The Republican party has voted unanimously against establishing the Affordable Care Act in the Senate and then in the House of Representatives, then voted some 40 times to repeal or cripple it; it has mounted a nearly successful campaign to nullify it through the courts and a failed presidential campaign that promised to repeal it; and it has used its control of state governments to block the law’s implementation across vast swaths of the country, at enormous economic cost to those states. Yet somehow, in the wake of all this, the party is consumed with the question Have we done enough to stop Obamacare?
This peculiar subject of introspection, as if Joe Francis were lying awake at night cursing himself for his prudery, reflects the deepening mix of terror and rage with which conservatives await the enrollment of millions of uninsured Americans beginning in October. On the substantive merits of the law, only the subtlest variations can be detected in the GOP’s evaluation. Mitch McConnell calls it the “single worst piece of legislation passed in the last 50 years in the country.” Representative John Fleming of Louisiana calls it “the most dangerous piece of legislation ever passed by a Congress” and “the most existential threat to our economy … since the Great Depression.” Virginia gubernatorial candidate Ken Cuccinelli harks back to the Fugitive Slave Acts for a comparative affront to liberty.
Having achieved near consensus on the policy, the party has fallen into intramural squabbling over which extraordinary threats to deploy. Shut down the government? Default on the national debt? (House leaders have wriggled out of demands to do the former by promising to do the latter.) Conservative activists have turned on their leaders as traitors for hesitating to employ the most obviously suicidal methods, affixing John Boehner’s name to the hated program (“Boehnercare”) or accusing McConnell of “empty rhetoric … about ending Obamacare.” These recriminations reprise the hallucinatory attacks by Cold War conservatives like Joe McCarthy and the John Birch Society, which over time migrated from their original targets onto such figures as President Eisenhower and the Army.
The historical echo is fitting in the sense that Obamacare has come to fill the place in the conservative psyche once occupied by communism and later by taxes: the main point of doctrinal agreement. (In constituent meetings, “this is the overriding issue that is being discussed,” one Republican member of Congress explained late last month. “Way more than immigration, way more than the debt.”) The transformation of Obamacare from a close relative of Republicans’ own health-care ideas to the locus of evil in modern life is owing to several things, including the almost tautological political fact that its success would be Obama’s: Permanent health-care reform would define Obama as a Reaganesque transformative figure, rather than the failure conservatives still hope him to be remembered as. The law’s slow rollout has made it a live issue, unlike the already-expired stimulus, and thus the main receptacle for simmering concerns over unemployment and the tepid economic recovery.
Most important, the law has, in its direct impact, opened a fissure over the role of government deeper than any since the New Deal. Obamacare threatens America’s unique status among advanced economies as a country where access to regular medical care is a privilege that generally must be earned. In a few weeks, the United States government, like those of France, or Australia, or Israel, will begin to regard health insurance as something to be handed out to one and all, however poor, lazy, or otherwise undeserving each recipient may be. “We can’t afford everything we do now, let alone provide free medical care to able-bodied adults,” as Missouri Republican Rob Schaaf, author of the state’s harsh anti-Obamacare initiative, put it. “I have a philosophical problem with doing that.”
The Obamacare wars have progressed from the legislative to the judicial to the electoral fronts, gaining intensity at every step. Now they move to a new battleground to secure the law and all it represents, or provoke its collapse. That an implementation battle is taking place at all is a highly unusual circumstance. Major new laws often stagger into operation with glitches, confusion, and hasty revisions, but not sabotage. Obamacare will come online in the midst of an unprecedented quasi-campaign atmosphere, with Republicans waging a desperate political and cultural war to destroy it.
The transformative potential of Obamacare is not a conservative hallucination. It is the resolution of a confounding dilemma decades in the making. The American health-care system is not merely the only one in the advanced world that’s closed off to a large share of the population; it’s also the most expensive by far. The normal structure of a public problem is that the worse the problem, the easier it is to solve—as traffic gets worse, more people support mass transit; the more soldiers die, the more pressure to end the war. American health care has long defied that dynamic. The worse the problem grows, the harder it has gotten to solve. The more waste and inefficiency that sprout through the medical system, the more of an interest doctors, hospitals, and pharmaceutical companies have in maintaining the status quo. The uninsured are diffuse and disorganized, unable to marshal any substantial political support, and the effect of their plight has largely been to make people with insurance fearful of any change lest they join them.