Political Flaws in the Affordable Care Act

The Affordable Care Act has had a rough few weeks. First, the Supreme Court agreed to hear King v. Burwell, a case that could result in millions of Americans losing subsidies for health insurance on the federal exchanges created by the law.

Then, videos of Jonathan Gruber, an MIT economics professor and an advisor during the ACA’s drafting, became a major fixture because of Gruber’s repeated references to “the stupidity of the American voter.” Finally, on Friday, House Speaker John Boehner sued President Obama in federal court over ACA-related grievances.

More than these recent hiccups, the ACA continues to struggle to gain traction among voters, though they largely, with the sole exception of the individual mandate, support its provisions. The results of this month’s midterms suggest that Democrats still have not found a way to communicate these provisions’ benefits, though given their lack of effort that result was foreseeable.

This failure to construct a political advantage out of a healthcare scheme that should be more popular stands in stark contrast to the speed with which the public grew accustomed to the Medicare program when Lyndon Johnson signed it into law in 1965. Today, of course, Medicare is very popular, and left-of-center commentators have rightly seized on parallels between the right’s anti-Medicare rhetoric of the 60s and its criticisms of the ACA to underscore why attacks on today’s law are misplaced.

What this analysis fails to mention, however, is that Medicare was far more popular far sooner. Even before it became law, voting against Medicare was a political risk, as 1964 Republican presidential nominee Barry Goldwater learned. Columnist Samuel Lubell noted a month before the 1964 election that Goldwater’s vote against an earlier Medicare bill saw him lose the support of older Republican voters who understood that they would benefit from the program, and associated it with other popular entitlements like Social Security.

Needless to say, the ACA has never enjoyed such public favor. Part of the explanation undoubtedly has to do with the ACA’s complexity and Medicare’s relative simplicity, a point made by Joe Nocera in a New York Times column at the height of the health exchange website debacle. But as Nocera’s interview with a former Johnson administration official in charge of the Medicare rollout attests, part of the ACA’s problem has been poor management. Medicare was hardly easy to get off the ground, and faced some significant opposition, notably from the American Medical Association. But it worked, basically immediately.

While complexity and poor management provide part of the explanation for why the ACA has had such trouble, however, these factors ignore a key issue that has hampered its implementation. Unlike Medicare, which was and remains a federal program, the ACA relies on states to take on key responsibilities, like the expansion of Medicaid and the establishment of insurance exchanges.

From its inception, this federalism has been troublesome. When the Supreme Court upheld most of the law in 2012, it ruled, using somewhat tortured constitutional logic, that the federal government could not force states to accept the Medicaid expansion. Now, millions of would-be-beneficiaries have been cut out of one of the law’s core provisions.

The Supreme Court’s decision in King v. Burwell might similarly gut the ACA’s exchanges. At issue is whether the IRS can offer subsidies to those purchasing insurance on a state exchange run by the Federal government, as opposed to one run by the state itself. The only fair reading of the law would answer this question in the affirmative.

But the only reason this issue even exists is that Congress entrusted states to build exchanges in the first place. With such vehement opposition to the ACA among state-level Republicans, Congress should perhaps have adopted a more centralized approach to this portion of the law. In fact, during his 2008 campaign, President Obama called for a “National Health Insurance Exchange,” but the vicissitudes of the drafting process led to the current state-based system.

In short, the largest lesson the writers of the ACA might have learned from Medicare is that policy has serious implications for politics. In the 1960s, the Medicare program provided straightforward benefits, and a competent group of federal officials had the freedom to implement them well.

The ACA was destined to be more complicated, but by putting its implementation at the mercy of the states, President Obama and Congress made it much more difficult to get it right, and unwittingly opened the door to mistakes and legal challenges.

One can only hope that these unlearned historical lessons do not prove fatal for a much-needed reform.

Nelson L. Barrette ’17, a Crimson editorial writer, lives in Winthrop House. His column appears on alternate Mondays.