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Obamacare is gradually becoming a fact of American life

CNN 3/20/2022 Analysis by John Harwood, CNN
President Barack Obama signs the Affordable Care Act into law in the East Room of the White House on March 23, 2010. © Doug Mills/The New York Times/Redux President Barack Obama signs the Affordable Care Act into law in the East Room of the White House on March 23, 2010.

Russia's assault on Ukraine has united America's political parties, as war abroad often does. It's more surprising to see diminishing conflict on a hot-button domestic issue -- but recent developments at both ends of Pennsylvania Avenue tell that story on health care.

More specifically, they show that the Affordable Care Act, signed into law 12 years ago this week, keeps growing more deeply embedded in American life.

One marker came early this month from Wisconsin Sen. Ron Johnson, a conservative Republican seeking reelection this fall. Answering complaints that the GOP had no agenda beyond opposing President Joe Biden, he identified a familiar target.

"For example," Johnson told Breitbart News, "if we're going to repeal and replace Obamacare -- I still think we need to fix our health care system -- we need to have the plan ahead of time so that once we get in office, we can implement it immediately, not knock around like we did last time and fail."

Facing backlash, Johnson promptly reversed course by saying he meant the Obamacare reference to be simply illustrative.

"I was not suggesting repealing and replacing Obamacare should be one of those priorities," he explained in a statement. That was quite a climb-down for a senator who six years ago called the ACA a "disastrous law" causing "very real harm" to Wisconsin families.

The second development came last week, when the White House quietly signaled plans to strengthen Obamacare by executive action.

It came in the disclosure that the Biden administration is pursuing a regulation to eliminate what analysts call the Obamacare "family glitch." The term refers to a legal interpretation limiting access to subsidies under the law for family members of workers whose employer-provided health care plans are too expensive.

"It's a big deal," said Larry Levitt, a health care expert at the Kaiser Family Foundation. Though details of the proposed regulation have not been published, Levitt estimates that it could save "thousands of dollars a year" for more than 5 million Americans.

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From the beginning, Republicans targeted Obamacare with unremitting zeal. They withheld their votes in Congress en masse in an attempt to keep Democrats from passing it.

After that failed, die-hards sought to block its implementation lest Americans, as Texas Sen. Ted Cruz put it, grow "addicted to the sugar" of health care subsidies. After that also failed, then-President Donald Trump and a GOP-controlled Congress tried unsuccessfully to repeal it in 2017. They lost control of the House in the next year's midterm elections.

Today, more Americans than ever have health care coverage under the ACA. That includes 14.5 million people purchasing plans for 2022 coverage from Obamacare insurance exchanges, well over the peak during President Barack Obama's last year in office.

A comparable number gained coverage from provisions of the ACA that expanded the Medicaid program to low-income adults. The proportion of Americans without health insurance has fallen by about half, to below 10%.

"It's not just that it has survived," observed Neera Tanden, an Obama administration health policy aide who now works in the Biden White House. "It's thriving."

Biden, who famously whispered to Obama, "This is a big f---ing deal" at the ACA signing ceremony, resisted calls from 2020 Democratic rivals to scrap the law in favor of alternatives such as "Medicare for All." As President, he has worked to strengthen it, though with somewhat less fanfare than his proposed new programs have received.

Last year's $1.9 trillion American Rescue Plan temporarily expanded premium subsidies for most of those with coverage on the exchanges. Unlike the more celebrated child tax credit expansion, which expired after one year, expanded Obamacare subsidies continue through 2022.

Biden's star-crossed Build Back Better legislation would make those subsidies permanent. It would also extend Medicaid coverage to an estimated 2.2 million additional Americans in the so-called Medicaid gap -- which refers to some low-income residents of the 12 states that have refused to expand Medicaid using incentives provided by the ACA.

Holdout Democratic Sen. Joe Manchin of West Virginia scuttled Build Back Better in December. But both provisions remain strong candidates for inclusion in a stripped-down alternative that the White House still hopes Manchin and the other 49 senators in the Democratic Caucus might approve.

The "family glitch" provision won't require congressional approval. And it's not the only way Biden could strengthen Obamacare without legislation.

Ezekiel Emanuel, a former Obama health care adviser who teaches at the University of Pennsylvania, noted that more than half of the roughly 31 million Americans still without health insurance are actually eligible for subsidized ACA coverage. By more vigorously "pushing on the states" that administer Medicaid and the exchanges, Emanuel said, the administration may be able to enroll a significant chunk of them.

In any case, the law's resilience has demonstrated why Republicans fought it with now-or-never intensity. In August 2013, as he sought a government shutdown to "defund Obamacare," Cruz warned: "If we get to Jan. 1, this thing is here forever."

It didn't work. And the evidence so far suggests his warning was accurate.

Sen. Ron Johnson speaks on Capitol Hill on February 8, 2022. © Andrew Harnik/AP Sen. Ron Johnson speaks on Capitol Hill on February 8, 2022.
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