The rollout of the health care exchanges on Healthcare.gov went badly.  For two months, people were effectively unable to enroll, due to software glitches in the programming of the website. Half of the states rejected ACA money to expand Medicaid, even that expansion cost those states nothing, largely for irrational reasons. The anti-ACA misinformation campaign was ferocious; a majority of Americans now think that the Affordable Care Act is a good thing, but that ‘Obamacare’ is a disaster, despite them being exactly the same thing.  The President’s early sales pitch misfired as badly as it could have done.  When he said ‘if you like your current health insurance, you’ll be able to keep it,’ that wasn’t strictly true.  Lots of people had cheapo, low-cost, low-benefit insurance policies they liked just fine.  They offered the illusion of adequate coverage, but didn’t cost much; obviously, if you didn’t get sick, that kind of policy would seem perfectly adequate.  Insurance companies made a cheap buck off those policies, knowing they could only offer them for a year or so; the ACA would outlaw them, and it would look like the President’s fault. What the President should have said was ‘if you have a good health insurance plan, offering adequate coverage, you’ll be able to keep it.’  He didn’t say that, and he’s paid a high political price for it.

The initial goal was for 7 million people to be enrolled in the Healthcare.gov exchanges.  Two months ago, that goal looked completely unattainable, for all the reasons listed above.  The early enrollment period ended yesterday.  Although final figures aren’t yet available (some late enrollments still need to be processed), they will exceed 7 million by a considerable amount.  That’s 7 million people who did not previously have insurance, many of them having been denied coverage because of pre-existing medical conditions.  Now they’re all covered; getting affordable health coverage, and for many, life-saving health care.  The website works.  The ACA works.  It’s going to continue to work.  Service will improve.

Republicans continue to shout from the rooftops that Obamacare is a catastrophe, that it’s a complete failure, that it’s the worst bill in American history.  Quite possibly, Tea Party favorites like Senator Ted Cruz (R-Pluto), will continue to compare Obamacare to slavery, or the Holocaust, or the zombie apocalypse.  Republicans are counting on this being THE big issue in the 2014 Congressional elections, and they’re hoping that they could very well win the Senate, and increase their lead in the House, based entirely on Obamacare.  That could happen, I think.  Off-year elections are low-turnout elections, and conservatives are unified in their hatred of this President and his signature legislative achievement. If enough young voters stay home, a strong showing by conservative voters could cost the Democratic party Congress.

But long-term, opposition to Obamacare will increasingly become a losing strategy.  Because in it’s own slipshod, ramshackle fashion, Obamacare does work.  Is it a flawed bill?  Of course.  Could it be improved?  Absolutely.  What I would love to see is a sensible, bi-partisan approach to the ACA that acknowledges the bill’s strengths and works to fix some of its problems.  And writing those words ‘sensible’ and ‘bi-partisan’ caused me to throw up a little in my mouth.

What I am certain of is that the ACA will not be repealed, and that opposition to it will fade over time.  And there will be no viable conservative alternative, because, let’s face it, the ACA IS the conservative alternative.  What liberals wanted was a single-payer system.  What liberals wanted was for health insurance companies to go out of business.  Republicans say they want a ‘market based’ alternative.  What could be more market-based than a health care exchange?  What could be more market-friendly than a website where lots of health insurance companies compete for your business?

What everyone hates about health insurance is a situation where you have a serious illness and your insurer won’t pay for your treatment.  What everyone hates is the concept of a ‘pre-existing condition’ that makes it impossible for you to get any health insurance at all.  It’s the double-bind in which parents without insurance coverage find themselves.  Your kid’s sick.  You don’t have insurance.  Your only choices are both irresponsible.  You can go to an emergency room and rack up a bill you can’t afford to pay.  Or you can not get treatment for your child, who may well have a serious, but treatable illness.  Choice A stinks.  Choice B stinks worse.  We’re the richest country in the history of the world.  We have to be able to fix this.

But it also doesn’t make sense to pay for something you don’t need.  If you’re not sick, paying health insurance premiums is a waste of money. Wouldn’t it make more fiscal sense to only get health insurance after you get sick?  By the same token, paying fire insurance premiums is a waste of money.  What makes more sense is to buy fire insurance only when your house is actually on fire.  But that defeats the purpose of insurance.  So we say to everyone who buys a home ‘oh, and you also have to buy fire insurance.’  We say to everyone who wants to operate an motor vehicle ‘you have to buy auto insurance.’ And that’s why the ACA includes a health insurance mandate.  We’re going to make you buy health insurance (and auto insurance, and fire insurance), because that’s the only way to make sure the money is there to care for people who become really really ill.  (Or wreck their cars, or burn down their houses).

So whenever you hear people say ‘what I like about the ACA is the prohibition on people who can’t get coverage due to ‘pre-existing conditions,’ but I hate the mandate; this is America; we can’t make people buy insurance,’ understand that those people don’t know what they’re talking about.

One thing I don’t like about the ACA is the way it continues to link employment to insurance coverage.  I think the ACA has incentivized companies to cut employee hours so as to avoid having to pay for health insurance for those employees.  That’s happened a lot at universities, for example, and it’s reprehensible.

I’m intrigued by the concept of ‘defined contribution’, where companies no longer have to administer health insurance, but simply create a pool of money for insurance, and allow employees to buy their own coverage on an exchange.  I think companies would like the flexibility of defined contribution.  And all employees would have access to the money set aside for health insurance, though with less money available for part-time employees.  I like the flexibility of being able to choose between a PPO (Preferred Plan Organization) or an HMO (Health Maintenance Organization), each of which have advantages and disadvantages.

But the reality is, misinformation aside, the ACA works, and better than most people thought it would.  Any narrative about ‘the failure of Obamacare’ will become increasingly quaint and old-fashioned. We’re moving towards a time when everyone in the country will have access to affordable, high quality health care.  We’re not there yet, but the ACA is a step in the right direction.  Let’s put this debate behind us, and take the next step forward.