When Congress was debating health care reform in 1993, conservative strategist Bill Kristol wrote a now-famous memo counseling Republicans that they must prevent the passage of reform, lest it "relegitimize middle-class dependence for 'security' on government spending and regulation … revive the reputation of the party that spends and regulates, the Democrats, as the generous protector of middle-class interests … [and] strike a punishing blow against Republican claims to defend the middle class by restraining government." The problem Kristol foresaw -- and today's Republicans saw with Barack Obama's health care reform -- was not merely that Americans would reward Democrats for the passage of a beneficial program, but that health care reform would bind them to government for all their lives, undermining the ideological case Republicans make.
Many of those who supported the passage of the Affordable Care Act earlier this year (myself included) agreed. I wrote that once the bill passed, it would no longer be a hypothetical program but an existing one, and people would judge it by their interactions with it, not by something a politician said about it.
That hasn't yet occurred (Americans are still split down the middle on the merits of the ACA). The provisions that have taken effect, such as the one allowing children to stay on their parents' policies until age 26, don't affect most of us. But there's a real question about how much political impact the ACA will have even once it is fully implemented in 2014, because of the way it was constructed. If you're on Social Security, you get a monthly check from the federal government. If you're on Medicare, you get all your medical bills paid by the federal government. But the ACA, for all the good it will do, will be operating at a distance for most Americans.
When Medicare was being debated in the 1960s, the conservative free-marketeers opposed to the program used arguments almost identical to those we heard offered against the ACA. Medicare, it was said, was the Bolshevik camel's nose inside our tent, with liberty the inevitable casualty of the government providing health insurance to the elderly. Ronald Reagan, who was soon to become governor of California, famously said that if Medicare passed, "you and I are going to spend our sunset years telling our children, and our children's children, what it once was like in America when men were free."
The Republican officials challenging the ACA in court have characterized its individual insurance mandate as an act of tyranny ranking somewhere between the Stalinist purges and Mao's Cultural Revolution. But in the "government takeover" of health care (recently declared the 2010 "Lie of the Year" by the fact-checking site PolitiFact), Americans will continue to visit their private doctors to receive care paid for by their private insurance companies. The irony is that if the ACA actually were a "government takeover," people would end up feeling much better about government's involvement in health care. But since it maintains the private system, conservatives can continue to decry government health care safe in the knowledge that most people under 65 won't know what they're missing, or in another sense, what they're getting.
That doesn't apply to everyone -- there will be millions who will either be on the newly expanded Medicaid, or receive subsidies to buy insurance through the newly created exchanges. These people will presumably have at least some conception that the government is helping them with their health care. But most middle- and upper-class Americans -- the ones who vote and wield political influence -- will continue to be embedded in a private health care and insurance system. As a result, they won't be having the same kind of interactions with the federal government that someone does when they receive Medicare and Social Security.
If you get your insurance through your employer, as most people will continue to do, the government's protection will be almost invisible to you. Even if you're going through an exchange, the only interaction you'll have with government will be at the point of purchase. After that, you'll be dealing with your private insurance company. Furthermore, that exchange won't say, "Welcome to the Obamacare Federal Government Health Exchange." Since the exchanges will be run independently by the states, it will be called something like "WisconsinCare" or "OregonHealth."
As a result, you won't see the protections the ACA offers. Let's say you've had a serious illness before, and you're trying to get insurance on the individual market. As things stand today, if you're lucky enough to be able to convince an insurance company to cover you, it's going to cost you an arm and a leg. After 2014, you'll be able to go to an insurance exchange and pick what will probably be an affordable plan, and no one will even ask you about your family's medical history. That's because plans offered through the exchange will be required to hold to "guaranteed issue" and "community rating" -- you won't be denied because of a pre-existing condition, and everyone of the same age will pay the same rates (with a couple of exceptions, like smokers paying more).
Now you've got a nice-looking plan from a private company. You can visit your doctor, and the bills will be paid. Are you going to say, "Thanks, Barack Obama!"? Perhaps, if you have a good understanding of the recent history of health care policy. But most people don't. To all appearances, it will just appear that the private system has gotten less vicious.
What's the political impact? While Republicans are unlikely to muster the courage to take concrete legislative steps to undo the ACA, little of what Bill Kristol feared in 1993 will have come true. Americans will benefit from a more secure health insurance system, but most won't attribute that security to government. Railing against "government health care" -- and "government" everything else -- will still be the foundation of conservative rhetoric.
For all the success Republicans had in the last election, they are still spooked by accusations they might want to cut or privatize Social Security and Medicare. That's why you saw so many Republicans who criticized the ACA saying that those who supported it wanted to cut Medicare (the bill contained $500 billion of savings in the program, but not in ways that will compromise the care beneficiaries receive). That isn't to say they don't still yearn to privatize the programs, but when they try (as George W. Bush did with his 2005 attempt to partially privatize Social Security), they talk about "strengthening" or "modernizing" the programs, in order to convince voters of their heartfelt commitment to social insurance.
But because the ACA makes the government's role so obscure, Republicans won't have to twist themselves in knots in order to oppose it. You might remember the venom with which they fought the inclusion of a public option that would have operated like Medicare. Their greatest fear was that people would use it and like it. Then they'd have to pretend they supported it all along, just as they do with Medicare. But they succeeded in killing the public option (with the help of conservative Democrats like Ben Nelson and Joe Lieberman), and got something that ought to be much more to their liking: a government program that won't feel like government at all.