When it was enacted in 2010, Obamacare was supposed to be the final culmination of 60 years of effort by Democrats to realize the dream of universal health insurance. It was a complicated scheme, designed in such a way as to bridge the gap among Americans of different ideologies on how to address an alleged evil.
But dreams are rarely easy to bring into reality, especially when one person's dream is another's nightmare. Legislation that appeared to show the possibilities of compromise has ended up proving its limits.
Compromise is possible when two contending groups share a goal while differing on the means to achieve it. The problem in the realm of health care is that Democrats and Republicans don't agree on either one—or even, really, on whether a serious problem exists. Legislation passed with the bare minimum of popular support is inherently vulnerable.
It should be no surprise that neither side is particularly enamored of the program, since it reflected neither of their preferences. Democrats mostly preferred a Medicare-for-all system, with the federal government directly providing health care coverage. Barack Obama was one of them, though he eventually concluded it was politically impossible.
Instead he offered a public-private hybrid that preserved the existing private health insurance system while imposing new regulations, furnishing help to many to pay for it, and expanding Medicaid coverage.
He probably started out thinking this middle way would attract some Republican support. After all, its basic structure mirrored a 1989 proposal from the conservative Heritage Foundation. It was modeled on an overhaul adopted in Massachusetts at the behest of Mitt Romney.
It didn't attract Republican support but near-unanimous Republican opposition. The president's mistake—one of them, anyway—was failing to see that he had borrowed ideas Republicans were eager to get rid of. By the time he arrived in office, they had lost interest in making citizens buy insurance, even to minimize public burdens.
Or maybe the GOP had simply lost interest in addressing the problem that motivated Democrats: the lack of health coverage for some 40 million Americans. It was not merely their problem, since almost all hospitals are required—under a 1986 federal law signed by Ronald Reagan—to provide emergency care to patients regardless of their ability to pay.
But the individual mandate, conceived as a way to force potential freeloaders to take responsibility for themselves, was a bridge too far for conservatives. They saw it as a huge federal violation of personal autonomy, as well as an unprecedented and unconstitutional assumption of power.
Arguing the latter point, they came within a whisker of getting the Supreme Court to invalidate the law. Republicans also predicted the plan would be impossible to administer, a forecast that has gained enormous credence thanks to Kathleen Sebelius.
They have the advantage of opposing the expected evils of Obamacare, which have eclipsed the defects of what went before. One way to make a program popular is to make the benefits visible and the costs inconspicuous. But the individual mandate and the signup snafus reversed the formula. Lots of people are leery of being shafted or coerced, while those who will gain appear to be mostly unaware or ungrateful.
Not that a different approach would have been more successful. In early 2010, pollster Douglas Rivers of YouGov/Polimetrix reported that when asked what would happen if Obamacare passed, most people said they would get "worse care at a higher cost." And if it didn't pass? They would get "worse care at a higher cost."
Republicans have succeeded in changing the subject. Instead of discounting the disease, they can focus scrutiny on the president's defective remedy. They can also divert attention from their failure to do much of anything about the supposed ailment when they held power.
They oppose Obama's plan as a burdensome, costly federal solution, only 10 years after they approved George W. Bush's burdensome, costly federal solution to another supposed failure of American health care: the obligation of retirees to pay for prescription medicines.
That program is now accepted and protected by politicians. Had Obamacare been equally popular, it might also become an unchallenged part of the landscape. But it became law without ever generating a durable national consensus.
Lacking that consensus, enactment was not the end of the fight. It was just the opening round in a fight that will not be over soon.