The Affordable Care Act’s shortcomings are well-known, and this magazine hasn’t shied away from editorializing about them. The law didn’t attack the fundamental flaw in our system: We still treat health care as a commodity, rather than as a public good and basic right. A Medicare-for-all plan would have better controlled costs, reduced complexity, and left workers free to choose better jobs without losing access to their doctors. The Democratic Party consensus now holds that, at minimum, Congress must finally add a “public option” to Obamacare’s private-insurance markets.
Of course, Republicans have no intention of improving the law, and defending against its wholesale repeal is one of the preeminent tasks in front of progressives in the weeks ahead. So it’s crucial that we understand two realities about the fight we now face over health care.
First, Obamacare did radically reform the market-based system. It has made coverage possible for more than 20 million people and cut the uninsured rate by nearly half, while ensuring everyone can get the preventive care that prevents or treats heart disease, diabetes, breast cancer, and other entirely avoidable killers. Racial disparities once considered intractable have shrunk, and 2.3 million people under the age of 26 have gained insurance through a parent’s plan. But here’s the key point to understand about all of this: The law achieved this massive reformation largely through public investment in the working poor.
Yes, premiums have gone up as insurers have tried to figure out how to profitably cover all of the people they used to legally dodge (such as people with dementia, those battling opioid addiction, and even pregnant women—a list that encompassed more than 52 million people in 2015). But more than eight out of 10 people who have bought insurance in each enrollment period thus far have done so using subsidies. In 2016, seven out of 10 marketplace consumers paid $75 or less a month after their subsidies were applied. Millions more now qualify for Medicaid in states that once denied them help.
Through this public investment, the law allowed millions of workers to escape a devil’s choice of modern capitalism. The poverty wages that many employers offer and the expanding gig economy left millions of people too poor to get adequate health coverage, but too rich to get help from the safety net. You could choose work, or you could choose health. Obamacare created new choices.
Which brings us to the second thing to understand as we face down repeal: Republicans will not simply return America to the days of health care for some. Whatever plan Donald Trump and Paul Ryan produce will surely include an aggressive cut to the economic safety net we’ve fought to maintain since 1965. Ryan has spent his public life crusading against the poor, and his recent apology for years of poor-shaming rhetoric should not lull us into complacency about his agenda. Before Trump was promising to make America great again, Ryan was warning of a moral “tipping point” in which America will become a country of “takers, not makers.”