Back when the Affordable Care Act passed, I was relatively unconcerned about its middling support in polls. Once the law went fully into effect, I argued, people would begin to reap the benefits and support would increase. After all, with the exception of the individual mandate, virtually all of the law's provisions were extremely popular.
These days I'm not so sure. Not because the popularity of the law hasn't increased yet -- the key provisions are still two and a half years away from taking effect. But because it's becoming clearer that the law was designed in such a way as to make its benefits almost invisible to people. For all that Republicans characterize it as a "government takeover," the ACA's problem is that people won't see it as government at all.
Suzanne Mettler has an important article in the Washington Monthly about the "submerged state," the fact that much of what our government spends is in forms that people don't see as government. People who get thousands of dollars from the government for things like the mortgage-interest deduction nonetheless believe they're getting no government benefits; this means that anti-government rhetoric continues to resonate, even as most Americans -- particularly the affluent -- suckle at the federal teat:
American politics today is ensnared in the paradox of the submerged state. Our government is integrally intertwined with everyday life from health care to housing, but in a form that eludes our vision because it makes governance invisible. As a result, many Americans express disdain for government social spending, incognizant even when they themselves benefit from it. They are disturbed by growing deficits, but do not realize that policies whose benefits flow disproportionately to the affluent consume a large portion of growing federal entitlements. They are easily seduced by calls for small government, not realizing that champions of that philosophy brought us the most costly policies of the submerged state.
While Mettler doesn't talk about the ACA specifically, I fear it will end up being one of the core components of the submerged state. It's true that many of the previously uninsured who are poor will, after 2014, be brought into Medicaid. But most Americans will benefit from the ACA without, from their perspective, getting anything from government. If you go to a health insurance exchange to choose a plan, you won't be discriminated against if you have a pre-existing condition. The insurer you pick won't be able to kick you off if you get sick, and they'll have to conform to a series of other regulations designed to ensure that they treat you fairly. The providers you visit may be getting incentives to improve the quality of your care at a lower cost. But none of this will come with a label that says "government." The exchange will just be called "ArizonaHealth" or "NorthDakotaCare." Through it you'll get coverage from a private insurer. Your doctors and nurses will still be private. No one will have an "ObamaCare" card in their wallet, and though government will be heavily involved in health care through payments, incentives, and regulations, all of that will occur at a level that is invisible to patients.
So unlike Medicare or Social Security, the ACA won't benefit from its success, presuming that success comes to pass. Those programs are politically armored by their visibility. Ironically, it's the compromise Democrats made with the conservative perspective -- not only moving away from single-payer but refusing even to offer a minimal public option people could choose -- that gives conservatives the continued ability to attack the ACA as "big government." By making it a submerged program, Democrats ensured its continuing vulnerability.
