MILWAUKEE — Supporters downplay the notion. Opponents ignore it. Yet at the core of the Affordable Care Act are many ideas backed by conservatives and decried by liberals.
The law makes use of tax credits, partially relies on commercial health plans and enables people to shop online for a plan of their choice — all concepts championed by conservatives.
It also puts an emphasis on personal responsibility, a conservative mantra, in requiring most people to buy plans with high deductibles as well as in requiring people to have health insurance.
Three and a half years after it was passed, however, a standoff between conservatives who want to overturn the law and liberals who want to uphold it has brought portions of the federal government to a standstill.
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“The huge irony is that Democrats are trying essentially the Republican idea,” said James Morone, a political-science professor at Brown University who has written extensively about the politics of health-care reform. “These marketplaces are efforts to reframe health-care competition.”
To be sure, the law abounds in provisions — from higher taxes to increased regulation — that conservatives philosophically oppose. But it also contains provisions, such as its partial reliance on private insurance companies, that liberals oppose.
The marketplaces being set up through the law and many of the new regulations, such as requiring insurers to offer health plans of similar value and cover a basic package of benefits, are designed to increase competition by making it easier for people to compare health plans.
“That is to me the overwhelming irony — that the Democrats have essentially lashed their fate to what is principally the classical Republican idea,” said Morone.
The law clearly doesn’t rely solely on markets. It also expands the Medicaid program to include uninsured adults with very low incomes. And expanding a government program that now covers more than 62 million Americans — more people than Medicare — definitely is not a conservative idea.
The U.S. Supreme Court ruling last summer gave states the option of not expanding their Medicaid programs, and 24 states have opted not to do so.
At the same time, many people to the left of the political spectrum — who have long pushed for a single-payer government program, similar to Medicare, that covers everyone — opposed the Affordable Care Act for being too conservative.
“There are people on the left who are not happy with this at all,” said Stephen Parente, a health economist at the University of Minnesota and a former adviser to Sen. John McCain’s presidential campaign.
In a 2010 essay, Parente noted that “the roots of the law lie far more with Republican market-based health reform solutions than the single-payer and Medicare-for-all national health insurance programs proposed by Democrats since the end of World War II.”
Except for its expansion of the Medicaid program, Parente said, the law has similarities to McCain’s proposal in his campaign, such as using refundable tax credits to enable people to buy their own health plans.
The plans in the marketplaces overall also have high deductibles, which many health economists support because the deductibles encourage people to be better consumers of health care.
“That’s sort of the dirty little secret in the room,” Parente said.
The law’s reliance on tax credits and its expansion of Medicaid — as well as its requirement that health insurers cover people with pre-existing health problems — cost money. And the projected cost of expanding coverage to tens of millions of uninsured Americans is one of the reasons for the ongoing debate over the law.
The Congressional Budget Office projects that the Affordable Care Act will account for 3.5 percent of federal spending through 2023.
The law is not projected to increase the federal budget deficit because of the combination of taxes and lower increases in Medicare payments to hospitals and Medicare Advantage plans.
“Basically, this is just one of the choices we make as a society,” Morone said. “If you want people covered, it’s going to cost some money. But in the long run, you hope that a more efficient system is going to have less inflation built into it.”
The most significant changes in the law affect a small piece of the health-insurance market: the market for people who don’t get health benefits from an employer. It is a market — with its exclusion of people with health problems — that many health economists consider dysfunctional.
An estimated 19.4 million people get coverage through the so-called individual market.
In comparison, 156 million people were covered through an employer in 2012.
The balance are covered by government programs such as Medicare and Medicaid.
The ongoing controversy over the law, Morone said, is almost unprecedented, with the exception of Prohibition.
“In modern times, the fight can be ferocious, but once you pass the law, that’s it,” he said. This was true even for the Civil Rights Act of 1964. “The day it passed, that was it.”
But Len Nichols, a health economist at George Mason University, said the debate “has precious little to do with delivering care and coverage to low-wage workers and everything to do with the proper role of government.”
That, too, is how Morone sees it. To him, the fight is over two things.
“One is which party is going to be dominant,” he said. “Republicans fear that should this program be a success, it would be a real legacy for Obama.
“Secondly, and this is another reason it is so fierce: We really are fighting about the Reagan legacy. Republicans fear, and with some justification, that Obama is challenging the philosophic premise that has dominated American politics since Ronald Reagan — which is government is not the solution to our problems.”
Republicans don’t want to hear that government could be a solution to an important problem, he said. And Democrats want to believe that it can be.
“If you think the fight is about that, then it really is about all the marbles,” Morone said. “Don’t look at the money. Look at the philosophy.”
That also may explain why the conservative ideas in the law get little attention. Yet those ideas, such as drawing on the power of markets, could help determine if the law is a success. And Morone said this could be the biggest irony of all.