Long before Barack Obama became president, the worst flaw in our health care system was obvious: Millions of people lacked insurance, exposing them to the dangers of untreated illness and the risk of ruinous hospital bills -- and imposing the expense of caring for the uninsured on everyone else. Those lucky enough to have coverage, meanwhile, had to worry about losing it if they got sick or changed jobs.
It might seem that taking measures to eliminate these problems would be good politics. In practice, it has been better politics to criticize those measures. One reason is that most Americans had insurance before Obamacare and didn't see what they would gain from it. That's why Obama felt the need to make a promise he was bound to break: "If you like your health care plan, you can keep it."
Even the comfortably insured had their gripes with the status quo he inherited. But that didn't mean they wanted it to change. In 2010, pollster Douglas Rivers of YouGov/Polimetrix reported that most Americans, when asked what would happen if Obamacare passed, expected "worse care at a higher cost." If it didn't pass, though, they expected exactly the same thing.
It did pass, and it failed to please most people. In a September 2016 Gallup Poll, 51 percent of respondents said they disapproved of Obamacare. But it would be a mistake to attribute too much consistency to public attitudes. A poll last month by the Kaiser Family Foundation found that only 26 percent of Americans want it repealed.
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Majorities in both parties support the law's provisions forbidding insurance companies to deny coverage based on pre-existing conditions, allowing children to stay on their parents' policy until age 26, eliminating copayments for preventive care and subsidizing premiums for lower-income people. What do they dislike? The individual mandate to buy coverage.
From a political standpoint, Obama made two big mistakes. First, he took action that saddled him with the blame for any complaints Americans have about their health care system. Even before the Affordable Care Act, premiums sometimes rose, treatments were sometimes denied and people sometimes had to change doctors. But when such things happened afterward, they automatically became his personal premeditated crime.
Second, he assumed the citizenry was mature enough to accept that there is no such thing as a free lunch. Obama figured that if Americans were protected against loss of coverage and astronomical bills, they would accept their reciprocal obligation to make the system work by purchasing insurance.
What was he thinking? They didn't accept it. They wanted -- and still want -- the benefits of the Affordable Care Act without the burdens.
They've actually gotten something approximating that. This year, the penalty for not having coverage is $695 -- much less than the typical annual premium. Consequently, many people, particularly the young and vigorous, choose to do without.
They can get off scot-free, because the only thing the IRS can do is reduce the tax refunds (if any) of the shirkers. It can't garnish wages or impose liens.
Americans may not be crazy about the new system. But Republicans may find there are more hazards in undoing it than there were in creating it. Since its passage, some 20 million Americans who didn't have insurance before now have it -- and a study by the Urban Institute forecasts that if the ACA is repealed, 30 million will lose coverage. The GOP would take the fall for that. Some people will have other problems with their health insurance, as people always do, and they, too, will blame it on those in power, regardless of the cause.
Congress could keep the popular parts and junk the mandate, but that would cause even more healthy people to bail out, which in turn would push up premiums, which in turn would cause more people to drop coverage, which would leave Americans without the impossibly sweet deal they demand from their leaders.
Republicans may find that when they try to carry out the promises they've made, the public will not reward them for good intentions but punish them for any result that falls short. There is a term for this tragic outcome: poetic justice.
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