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How conservatives won with Obamacare

Drew Anthony Smith

A few months after Obamacare's launch — back when HealthCare.Gov still seemed like a computer virus built by Ted Cruz to forever discredit the federal government — I attended a dinner where an Obamacare skeptic laid out a simple test for predicting the program's survival: were insurers joining or fleeing?

We know now that they're joining. Obamacare will offer more insurance choices in 2015 than it did in 2014. And that's because insurers believe Obamacare is working. They see enrollment above expectations; consumers who are basically happy with their insurance; an undeniable drop in the uninsured population; people paying their premiums; exchanges that are going to work better in 2015 than they did in 2014; a law that's costing less than expected; an age mix that will likely improve as the individual mandate toughens; and a political system that isn't likely to repeal the law now nor ever.

Put simply, they see a new and growing business. And they want to be part of it.


Amidst all this Paul Krugman points out something I've noticed too: "what you get whenever you suggest that things are going OK is an outpouring, not so much of disagreement, as of fury. People get red-in-the-face angry, practically to the point of incoherence, over the suggestion that [Obamacare's] not a disaster."

Part of that is a bad information loop: conservative coverage of Obamacare tends to be a parade of horror stories, coming disasters, and promises that a political reckoning is right around the corner. The tone of the coverage in conservative quarters today isn't all that different than it was during the law's initial weeks, when it really was a disaster. And if you already know that Obamacare is a catastrophe, articles suggesting otherwise will look like dangerous, partisan spin.

But deeper than the coverage is the tribalism: the unrelenting focus on the law, and its close association with President Obama himself, has made Obamacare a vessel for the core political war of our age. Obamacare is a stand-in for Obama himself, and for even for liberalism. So much has been invested in Obamacare's failure that its success would be ideologically catastrophic for its critics.

Which is pretty strange, actually. Because Obamacare's success is going to end up validating some pretty important conservative ideas — and, potentially, forestalling some liberal ones.

The liberal dream wasn't a health-care system where success can be partly measured by the enthusiasm of private insurers. The liberal vision was single payer, or some kind of France-like multi-payer system. The first version of a national health-care proposal with the basic shape of Obamacare was when Senate Republicans presented it as an alternative to Bill Clinton's health-care plan.

There is a read of the last two decades in which Republicans pulled off the greatest act of policy jujitsu in American history: they got Democrats to abandon their dream of single payer, adopt a Republican health-care plan, and do the hard work and pay the high political price of passing and implementing the law. It's an astonishing policy victory that Republicans experienced as a shattering political defeat.

The weirdness of this was evident in the 2012 election, where the Republican nominee couldn't run on his signature achievement as governor of Massachusetts because the Democratic president had stolen it from him.

Some Republicans, at some times, recognize that there's much for conservatives to like in Obamacare. In a 2013 column for Reuters, Avik Roy and Doug Holtz-Eakin wrote, "The great irony of Obama's triumph, however, is that it can pave the way for Republicans to adopt a comprehensive, market-oriented healthcare agenda." The reason it could do that was so many of the ideas in Obamacare were conservative in the first place. The Affordable Care Act may not be a conservative law but it's a law built upon a conservative platform — or at least a platform that's much more conservative than the alternatives.

Which isn't to say there aren't policies in Obamacare that conservatives hate. The law expands Medicaid and finances itself by raising taxes on the rich — both of which are approaches to health reform that Republicans loathe. But that's another reason for conservatives to rejoice over Obamacare's recent success. Initially, those were the only parts of the law that worked: for all the federal government's failings, it knows how to tax rich people and add people to Medicaid. What was collapsing was the part Republicans helped come up with: the regulated insurance exchanges that are core not just to Obamacare, but also to Rep. Paul Ryan's Medicare reforms.

Luckily for conservatives — and for Obamacare — the exchanges ultimately did work. The basic structure conservatives had developed for health-care reform was viable. And much as Roy and Holtz-Eakin predicted, Obamacare is proving a platform where conservatives can push the health-care system in directions they prefer: it's given them leverage to force conservative reforms to Medicaid that the Obama administration would never have accepted, for instance. And it's easy to imagine some future Republican president pulling Medicaid or Medicare entirely into the exchanges and, in doing, pulling America further away from a single-payer health-care system.

Obamacare isn't nearly as pure a victory for liberalism, nor a defeat for conservatism, as is often portrayed. Just as Republicans look back on Bill Clinton's presidency more fondly, and just as today's Democrats find a lot to like in George H. W. Bush's administration, Republicans are one day going to look back on Obama — and Obamacare — and find quite a bit to like.

Read Vox's full guide to Obamacare here.