A version of this story appeared in CNN’s What Matters newsletter. To get it in your inbox, sign up for free here.
It took a dozen years, but the Affordable Care Act finally feels like a permanent part of American life.
Once a major dividing line in US politics, the massive law that remade the US health care system also moved elections – and withstood repeal effort after repeal effort and Supreme Court challenge after Supreme Court challenge, including last year.
Passing the law Republicans derisively called “Obamacare” cost Democrats control of the House in 2010, when backlash led to what former President Barack Obama called a “shellacking.”
It angered conservatives by placing more government control over the health care industry.
It disappointed liberals who remain convinced it didn’t go far enough.
Now Democrats are more likely to promise to protect the law to avoid another possible shellacking in November’s midterm elections.
Appearing at the White House Tuesday, Obama said the law had spread coverage to 30 million Americans.
It’s more popular today, he said, “because it’s done what it was supposed to do.”
Republicans who suggest repealing it these days might quickly issue statements making clear that’s not their current priority.
CNN’s John Harwood looked at the example of Sen. Ron Johnson, the Wisconsin Republican who was once a fierce ACA critic, but who issued just such a statement in March.
The tables have turned.
The law is still not exactly wildly popular
A majority of Americans – 55% – have a favorable view of the ACA in a Kaiser Family Foundation tracking poll from March 2022, compared with 42% who have a negative view.
And the law is still tainted by partisanship: Most Democrats view it favorably, while most Republicans view it unfavorably, per Kaiser’s polling.
When I asked CNN’s Tami Luhby, who covers health care policy, what changed the public’s mind about the ACA, she said it was almost losing it.
The moment the public bought into the Affordable Care Act
Looking at a graph of Kaiser’s polling, it’s hard not to notice that the ACA has been more popular than unpopular since just about the moment Obama left office.
The change in attitude can be seen in early 2017, when former President Donald Trump swept into Washington and Republicans had control of the House and Senate. Repealing the Affordable Care Act was among their top priorities. Perhaps it was the danger of losing it that made some Americans appreciate it.
Republicans at the time were on the cusp of repealing it and, were it not for the surprise move by Sen. John McCain of Arizona to buck his party and save the law, it would be gone today.
The issue of health care access and affordability is far from solved, and prescription drug prices in particular are a major issue for voters. A Kaiser Family Foundation survey in December found substantial portions of Americans have difficulty affording care for dental, vision and other things not covered by insurance.
President Joe Biden was joined by Obama at the White House Tuesday to announce a new rule to fix a glitch in the law that excluded some families from getting federal subsidies to buy insurance on the health care exchanges it created.
More than ACA exchanges
There’s a common misconception that only people who buy their insurance on ACA exchanges have “Obamacare.” The number of people buying insurance that way has grown, but more people got insurance from the law because of a massive expansion of Medicaid.
Voters have endorsed Medicaid expansions
Not all states have yet expanded their Medicaid programs, but when voters, even in red states, have been given the chance to do it with ballot initiatives, they have. That’s the case in Idaho, Maine, Missouri, Nebraska, Oklahoma and Utah, according to a tally kept by Kaiser.
Other changes implemented by the law have always been popular, like guaranteeing access to coverage even for those with pre-existing conditions and allowing young adults to stay on their parents’ plans.
“It is woven so much into the fabric of the American health care system that you can no longer rip it out,” Luhby told me.
This is why Republicans fought so hard
CNN political director David Chalian said it might have seemed unimaginable in the divisive atmosphere when the law passed that it would one day become so enmeshed.
“But it was precisely what Republicans did imagine and, in part, why they fought so hard against it – they understood (as did many Democrats) that once you pass a huge government benefit like that into law, it is very, very hard to take it away – they almost always tend to get more popular with time. (See: Medicare)”
Long time coming
The effort to pass the Affordable Care Act lasted for about a year. But the fight over health care in the US has been going on for generations, in fits and starts from the late 1800s through the passage of Medicare in the 1960s, and it continues today.
Progressives like Sen. Bernie Sanders of Vermont are still pushing for a government-run health care option for younger Americans, something Biden does not support.
How can anything else get done?
Passing the ACA took a veto-proof Democratic majority to get the bill passed into law, and doing so cost Democrats so much political power in the short term. It’s hard to imagine either party getting a veto-proof majority to pass major legislation through the Senate in the near future.
That’s bad news for other issues that need attention, like climate change, which is rapidly changing the world, and immigration, which multiple presidents have tried and failed to address in a major way.
Could the ACA pass today?
It was in fact the same Congress that passed the Affordable Care Act that passed a major piece of climate change legislation through the House. It failed in the Senate.
The problem of climate change has only intensified in the intervening years, but the likelihood of big US action feels just as far off. A Democrat, Joe Manchin, first elected as a senator from West Virginia in 2010 with a promise to block climate change legislation, did just that last year.
Back then he said he would have opposed the Affordable Care Act too, which means it would never pass in today’s Washington.