It is possible to imagine that several decades from now, when a Democratic president sends a proposal to Congress that would require cuts in the Affordable Care Act, a right-wing activist will say: “Get your government hands off my Obamacare!”
That’s almost exactly what happened in 2009 and 2010 when conservatives fought President Obama’s health care proposal by warning that it would require cuts to Medicare.
In recent months, we’ve seen how ACA continues to become entrenched in our political system. A sizable number of Republican governors in red states are now allowing the expansion of Medicaid under ACA to take place. For a while this seemed unlikely. In 2012, the Supreme Court struck a blow to ACA by ruling that the expansion of Medicaid was optional. Many Republican governors vowed they would not allow Medicaid to grow.
But slowly this opposition has faded. In December 2012, Nevada Gov. Brian Sandoval became the first Republican chief executive to offer his support for Medicaid expansion under the new law. “All in all, it makes the best sense for the state to opt in,” he said.
Other Republican governors have followed. There are 10 states with Republican governors who have expanded Medicaid.
The most recent battle has taken place in Tennessee, where Gov. Bill Haslam, one of the staunchest opponents of Medicaid expansion in recent years, is now in the final stages of negotiating with the federal government over the details of moving forward. Haslam has pushed for modifications, such as requiring some recipients to put money into health savings accounts.
Still, Haslam, once an anti-ACA warrior, has now said that expanding Medicaid is “morally and fiscally the right thing to do.” The state hospitals are so eager to make this happen that they have pledged to cover any remaining costs the federal government does not pay.
The fight still has a long way to go. A key Senate committee in the Tennessee legislature rejected the plan during a special session. Proponents of the expansion, including the governor, are continuing the battle, and with so many major interests in the state lined up behind the plan, the pressure will only continue to intensify.
Indiana Gov. Mike Pence has moved his state in the same direction. The same is true in Wyoming, Utah, Alaska and several other conservative states. Slowly but surely, ACA is becoming the law of the red land, not just the blue, though 15 GOP-led states still have not opted in.
In other words, one of the big bets that was made by President Obama’s administration and his Democratic allies in Congress is really paying off. Their idea was that building part of their new program on top of a popular, pre-existing policy would make it harder to resist.
A sizable subset of Americans, and, importantly, government and health care officials, were familiar with Medicaid — how it worked, what it provided, the ways in which it benefited almost every state and health care system.
Although Medicaid started as a very small part of the “Great Society” during President Lyndon Johnson’s administration in 1965, it has gradually expanded into a huge program that covers a broad portion of the public, including pregnant women, children and other categories of people who had had only limited access to care. Though it started as a “welfare” program, it has come to be perceived by many Americans as an “entitlement,” another third rail of politics that politicians can’t touch.
Indeed, the idea of building new public policies on top of the old wasn’t original to President Obama. When President Johnson created Medicare, he put it in the Social Security system. Medicare was paid for through Social Security taxes and originally administered by the Social Security Administration.
The idea was to undercut some of the fierce opposition of the American Medical Association, which called Medicare socialized medicine, by implementing the program with something that would make it harder for politicians to say no.
With the expansion of Medicaid in Republican states, the Affordable Care Act is becoming more difficult to dismantle. The CDC has reported how the number of uninsured Americans is steadily falling in states that have expanded Medicaid. Not only is Medicaid expanding, but federal officials recently reported that there are now 10 million Americans who are enrolled in the health care exchanges, meaning that ACA is on track to meet the administration’s goals.
Recently, the congressional Republicans voted for the 56th time to repeal Obamacare. Each vote looks more futile than the next, each making the GOP seem disconnected from political reality. As more voters, health care providers and government officials come to depend on the benefits from these programs, the weaker the opponents will be. “They’re baaaaaying at the moon, 56th time,” quipped House Minority Leader Nancy Pelosi.
The biggest threat to ACA remains the courts, not Congress. The Supreme Court is going to hear and likely rule by June on a major challenge to the program: the right of the federal government to offer subsidies to Americans who rely on federal, as opposed to state, health care exchanges.
If this challenge succeeds, the Obama administration will have to mobilize supporters to pressure the affected states to set up their own exchanges. The ability of the administration to succeed will be much stronger now that the benefits have started to kick in for so many millions of Americans.
Many of the nation’s biggest domestic programs, like ACA, start in a heated political atmosphere. But history shows these programs can become part of the status quo, with those receiving their benefits becoming a powerful force for their continuation.
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