate unnecessary jobs and "liberate" productivity.

"Health care has a lot of repetitive tasks and labor," he said. "I'm excited by opportunities like making revenue cycle go away, or making it so that [patient] scheduling doesn't require multiple calls."

Baicker, at Harvard, thinks that health care providers could create a more productive, higher value health system by focusing on the workforce. "One health care job is not the same as another health care job," she says, suggesting that hospitals can increasingly substitute physician assistants and nurse practitioners for higher-cost counterparts if they're allowed to practice at the top of their license — essentially, if state regulators allow them to do the full range of what they’re trained to do.

"If we can deliver the same or better health benefits while spending less, that's an improvement in the health care system."

Some economists think the sector's already on the road to improvement. Paul Hughes-Cromwick of Altarum Institute notes that while job growth remains high, health care cost growth remains relatively low. Paired with new data from the Labor Department's survey of job openings and labor turnover, he thinks it's a sign that health care's job growth "bubble" could pop in coming months — which could be a good thing for tamping down health costs.

"The early tea leaves [point to] a slowdown," Hughes-Cromwick says.

Meanwhile, the Obama administration is testing ways to improve efficiency in the sector by focusing on upfront hiring: Officials in April announced a job-driven training initiative to prepare workers for health care careers. The goal, White House officials say, is to match community college graduates to emerging job opportunities as the health system evolves, post-ACA.

"We are trying to move toward paying for high-value care," says White House economist Matt Fiedler. "The goal of health care policy is not to make sure we're creating a certain number of jobs in the health care sector … but to make sure we're creating the right jobs."

To make real progress toward that goal, Harvard's Baicker stressed, will require lawmakers to stop viewing health care as a jobs program. That predicament clearly bedeviled the Obama administration when policymakers were drawing up the ACA in the first place. And it will require an even more remarkable act of will from a Congress that hasn’t been able to stop arguing about whether the law should even exist. Time isn't on their side. Neither are demographics. About 10,000 Americans are now turning 65 and becoming eligible for Medicare every day — all needing more care, and all creating more jobs that America, in the long run, might not really want.

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