As it celebrates its fifth anniversary, President Obama's landmark health reform is now on course to join Social Security as an indispensable and widely embraced anchor of everyday life for large numbers of Americans. Pundits still focus on the challenges and controversies ObamaCare has faced, but from a broader historical perspective, its progress has been surprisingly fast and smooth.
Today, Social Security enjoys nearly universal support, but that was hardly the case when it was first enacted in 1935 or during the early years of implementation. Political and business opponents remained fiercely opposed, and in 1939, President Franklin Roosevelt had to go back to Congress for significant revisions to taxes and benefits. During World War II, taxes for Social Security were suspended and repealers said the law was unworkable and tried to leave it for dead. Things improved as the law expanded and benefits flowed from the 1950s. But it was not actually until the presidency of Richard Nixon, decades after enactment, that Social Security was broadly embraced and its benefits were made sufficiently generous and protected from the ravages of inflation to allow Americans to count on it for a dignified retirement.
Arguably, the Affordable Care Act is faring better, faster, despite fiery partisan conflicts that continue to this day. Although it took decades for many Americans to benefit from Social Security, the latest Gallup survey shows reports that the percentage of Americans lacking health insurance has fallen from 18 percent at the end of 2013 to 12.3 percent as of March 2015. Using different approaches, other studies also find steep declines in the number of uninsured, showing that about 16 million Americans have gained coverage just two years into a multi-year enrollment process.
Another goal of health reform was to "bend the cost curve." For decades, U.S. spending on healthcare led the world, even though millions lacked coverage and we lagged even developing countries in basic well-being measures such as infant mortality (a metric on which the United States ranked 31st, just between the Slovak Republic and Chile). After health costs grew as much as 16 percent per year during the 1980s and by near double digits into the 2000s, heath cost increases have now slowed to 3 to 4 percent per year, the lowest annual rate of increase in 50 years. The nonpartisan Congressional Budget Office revised sharply downward its initial projections of the cost of the Affordable Care Act. Tens of millions are newly covered, businesses and hospitals are benefitting, and the projected federal budgetary outlays for the Affordable Care Act have been reduced by an additional $5 billion in 2014 and by $104 billion for the coming decade.
Of course, Republicans in Congress continue to vote for repeal, and GOP presidential contenders seem to think they still must promise to wipe out this landmark reform. But, tellingly, many Republican-led states are embracing the law because it delivers benefits to so many citizens, profits to their businesses and budgetary relief to state coffers. Bit by bit, Affordable Care Act implementation is creating a new reality that is gradually lowering the volume of partisan outcries against it. Even in states where Republican lawmakers have tried to block health reform, a flood of Americans have newly enrolled on the federally facilitated insurance exchanges — 1.5 million in Florida and 1.2 million in Texas, as well as over half a million apiece in North Carolina and Georgia. Expansions of Medicaid — the Affordable Care Act's strategy to extend coverage to the near-poor — have been adopted in more than 20 states where Republicans wield one of the levers of power. And even the most recalcitrant states have seen many more citizens sign up for their preexisting Medicaid programs after implementing administrative improvements enabled by the healthcare law. Tea Party dreams of repeal have lost touch with reality.
Overall, the Affordable Care Act is on track to benefit up to 50 million previously uninsured or underinsured Americans by the time Obama leaves office. And of course, the law also includes rules that make insurance more reliable and generous for the majority of Americans who have employer benefits or Medicare.
There could be one last substantial threat. The Supreme Court recently heard arguments to bar subsidies flowing to millions of Americans with modest incomes who have signed up for private health plans in dozens of states that rely on federally facilitated health exchanges. But the oral argument heard on March 4 revealed significant hesitation among the Supreme Court justices. Even if the court decided to strike down the subsidies, the outcome would hardly be what GOP advocates of repeal expect. The law will fully survive in many states, and the 2016 elections would see huge political backlashes against the supporters of taking away benefits Americans already enjoy.
Barring a detour forced by a Supreme Court ruling cutting back health insurance subsidies, the Affordable Care Act is speeding forward, on track to join Social Security and Medicare as part of the "third rail" of U.S. social protection, delivering benefits to millions that few career politicians can attack without paying a big price. In actuality, if not yet in the realm of partisan rhetoric, the Affordable Care Act is successful — and here to stay.
Jacobs is the Walter F. and Joan Mondale Chair for Political Studies at the University of Minnesota. Skocpol is Victor S. Thomas Professor of Government and Sociology at Harvard University. Both are members of the Scholars Strategy Network.