When President Barack Obama signed the Affordable Care Act into law in 2010, much of the media framed the bill as a vast expansion of the existing social safety net. Because a Medicaid expansion was one of the law’s cornerstones, it appeared largely as a benefit for the working poor, which narrowcast its public support.
Since then, however, the nation’s reliance on Obamacare’s more universal protections—most notably for those with pre-existing conditions—has changed public perception. The ACA today has joined Social Security and Medicare in the pantheon of American entitlements: It’s popular, and Americans from all walks of life have come to rely on its protections, especially in the middle of a pandemic.
With that shift, Obama’s signature domestic achievement, once politically vulnerable, has become a third rail for any critics who still want to attack it. Now, on the eve of the next administration, the ACA’s improved public image creates a political opening for President-elect Joe Biden to work with Congress to expand the original bill and offer more coverage to more Americans—just as Social Security and Medicare were expanded over time, too.
Obamacare’s rising status as an entitlement gives it a new kind of political power—and points to one of the key reasons Democrats did so well in the 2018 midterms, and that Biden won so convincingly earlier this month. Conservatives still feel comfortable criticizing programs that exclusively target the working poor—food stamps, school lunch, unemployment insurance, Pell Grants—because many middle-class voters see them as benefits for someone else. But entitlements, by their very nature, have a universal appeal, putting them beyond the reach of the GOP’s political hatchet.
In 2016, candidate Donald Trump was savvy enough to recognize this when he vowed publicly not to touch Medicare and Social Security. But blinded by his hatred for his predecessor, he subsequently failed to realize that Obamacare, too, had crossed the entitlement Rubicon. Irony of ironies: Because President Trump attacked Obamacare so relentlessly, he is leaving Washington with the law much stronger politically than it was when he took the oath of office.
Obamacare’s political evolution has been as overlooked as it is remarkable. As White House chief of staff when the bill became law, I saw firsthand in 2009 and 2010 how vehemently some Americans opposed the bill. Specious attacks—like the false claims that it would “socialize medicine” or create “death panels”—both incensed conservatives and turned many moderates against our effort. And because so many Americans viewed the bill as a boon for the working poor (as well as the unemployed) financed by everyone else, Republicans could attack it almost with impunity, as they did. When Trump took office four years ago, the “program” was still net unpopular.
But Obamacare flipped to net favorable quickly after Trump’s election, and it now emerges stronger from Trump’s White House tenure. After years of Trump castigating the law without offering an alternative, the country realized nothing had actually been “socialized,” and that the law’s various provisions are nothing close to the “disaster” Trump claimed ad nauseum. A person who began with very little credibility on health care lost even more. Simultaneously, the law’s insurance exchanges and protections for young adults have been woven relatively seamlessly into the nation’s health care woodwork. Far from making it any worse for the wear, the ACA has improved the health care system overall. Finally, with the emergence of Covid-19, whole swaths of the electorate saw just how important the protections really were.
Beyond Trump’s personal divisiveness, nothing was more responsible for the Democrats’ big victories in the 2018 midterms than the party’s vow to protect Obamacare. Even Senate Majority Leader Mitch McConnell was savvy enough to understand the electorate’s evolving sentiment. When the president pressed Congress in 2019 to try once again to repeal and replace the law, McConnell retorted in his quietly devastating way: “I made it clear to [the president] that we were not going to be doing that in the Senate.”
There’s no mistaking why, during the presidential campaign this year, Biden made health care such a crucial focus of his advertising, second only to Trump’s character. As evidenced by Justice Brett Kavanaugh’s recent questions from the bench about a lawsuit over the ACA, the conservative Supreme Court also would prefer to leave Obamacare alone. If they don’t, the 2022 midterms are liable to be a repeat of 2018.
That should point Democrats at both ends of Pennsylvania Avenue to three crucial takeaways for the months ahead. First, the elements of the bill that proved so controversial a decade ago—namely, the provisions that extended coverage to the working uninsured—eventually faded to become only a single element of the law’s broader appeal. Today, the protections for young adults and those with preexisting conditions have become a fixture of the American experience. Progressives often debate whether it’s more expedient to target benefits or spread them more widely. As is most often the case, the surest way to help the working poor is to tie their benefits to those that serve the middle class.
Second, Democrats should see Obamacare’s more enduring political success as a signal for how to carry the torch for reform further still. After Social Security established a retirement floor in 1935, progressives added new benefits, including disability pensions in 1956. After establishing Medicare in 1965, Washington created the prescription drug benefit in 2003. Democrats should push Obamacare on the same trajectory.
That should begin with a new effort to deploy the ACA’s Medicaid expansion in the 12 states that haven’t yet embraced it. Recall that Obamacare originally gave states the opportunity to expand (the state-administered and federally subsidized) Medicaid for the poor to those living slightly above the poverty line. The bill offered to cover the expansion’s full cost for the first several years, asking states to pay a mere pittance of the cost as time went on. Thirty-eight states have embraced the opportunity—but some Republicans still refuse. As governors plead with Washington for budget help amid the pandemic recession, President Biden should make them an offer that would be hard to refuse: for the federal government, once again, to cover 100 percent of the Medicaid expansion’s costs for all states. By merging budget aid with assistance for those afflicted with Covid-19, Democrats can make this a policy win-win.
Lastly, to take some pressure off the ACA’s insurance exchanges, Congress should pass legislation lowering the age of eligibility for Medicare from 65 to 58, regardless of which party takes the Senate majority. Much as the GOP embraced Medicare’s prescription drug benefit despite the cost, this should appeal to Republicans in Congress because their voting base trends older. Biden has proposed adding a public option to the ACA, as well—something Congress refused to embrace a decade ago, but that now represents the next logical step. It may not yet be politically feasible. But in the meantime, the burgeoning group of middle-aged uninsured Americans too young to meet Medicare’s present cutoff should be given an opportunity to buy in early—a down payment on the goal of "Medicare for All."
A decade ago, many would have been hard-pressed to argue that good policy was good politics in the case of Obamacare. Just think of the rise of the Tea Party and the bloodbath of the 2010 midterms. But over the long run, as they say, “truth will out.” A decade after its passage, Obamacare’s survival is no longer in doubt, and its future has never been more promising. It has insured millions of Americans, even as its protections have become staples of middle-class life. At the law’s signing ceremony, then-Vice President Biden called the bill a “big f—ing deal.” As president, he will have an opportunity to make it even a bigger one.