Three Lessons on Obamacare's Fourth Birthday

President Obama signs the health insurance reform bill in the East Room of the White House on March 23, 2010 Photograph by Andrew Harrer/Bloomberg

Four years ago, on March 23, 2010, Barack Obama signed the Affordable Care Act into law. Vice President Joe Biden was right: It was a big [expletive] deal. Obama said that day that “all of the overheated rhetoric over reform will finally confront the reality of reform.” Here are three lessons we’ve learned since rhetoric met reality.

A divided government makes it hard to govern.
It’s almost too obvious a point to make, but the current political landscape is a consequence of the fierce opposition stance Republicans took after Obama’s 2008 election. Determined not to hand the new president a legislative victory, not a single GOP member of Congress voted in favor of the Affordable Care Act. That set up the dynamic with one party invested in the law’s success and the other equally invested in its failure. Red state governors (along with some Democrats) declined to build state insurance marketplaces, as the law envisioned, leaving the White House a bigger task than initially imagined. Many Republican-leaning states also refused to expand Medicaid, after the Supreme Court ruled that part of the law optional. Some conservative groups are trying to discourage people from getting health insurance in an effort to undermine the law.

Reforming the health-care sector, which makes up 17 percent of the U.S. economy, would have been a difficult undertaking for any administration under the best of circumstances, even with a Congress committed to good-faith governing. When the split between parties is visceral hostility, the challenge is that much harder.

Even those on board with health reform underestimated how hard it would be.
It’s not just partisan opposition that can derail a policy. Some blue states that fully embraced Obamacare have had the most difficult time making their new insurance marketplaces work. Oregon, Maryland, Massachusetts, and Minnesota had spectacular flameouts. And blame lands squarely on the administration for’s failures, along with the law’s long list of delays and modifications. At the same time, technical success creating new insurance markets in places like Kentucky show that the underlying idea can work.

Policy details matter.
Many of the problems that surfaced in the past year were consequences of the law that weren’t fully clear to the public when the ACA was being debated. Economists and actuaries knew that in order to stop insurers from denying sick people coverage, some people would have to pay more. That nuance was never communicated. Obama’s “If you like your health plan, you can keep your health plan” promise compounded the problem when millions of people got hit with cancellations because their plans didn’t meet the law’s coverage requirements. There are also flaws in the law like the subsidy cliff: Earning just too much to qualify for government help—around $94,000 for a family of four—can cost people thousands of dollars a year in higher premiums.

Situations such as that show why Nancy Pelosi’s infamous remark—”We have to pass the bill so that you can find out what is in it”—has become conservatives’ favorite sound bite. Most Americans aren’t going to dive into wonky policy details, and shouldn’t be expected to. But any change as sweeping as health reform requires trade-offs. Instead of an honest, good-faith discussion about what trade-offs the country should make, the public got heated words and propaganda from both sides.

Maybe we can’t expect more in a political atmosphere as charged as America’s has been for a generation now, but the public pays a price for it.

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