Obamacare turns five years old Monday. Let’s go straight to what you need to know.
▪ The law is working more or less as it was supposed to.
The two goals of the Affordable Care Act were to expand coverage and to cut costs. The first part has worked as the drafters expected. Even though the effort has fallen short in states that have refused Medicaid expansion (which U.S. Supreme Court allowed them to do), the law has sharply increased the number of Americans with health insurance. The picture is murkier when it comes to costs. Health-care inflation has slowed considerably. It’s just hard to know to what extent, if at all, Obamacare is responsible.
But the doomsayers have been wrong pretty much across the board. Employers haven’t cut back hours to avoid being forced under the law to offer health insurance. Nor has the private sector increased the overall number of uninsured by sharply cutting back on employer-linked insurance. The costs of the program haven’t exploded(they’re well below projections), and the federal deficit hasn’t ballooned (it’s falling, thanks in part to the ACA). The pure fictions (death panels!) never came true, of course.
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Two caveats: First, just because the program is working as designed doesn’t mean it has fulfilled some of the over-the-top claims of its supporters, including President Barack Obama: No, not everyone who liked his or her plan was able to keep it, to cite just one example.
Perhaps more important, none of this means that the basic ideological opposition to this type of government involvement in health care has been proved wrong, even if the system works the way supporters hope. Conservatives’ claims about government being incapable of functioning can be disproved when a program works as intended, but principled beliefs about the proper role of government remain just as viable (right or wrong) as they were in 2009.
▪ The law is unpopular and likely to stay that way.
The current HuffPollster estimate has 40 percent of people supporting the law and 45 percent opposing it. The law’s unpopularity has been mostly stable for years, except right after the botched rollout in October 2013, when opposition spiked before gradually returning to normal, with the small plurality opposing it. Most individual components of the law poll better than the law itself, with the main exception being the unpopular individual mandate.
As time goes on, fewer and fewer people will associate the law with the direct benefits they receive from it. For example, in the first year or two, people newly eligible for Medicaid might have known that Obamacare was responsible; in the future they'll just know they are eligible for Medicaid. Overall, as long as the Affordable Care Act remains the most recent major reform, people are going to blame it for anything that goes wrong in health care, whether or not it’s related.
▪ The law isn’t going anywhere.
The U.S. political system has a strong bias in favor of the status quo, and Obamacare, popular or not, is now the status quo. Even if Republicans gain unified control of the White House and Congress soon, trying to eliminate Obamacare — as opposed to just fulminating about it — will prove difficult and risky. After all, the healthcare system that existed before the current law is long gone, and a flat-out repeal would lead to chaos.
Is there an alternative? There’s a reason Republicans haven’t settled on one for five years. Legislating involves trade-offs, and it would be impossible to replace the current system without creating a new set of unhappy losers. A future Republican administration would be inviting the same troubles Democrats currently suffer, in which people blame any health- system problems on the current law because it’s the most visible target.
That doesn’t mean there won’t be real battles over government involvement in health care. Republicans will reduce subsidies and ACA-related taxes. Democrats, next time they have a chance, will try to increase them. A lot remains wrong with U.S. health care, and politicians from both parties will look for new initiatives to address those problems. And, yes, some Democrats will always wish for a single-payer system, while some Republicans will continue to try to come up with a viable Obamacare alternative, although both will remain pipe dreams for the foreseeable future.
In the end, we’re headed away from the repeal politics we’ve been stuck with for the last five years, and toward treating health care as a normal political issue.
Jonathan Bernstein is a Bloomberg View columnist covering U.S. politics.
© 2015, Bloomberg News