No issue has aroused more partisan passion over the past six years than the Affordable Care Act. Yet the law is playing only a secondary role in the U.S. elections.
Sure, Republican presidential candidates cater to their base by vowing to repeal and replace Obamacare, and on the Democratic side, Senator Bernie Sanders of Vermont promises to replace it with a government-run universal coverage system.
But it doesnâ€™t dominate the dialogue and isnâ€™t a top priority on either side. Among the most embattled Senate Republican incumbents, the campaign websites of New Hampshireâ€™s Kelly Ayotte, Mark Kirk of Illinois or Ron Johnson of Wisconsin barely mention the ACA. An exception is Pat Toomey of Pennsylvania.
The explanation may be that for all its controversy and imperfections, the sweeping law has taken hold. â€œThis is in the fabric of the nation,â€ says Health and Human Services Secretary Sylvia Mathews Burwell.
To be sure, the presidential election outcome will be a determinant of whether Obamacare is reshaped, bolstered or downsized.
But even some sceptics acknowledge that its numbers are rather impressive. About 20 million more Americans now have health insurance than before the law was enacted in 2010; in the last enrollment period on the health care exchanges, 12.7 million signed up, almost 40 percent were newcomers. The expansion of Medicaid for the poor is making a mark.
Millions of Americans with pre-existing conditions no longer can be denied coverage; kids can stay on their parentsâ€™ plans until age 26, and health care inflation is the lowest in years.
Burwell, in an interview, noted that there are a lot of less-known successes, such as a sharp reduction in patient harm at hospitals. She acknowledges challenges, which she put in â€œthree bucketsâ€: reforming the health-care delivery system to encourage quality, not quantity, of care; addressing a few places where markets still are broken such as Alaska, and making technical fixes to so the law works a little better.
Critics find more. Premiums have soared this year in a number of states. Congress, in a bipartisan move, postponed and is threatening to kill a few important provisions that could create budgetary and cost-control problems; 22 states where Republicans hold sway have refused the expansion of Medicaid coverage.
In the presidential campaign, the rhetoric still can get hot. Texas Senator Ted Cruz says the ACA is â€œthe biggest job- killer in this country. Millions of Americans have lost their jobs.â€ Over all, from March 2010, when the law was enacted until today, the economy has added 13.7 million jobs.)
But most Republicans insist that they would keep popular provisions such as guaranteeing coverage for people with pre- existing conditions. Governor John Kasich embraced the ACAâ€™s expansion of Medicaid in Ohio. The Republican front-runner, Donald Trump, has said he likes the mandate to get health insurance â€” the centerpiece of the ACA and chief target of most conservative critics â€” and that he wouldnâ€™t let people â€œdie sitting in the middle of the street.â€
When speculation surfaced of a possible Trump-Kasich pairing, the conservative Weekly Standard lamented that itâ€™d be â€œThe Nightmare Ticket for Opponents of Obamacare.â€
If Republicans win in November, however, even Trump would have to try to dismantle the law. The targets: the Medicaid expansion, the mandate (though with some replacement), and cutting subsidies. The problem would be that millions of newly insured would likely lose coverage, creating a political backlash.
If Hillary Clinton is elected, she also would espouse changes to buttress the ACA. The emphasis likely would be on cost controls. Last week, her daughter, Chelsea, vowed that her mom would do something about the â€œcrushing costsâ€ of Obamacare.
The ACA may not play much of a role in the outcome of this presidential election, but the partisan controversy hasnâ€™t gone away.
Albert R. Hunt is a Bloomberg View columnist. He was
formerly the executive editor of Bloomberg News, directing coverage of the Washington bureau