Democrats hope — and Republicans fear — that Americans will embrace Obamacare, once the Affordable Care Act goes into full operation. Democrats hope that, once Americans enjoy the benefits from the legislation, it will become an entitlement as popular with voters as Social Security and Medicare. Republicans fear that Democrats may be right. That explains their increasingly desperate attempts to derail implementation of the landmark 2009 health care law.
But will Obamacare really become as popular with mainstream Americans voters as Social Security and Medicare? There are reasons to be skeptical about Democratic hopes and Republican anxieties.
Political scientists tend to agree on the characteristics of safety net programs that are popular with middle-class voters. Popular programs tend to be universal, simple and visible.
Both Social Security and Medicare fit all three tests. Although Medicaid is means-tested and limited to the poor, Social Security and Medicare are universal programs for which all citizens are eligible. They are simple and straightforward programs, carried out directly by a single level of government, the federal government, instead of outsourced to private agencies or divided among the states and the federal government. And both the payroll taxes that pay for all of the program (Social Security) or part (Medicare) and the benefits are transparent and visible.
In contrast, Obamacare fails all of the classic political-science tests of popular, sustainable social legislation. Indeed, it is practically the dictionary definition of the kind of overly-complicated, jury-rigged public policy that the political scientist Steven M. Teles calls “kludgeocracy.”
Obamacare is means-tested, not universal. The major beneficiaries of Obamacare will be poor people who are not provided health insurance by their employers and cannot afford it on their own. The sliding-scale subsidies decrease and finally end, as your income goes up. Unfortunately, as the saying goes in American political science, “programs for the poor are poor programs.” Means-tested programs tend to inspire resentment among those whose incomes are above the cut-off point for eligibility. There is reason to fear that Americans without subsidies will resent those with subsidies, while those with small subsidies will resent those with larger subsidies below them.
Obamacare is complicated, not easy to understand. Even the defenders of the Affordable Care Act have trouble explaining what it is. It’s not a single social insurance program like Social Security, Medicare or Medicaid, but a collection of subsidies, mandates, new taxes and regulations. Each of these might be defensible in isolation, but it’s hard to wrap your mind around the whole. That’s not a problem with popular federal programs like Social Security and Medicare and the G.I. Bill and student loans.
Indeed, the system created by the Affordable Care Act is not a government program at all, but a system of subsidies to the for-profit insurance industry, which intimidated Congress into outlawing any nonprofit public plan, like the one proposed by Jacob Hacker.
Add to this the fact that the program is designed as a federal-state hybrid, with both state and federal exchanges, sliding scale tax credits and even gold, silver and bronze plans like those of a gym or airline, and you can be forgiven for wondering whether Obamacare will raise the cost of the aspirin you need to treat the headache you get while trying to figure it out.
Obamacare is largely invisible. Social Security and Medicare are popular in part because of their transparency—you only need to check your biweekly payroll stub to see how much you are paying into the program, and you can go online to find out your estimated monthly check in retirement from Social Security. Much less visible are the tax credits and regulations that make up much of the system created by the Affordable Care Act. Another lesson of political science is that when public policy is invisible, activist government tends to receive little or no credit from voters who don’t realize the full extent of the benefits they are deriving from the public sector, to the political detriment of progressives.
None of this is meant as substantive criticism of particular provisions of the Affordable Care Act. We’re talking politics, not policy. My thesis is simply that while Social Security and Medicare are likely to be treasured by Americans and defended by many Republicans as well as Democrats in 2023 or 2033, it’s unlikely that politicians will be vowing with the same fervor to protect Obamacare.
They may, however, vow to protect particular aspects of the Affordable Care Act that have proven to be popular with voters, like bans on insurance company rejections of people with pre-existing conditions. Obamacare is a work in progress. Its elements will be revised repeatedly in the years and decades ahead, with some expanded and others altered or rejected.
During the long process of revision, as individual elements of the bill are separated from each other in successive waves of reform, the term ”Obamacare” may well be dropped. In hindsight, the Affordable Care Act may be viewed as the first step in a multi-decade process in which the federal government applies increasingly strict utility-style regulation to both health insurers and medical providers. Treating both health insurance and medicine as public utilities is long overdue in America. But because the Affordable Care Act focused on the easier (if still difficult) goal of insuring the uninsured, the big, important battles over restraining medical prices in the U.S., by methods like all-payer regulation, are in the future. And those tempestuous battles in the years ahead may make the turmoil over Obamacare look in retrospect like a mild summer shower.
This is not necessarily bad news for Democratic supporters of the Affordable Care Act. Whatever Obamacare evolves into may never be as popular with the public as Social Security or Medicare. But as time goes on, and Congress passes subsequent major health care reforms, it will be ever harder for conservatives and libertarians to blame everything that is wrong with American health care on a single piece of legislation passed in 2009.
The good news for all sides—including progressive supporters of a more universal system—is that the Affordable Care Act has just begun a generation-long process of fixing American health care. Those who lose a battle today may win one tomorrow. Obamacare is not the beginning of the end of the great American health care debate, only the end of the beginning.