Way back when, I made three predictions about the Affordable Care Act, which survived another brush with death on Thursday in yet another court case.
The one I was right about was that Obamacare would survive. That was relatively easy. The US political system has a strong status-quo bias, and once the ACA was passed it became difficult to dislodge. In part, that’s because it’s just difficult to enact things. But it’s also extremely difficult for elected officials to take stuff away from their constituents. It’s easy to bash Obamacare, but hard to shut down the exchanges it established or to take insurance away from people. It’s so hard to take away protections for pre-existing conditions that Republicans have been swearing up and down in recent years that they’d never imagine doing such a thing (even though repealing the ACA, as they wanted, would do exactly that). Perhaps worse, Obamacare was such a sprawling bill that scrapping it would risk massive chaos. Politicians rarely do such things.
More interesting, I think, are the things I got wrong. The first was that I thought Obamacare would last, but be unpopular. My logic was pretty simple. Republicans clearly were going to bash the law forever. And many of its benefits were either invisible — a lot of people now don’t realize that their minor medical issues would’ve prevented them from getting insurance pre-ACA — or, like the expansion of Medicaid, not branded as part of Obamacare. So I suspected that few would have reason to support the law, many would have strong partisan reasons for disliking it, and it would be an easy target for anyone who was unhappy with any aspect of health care.
And yet Obamacare these days is moderately popular. One reason is that Barack Obama himself is a moderately popular former president. Calling the law “Obamacare” may have hurt Democrats in 2010, but in the long run it probably helped it poll better. Another reason? Repeated Republican attempts to repeal the law probably helped Democrats associate it with its most popular provisions. On top of that, while the law was associated with a somewhat popular president, opposition was associated with congressional Republicans (members of Congress are rarely popular) and, eventually, with the unpopular Donald Trump. Advantage ACA.
My final prediction was that after the initial attempt to repeal Obamacare, the law itself would fade from the news, and we’d return to normal health-care politics — with Democrats seeking to spend more on benefits and Republicans focused on reducing spending and stopping mismanagement and fraud. I thought that would happen at least five years ago. Instead, we’ve been fighting over whether the ACA should exist, be repealed, or, as the Bernie Sanders Democrats say, be replaced with a single-payer system.
It’s possible we’re finally getting there. President Joe Biden’s decisive victory over Sanders in the nomination battle last year may have reset the Democrats’ agenda to incremental, rather than radical, change, and made the issue perhaps lower among the party’s priorities than it seemed 18 months ago. Besides, when it comes to Republican-aligned media, there are newer products to sell, whether it’s opposition to teaching about racism or flaky recounts to long-settled elections. Perhaps the parties will fight over somewhat higher or lower subsidies on the exchanges and other questions that, while important, leave the basic structure of health insurance in place. But perhaps not.
Bloomberg
