Despite seven years or relentless attacks, two Supreme Court challenges and dozens of congressional efforts to kill it, the Affordable Care Act -- aka Obamacare -- has again lived to see another day.
After the 2016 election with Republicans in control of both the White House and Congress, President Obama's signature health care reform seemed all but doomed.
As a candidate, President Trump repeatedly pledged to dismantle the law, promising an alternative plan that would offer "insurance for everybody” all while dramatically cutting costs (although he stopped short of providing any firm details).
Things got a good deal messier after that. Repealing the ACA without a reasonable replacement would cause millions of Americans to lose their health coverage, a prospect that, as it turns out, a lot of people aren't too thrilled about. That was made abundantly clear when scores of irate constituents recently packed into Republican congressional town hall meetings across the country to air their grievances.
In fact, despite the ongoing, high profile barrage of attacks against the ACA, and the striking number of former Obama backers who voted for Trump -- a candidate who vowed to dismantle it -- support for the law is actually at the highest level it's been in years.
Meanwhile, Republicans have struggled mightily to figure out what an overhaul would actually look like. It’s a tall order, after all: guaranteeing health coverage for everyone doesn't exactly jive with the party's agenda to slash federal spending and dramatically reduce government’s role in managing the health care market.
The result, the American Health Care Act, introduced by Republicans earlier this month, would have gotten rid of the individual mandate and replaced federal insurance subsidies with tax credits and block grants to states, among other major changes. In its analysis of the bill, the Congressional Budget Office projected that while the proposal would indeed save billions of federal dollars, it would also result in 24 million more Americans without health insurance over the next decade.
Even after big changes to the legislation, and a major push by President Trump and House Speaker Paul Ryan, the bill still failed to get enough Republican support in Congress to guarantee its passage (it was uniformly opposed by Democrats). Some moderates remained concerned it would cause too many of their constituents to lose health coverage, while a group of hardline conservatives opposed to big government argued that the bill was still too much like Obamacare.
A House vote scheduled for Thursday -- on the ACA's seven year anniversary -- was postponed at the last minute. And by Friday, just before the vote was finally set to happen, Republican leaders scrapped the whole deal, a major defeat for Trump and Ryan.
“Obamacare is the law of the land,” Ryan conceded. “We’re going to be living with Obamacare for the foreseeable future."
He added: "Doing big things is hard."
But why so hard? Why can't Americans agree on a good national health care fix?
It’s safe to assume that just about everyone wants affordable health care. Yet, finding consensus on a plan we can all live always seems out of reach.
Nearly every other high-income nation in the world has figured out a way to spend a lot less money than the U.S. does on health care, yet deliver high quality universal health care to their citizens. Countries can do this in a lot of different ways. In some systems, the government provides for all health care; others include a mix of government funding and private insurance.
In 2000, when the World Health Organization ranked different countries' health care systems, the U.S. landed in dismal 31st place -- despite spending more per capita than any country. Other studies paint a similar picture of inefficiency.
But in the U.S., citizens have long been wary of government involvement in health care. Some of the skepticism is cultural, related to the American emphasis on individualism and self-sufficiency.
Some of it has to do with support for organized labor, which has historically been much stronger in Europe than in the U.S., and health care is typically a key perk of union membership. Some of it is also a remnant of the Cold War, when many Americans began to worry that government involvement in health care was a big step toward socialism.
Truman's big push
To begin to understand why the U.S. is such an outlier on the health care front, we need to go back to November 1945. That’s when President Harry Truman proposed a new health insurance program that would cover all Americans. His plan would have made the government centrally involved in the provision of health care – a far more radical approach than that of the ACA, which for the most part just expands access to private insurance.
Most Americans were initially receptive to Truman’s proposal, with nearly 60 percent in support, according to a Gallup Poll conducted after the president's address.
The immediate enthusiasm, though, worried the American Medical Association, which was then one of the country's richest and most influential lobbies, representing the business interests of doctors. A nationwide plan to make health care more affordable for patients would also make it less profitable for many private-practice doctors.
And so the group quickly got to work on an ingenious ad campaign centered on two magic words: "socialized medicine."
Over the next few years, as Congress worked to craft a universal health care bill, the AMA invested in what was then the largest ad campaign in U.S. history, all aimed at convincing Americans to reject Truman's plan.
"Would socialized medicine lead to socialization of other phases of American life?" one pamphlet posited. "Lenin thought so.He declared, 'Socialized medicine is the keystone to the arch of the socialist state.' "
(The quote, by the way, was completely made up, but it stuck nonetheless.)
When the plan was introduced in Congress, Sen. Robert Taft, a conservative Republican from Ohio, interrupted his Democratic colleague, stating that the bill was "the most socialistic measure this Congress has ever had before it." National health insurance, Taft suggested, came directly from the Soviet constitution. He then announced that Republicans would boycott the hearings, and promptly marched out of the Senate chamber.
The AMA continued to push the "socialized medicine" angle. In one editorial, the group warned that national health insurance would turn doctors into "slaves." In a Tallahassee, Florida, hospital, doctors slipped political ads onto patients' breakfast trays.
Ahead of the 1950 midterm elections, the AMA spent more than $1 million on radio and TV ads -- far more than the government could spend to defend it. As one Truman ally ruefully noted, countering the AMA's ads was like "trying to put out a forest fire with a sprinkling can." When the election results rolled in, Democrats lost nearly 30 seats in the House and five in the Senate. Public support for the proposal had also plummeted, dropping from 60 to 24 percent in just five years.
And so the prospect of national health insurance was dead, for the time being at least. Over the following decades, the AMA would go on to fight many more nationwide government health-related reform proposals, including Medicare – a battle it did not win, even with the star power of Ronald Reagan as its main spokesman.
The 1961 recording of then-actor Ronald Reagan was part of Operation Coffee Cup, part of an elaborate AMA effort to prevent Social Security funding going to health insurance for the elderly and the poor.
The effort, of course, ultimately failed. In 1965, President Lyndon Johnson signed into law the bill that created the Medicare and Medicaid federal health insurance programs for Americans ages 65 and up, regardless of income (and later expanded to include younger people with permanent disabilities) and low-income Americans. To this day, Medicare — that harbinger of “socialism” and destroyer of freedom that Reagan warned about— remains one of the most popular federal programs, approved by an overwhelming majority of Democrats and Republicans..
But in 2010, the AMA did an about-face and decided to support federal health reform -- thanks in part to a lot of behind-the-scenes horse-trading. Today, the AMA's website refers to Obamacare as "a tremendous step forward on the path toward meaningful health system reform." The group has implored Republicans not to repeal the ACA without offering an adequate replacement plan, and has come out against the Republicans' bill.
The AMA, though, couldn't put the "socialized medicine" genie back in the bottle. The majority of Americans today might not know how the phrase originated, but many automatically consider anything linked to it an infringement of their rights.