Being an older small businessman who is a diabetic and has several family members with what the insurance bean counters like to call pre-existing conditions, I was deeply relieved and over-joyed when the health care news came out yesterday: it will help me and my family in dozens of different ways. For families like mine, for families like Susan Gardner's, this is quite literally a life-saving decision that will dramatically improve the lives of so many people. It was not only a great day for the tens of millions of people like me with long term health issues, it was a great day for our country as we finally join the rest of the developed world in providing health insurance for everyone. It will be great for our economy, and will make us a more moral nation. And on a personal level, having spent much of my life working to pass some version of health care reform, I sure was glad that all that work did not go to waste.
But this law getting passed, and the decision to affirm it, has far broader implications for the future of our country than on health care alone: it will shape the nature of our politics and democracy going forward in so many ways. I'm thinking less here in terms of our short term politics, because while I think it helps Obama a little I don't think it helps him that much- this election is going to be decided on which voters turn out, and on which economic philosophy swing voters decide they want to trust more. The long term implications for how people view the two political parties are huge, though.
Let's take each scenario in terms of who wins and loses the election. First, say Romney wins, and the Republicans control both houses of Congress. He is in a terrible position on health care, because most voters want him to focus like a laser beam on reviving the economy, but his base will be obsessed with repealing Obamacare. Repealing Obamacare, though, is not as simple or politically painless as many people think, because most of the things in the bill are very popular politically, and in fact Romney has promised to keep many of those popular things like not allowing insurance companies to use pre-existing conditions. That means that Romney and the Republicans will have to not just do a simple repeal, they will have to do some sort of a bill of their own, and having worked on health care reform all these years, I can assure them there is nothing simple about trying to pass any kind of health care bill simply because everything is related to everything else. Take the most popular thing in Obamacare, getting rid of pre-existing conditions: you can't just pass that all on its own without dramatically impacting the entire rest of the insurance marketplace.
Here's the other thing: this bill would not have gotten passed unless many different segments of the health industry, as well as a lot of other business interests, found it desirable. The hospitals like it a lot (did you see their stocks skyrocket yesterday after the ruling came out?) The drug companies think it is great. While there are parts of the insurance industry that hate the bill, and of course there are many things in it they would love to tinker with, many insurance companies really like the way things came out. Physician groups are split, but a lot of the biggest ones are big fans of it. These are interest groups who are very powerful inside the beltway, with Republicans as well as Democrats, and they are going to leaning very hard on Romney and the Republicans in Congress to not move very fast or change the good deals these groups got in the process. Meanwhile, for Senate Democrats, even if they lose the majority they will still likely be in the high 40s, with plenty of votes to sustain a filibuster and slow things to a standstill.
So with the general public calling on Romney to focus on the economy, his base demanding immediate action to repeal Obamacare, and the politics of health care incredibly murky and complicated and very likely slow-moving, Romney and Congressional Republican leadership will be caught between a rock and a hard place. I think they will be in a world of hurt, their economic policies will be making things worse, and 2014 and 2016 will be very good years for the Democrats.
If Obama wins, and the law goes fully into effect in 2014, people are going to start realizing they like having more health security. As with Social Security and other New Deal economic reforms, and Medicare in the 1960s, the health care dynamic will more and more become a strong boost for Democrats, allowing them to create a broader narrative about how their policies help middle class people. Here's the other thing: the health care bill, once established, not only has the potential to keep getting better, the political sentiment to keep improving it will keep growing. People will see that they like it pretty well, but keep seeing things they want to tinker with. Jacob Hacker, in a terrific and sobering piece for Democracy Journal, raises all kinds of smart policy points on why the ACA will need to be strengthened in order to engender growing political support, so there are clearly risks to my more optimistic scenario, but the thing about legislation like this is that there are enough tangible benefits for enough people that there will be a growing political sentiment to not take those things away, and growing passion to not only keep it but make it better.
What both Republicans and Democrats need to understand is that once a piece of legislation with this kind of scope and day to day consequences for the American public gets passed, it is very difficult to roll it back, and it becomes easier and easier to make improvements because voters keep seeing up close and personal how it will affect them. That has been the smart conservatives' fear all along: that health care reform would pass, that people would begin to appreciate the benefits, and not only want to defend it but want to improve it.
Now that this bill is law, with the threat of the Supreme Court taking it away over, progressives should certainly keep working to defend it, because the right wing and certain players in industry remain obsessed with doing away with it. That possibility will be at its peak if Romney wins the next election, but will be a danger for quite a while. Our focus, though, should also begin to shift to continually improving it, and to using the new engagement of millions of people in fighting to preserve what they have won in health care to extend that organizing and engagement beyond health care. The fact is that the battle over health care will be on-going, with the right wing/bad industry players and progressives going at it every year to improve or scale it back, and people are going to learn new lessons about politics and their own power from the ongoing fight. The health care law surviving the Supreme Court gauntlet will change the nature of American politics for decades to come, and progressives need to be ready to take advantage of that fact.