It's safe to say that if Americans don't understand the Affordable Care Act (ACA) by now—and they don't—they never will. The slightly better news is that consumers don't have to understand it in order to benefit from it, but even so, almost all the problems the ACA has encountered or will encounter are a result of the law's enormous complexity. That complexity grew out of early decisions made by Barack Obama, but along the way Congress added their own layers of complexity in order to pass it, then conservatives on the Supreme Court added some more. There were reasons, most of them perfectly good, for each of these decisions; everyone thought they were responding to reality or doing what was in the best interests of the country. But as full implementation of the law is upon us, we should acknowledge how much damage has been done by all this complexity.
In a recent article in National Affairs, Johns Hopkins political scientist Steven Teles bemoans the rise of "Kludgeocracy." The term kludge "comes out of the world of computer programming, where a kludge is an inelegant patch put in place to solve an unexpected problem and designed to be backward-compatible with the rest of an existing system. When you add up enough kludges, you get a very complicated program that has no clear organizing principle, is exceedingly difficult to understand, and is subject to crashes. Any user of Microsoft Windows will immediately grasp the concept." While Teles argues that our entire government has been overtaken by kludges, there's no better example than the health care system.
From when he first started talking about health care reform as a candidate, Obama made the decision that a complete overhaul of the system—particularly by enacting "Medicare for all," or a single-payer system—was politically impossible. Instead of that radical change which would have simplified so much, the way to achieve goals like universal coverage was to layer on top of the existing private insurance system a new set of procedures, regulations, and subsidies. Obama believed, probably correctly, that it was politically vital that people be reassured that the government wouldn't be forcing them off their current insurance and on to a different plan, even if the new plan might be better. He also sought to co-opt rather than fight as many as possible of the multitudinous power players with interests in the health care system as it is. Insurers, hospitals, doctors, medical device makers—all of them have built their businesses around the current system, kludgy though it may be. And most of them like it just fine.
Let me be clear at this point that the ACA is a policy and political accomplishment of the highest order, one that will produce extraordinary good for the American public. Millions will get insurance who couldn't before, the words "pre-existing condition" will be banished from our lexicon, and the law will do all kinds of other excellent things that are less visible. But it was still an enormous kludge. How can we ban insurance companies from denying people with pre-existing conditions? If you can't just give everyone insurance, you need an individual mandate. That means you have to make it easier for them to find insurance (hence the exchanges), and it also means an enforcement mechanism. What about poor people? Well, let's expand Medicaid to give them insurance. But the Supreme Court says states can opt out, so now you have one set of rules for some states and another set for others. Instead of one insurance exchange for the whole country, we'll allow states to make their own, meaning any two states might have different systems. And while we're at it—since if we fail we won't get another opportunity to reform health care for decades—we should try to reform the payment system to encourage a focus on quality of care and not quantity, and we should encourage the transition to electronic medical records, since it's insane that so much of the system runs on pieces of paper. Most or all worthy goals, with the best solutions people could devise at the time. But at every step, the complexity increases.
That then becomes a source of endless political vulnerability. Because it does so many different things, the ACA could be attacked from many different directions. Because only people whose job it is to understand health policy truly grasp all its particulars, Republicans could make up all kinds of scare stories about what it will do to you, your family, and maybe your pets. Of course, if conservatives had a powerful reality-based case to make against the ACA, they probably wouldn't have come up with so many false claims, absurd predictions, and outright lies about what it is and what it does, from "death panels" to doctors becoming "government agents" to spy on your sex life to the false idea that Congress "exempted itself from Obamacare." (This last one is debunked succinctly in this article in the National Review. Yes, the National Review.)
Ignorance and the complexity that feeds it will remain the greatest resource the law's enemies have. For instance, if you've been paying attention to your health insurance premiums, you've noticed that they've gone up each and every year for decades. But now, bosses are telling their employees that this year's increase is because of Obamacare. Which is strange, first because premium growth has actually slowed to its lowest rate in years, and second because almost all the regulations that affect employer-sponsored coverage haven't yet taken effect. So it looks more like bosses who despise Barack Obama and don't like the ACA are just taking the opportunity for a little politicking. But will employees have much reason to doubt what their bosses are telling them? Probably not.
The truth is that there is no program called "Obamacare" in the same way there's a program called "Medicare." Things would be a lot simpler if there were, and people would at least have a chance at understanding it. But if anything, "Obamacare" may become even more nebulous to most people as it goes into effect. If you get insurance on an exchange, you'll make your choice, and then deal with your private insurance company. You won't say "I'm on Obamacare," you'll say you have Aetna, or UnitedHealth, or CareFirst, or whatever. Those companies will have to treat you more humanely than they used to, but most people won't give credit for that where it's due. Republicans will still try to convince you that if you got strep throat you have an Obamacare infection or if you broke your ankle shooting hoops you got an Obamafracture, but the law as one singular package of regulations will matter less and less, at least politically. Once people are benefiting from it, Republicans will find repealing the law in its entirety impossible, because if you repealed it you'd actually be kicking people off their coverage and saying insurance companies could boot people for their pre-existing conditions again. Perhaps at that point they'll start saying exactly which parts of it they'd like to alter, instead of just screaming "Socialism!" But probably not.
To reiterate, the ACA will improve the lives of millions, and the Republicans waging such warfare to make sure people don't get health insurance are so despicable that it has become difficult to describe the full extent of their cruelty. But the political problems the law has encountered were set in motion at its inception, when it became clear that it would be a kludge added to what was already a system of absurd complexity. There may have been no other choice, which shows just what a mess American health care is.