Obamacare Is Turning 5 Years Old, And The Debate Has Barely Changed

A big f***ing deal happened five years ago Monday.

On March 23, 2010, President Barack Obama signed the Affordable Care Act -- a law designed to make health insurance available to all Americans and, over time, to make the health care system more efficient. Vice President Joe Biden s comment that the law was a B.F.D. , which an open microphone at the White House ceremony caught, was mainly a reference to the decades-long quest to establish some kind of universal health care system, bringing to the U.S. the same guarantees of financial security and access to medical care that have long existed in every other developed country.

But Bidens quip was also a statement about the grueling fight to get a bill through Congress. For more than a year, stretching back to Obamas very first days in office, Republicans and their allies had attacked the law relentlessly and, at times, hyperbolically. They didn't just doubt that the law would achieve its goals, they also predicted that it would wreak havoc on the federal budget, the economy and the health care system.

Biden, the laws congressional architects and a few key allies watched over the presidents shoulder as he slowly, painstakingly signed the bill with 22 different pens . The presidents advisers, along with almost every Democrat in Congress, watched from seats that nearly filled the East Room. Not a single Republican attended the ceremony, just like not a single one had voted for the law. But Obama predicted that his signature might change the political environment. As we mark the turning of spring, we also mark a new season in America, Obama said . In a few moments, when I sign this bill, all of the overheated rhetoric over reform will finally confront the reality of reform.

It didnt quite work out that way.

Five years later, by any reasonable and objective criteria, Obamacare has achieved a great deal. The percentage of adults without health insurance has dropped to 12.9 percent, according to Gallup . Thats the lowest the organization has recorded and corresponds, according to the Obama administration, to insurance for about 16.4 million people who might not otherwise have it. Health insurance is not the same as health care, but studies of previous coverage expansions suggest that as more people get insurance, they will be more financially secure and, over the long run, less likely to die .

Meanwhile, the budget deficit is coming down, and according to the Congressional Budget Office , the Affordable Care Act has contributed significantly to that reduction. Overall health costs -- i.e. what the U.S. as a whole spends on medical care -- are rising at historically low rates. Nobody can be sure what role Obamacare has played in that progress -- but its probably helped, and it certainly hasnt hurt.

To say that these results confound the prediction of critics would be a gross understatement. But, contrary to Obamas prediction, conservative rhetoric about the law has barely budged. Republicans routinely refer to the law as a disaster or a train wreck . They have pledged to repeal the law, voting to do so in the House of Representatives more than 50 times -- and made the laws eradication a pillar of the 2012 GOP presidential platform.

Obamacare's critics can point to real failures (like the websites that took forever to get working) and real tradeoffs (like higher taxes on the wealthy and higher premiums for young and healthy people who used to benefit from preferential pricing for people unlikely to get sick). Most famously, some people lost their old insurance because those policies did not live up to Obamacares standards for coverage and insurers decided to drop them altogether. These people did not get to keep their plans , even though Obama famously promised that everybody could. But efforts to repeal the law politically have repeatedly failed, perhaps because large majorities of Americans approve of the laws features -- and, according to surveys , tend to like their new insurance, even as polls show pluralities disapprove of the law itself.

Of course, conservatives have one last chance to do through the courts what they cannot do through electoral process. If the Supreme Court rules in favor of the lawsuit in King v. Burwell , the case it heard earlier this month, the federal government will have to stop providing financial assistance to people buying insurance in about two-thirds of the states.

Congress could repair the damage with a simple, one-sentence amendment to the law, because the basis for the case is disagreement over what a key passage in the text of the statute says. Alternatively, state officials could take action that would render the Supreme Court decision moot. But Republicans cant even agree among themselves whether government should be in the business of helping people get health insurance. Thats why the most likely result of such a court ruling could be no action at all -- and then, a dramatic reversal of recent progress as the ranks of the uninsured swell by more than 8 million. Lives would be ruined because of crushing medical bills, and in a few cases lives would be lost.

If the administrations legal arguments dont persuade the courts conservative majority to back off, recognition of those consequences might. But no matter what the Supreme Court rules, the relentless, over-the-top opposition to Obamacare has already extracted a cost. Even the laws advocates admitted from the get-go that the program had shortcomings. (Tom Harkin, then chairman of the Senate Health, Education, Labor and Pensions Committee, famously referred to it as a starter home.) People buying coverage through the new marketplaces remain confused about whats available and what policies cover, because the process and the products remain too opaque. Some consumers struggle with high out-of-pocket costs . Employers bristle at the new regulations, and at least some parts of the health care industry say the government is asking for too much.

An intelligent debate over these issues and how to address them would be constructive, interesting and even unpredictable. Its one that most of the laws advocates would love to have. But it cant take place when one of the two major political parties is waging an all-out, all-or-nothing fight to wipe the law off the books. Maybe five years from now, at the laws 10th anniversary, that campaign will finally be over.