There’s an odd sort of complacency, and even smugness, in some progressive circles over the problems being created by the flight of private insurers like UnitedHealth and Aetna from participating in the Affordable Care Act’s purchasing exchanges. It is being widely noted that this is precisely the sort of contingency that a “public option,” originally supported by the president and most congressional Democrats but abandoned in the final legislation to get it through the Senate, was designed to address. In the most prominent “told you so,” Bernie Sanders has predictably commented that the leverage of private insurers over Obamacare shows why we instead need a single-payer system that abandons private insurance entirely.
That is all well and good, but the very same political problems that prevented the adoption of a public option (much less “Medicare for all”) in 2009 and 2010 when Democrats controlled Congress by comfortable margins have gotten worse, not better. Yes, if Hillary Clinton is elected in November she has already announced support for adding a public option to Obamacare, and there’s a decent chance she will bring a narrowly Democratic Senate along with her. A Democratic House, however, remains a very long shot, and even if it happens, getting something as controversial as an Obamacare “fix” through a closely divided Congress is at best an even longer shot. Yes, in theory, something like an increase in insurance subsidies to lure the private companies back in could be enacted via a budget reconciliation bill that is immune to a GOP Senate filibuster. But progressive Democrats who want to abandon private insurance entirely aren’t likely to go along with that, and it’s doubtful a major structural reform could be accomplished without the kind of legislation that could be filibustered (barring elimination of the filibuster altogether).
In all likelihood, then, congressional Republicans will maintain their veto power over any Obamacare “fix.” And there’s absolutely no evidence they’ll be interested in anything short of the destruction of the whole Affordable Care Act. The lusty cheers with which they are greeting the system’s current problems ought to show that to anyone under the illusion that the GOP is concerned about the human cost of insufficiently available or affordable health insurance. It will be astonishing if Donald Trump doesn’t make the repeal of Obamacare (and its replacement with something “incredible” down the road, by and by) a presidential campaign issue down the stretch. If Republicans hold on to one or both congressional chambers, the odds of anything good happening to Obamacare are virtually nil. If Trump somehow wins, the fate of Obamacare may be the least of the country’s problems, but it will be a problem nonetheless.
If Clinton does win but does not have the congressional support to do much with it, could Democrats perhaps make an Obamacare “fix,” or even a move to single-payer, a big campaign issue in the 2018 midterms and roll to victory? Fat chance of that. Between the almost certain anti–White House backlash we will see after three straight Democratic presidential victories, the Democratic coalition’s persistent midterm turnout problem, and the most pro-Republican Senate landscape in living memory, the kind of gains Democrats would need to enact major progressive legislation will be very unlikely.
So even if they hate Obamacare’s structure and the very existence of private health insurance, progressives should hope against hope that private insurers hang around and that the ACA continues to function. Much of the coverage gains achieved by Obamacare were via state Medicaid expansions that are unlikely to be revoked, at least in the bare majority of states that enacted them. So the picture is not all bleak. But it’s politically unseemly and morally questionable for progressives to enjoy the problems bedeviling the ACA, even if they told us so.