Health Care and the Facts-on-the-Ground Presidency

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From health care reform to immigration, President Obama is counting on Washington's inertia to make changes that last.

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Republican reaction to the Supreme Court decision upholding the Affordable Care Act was swift and outraged. Romney Press Secretary Andrea Saul tweeted that he'd raised more than $300,000 in the first hour after the verdict was announced. "The only way to save the country from ObamaCare's budget-busting government takeover of health care is to elect a new president," said Republican National Committee Chairman Reince Priebus as Republicans launched a #FullRepeal hashtag on Twitter and announced another (and largely symbolic) House vote to repeal the ACA the week of July 9.

But with the Supreme Court having upheld the ACA, Republicans are now clearly fighting a rear-guard action against a law that is partially implemented and which seems likely to grow in popularity now that it has been ratified and turned into something people can look forward to taking advantage of over time. The Supreme Court decision forces Republicans to express their conservatism not through new program proposals but by standing athwart history yelling stop. Obama has created a set of facts on the ground, and the inertial power of Washington and massive complexity of the health-care field that made universal health-care coverage little more than a Democratic fantasy from 1948 through 2009 will now tip the balance of power in the direction the president has set. Republicans can rail about it all they like, but in Washington, it is hard to ever completely undo what has been done.

Obama has created a set of facts on the ground -- real change -- and the Republican promise to repeal the ACA on day one of a Romney Administration is now a promise to re-litigate the past rather than move America forward. I mean seriously: After four years of arguing about health care, do the American people really want another four-year argument that turns the national conversation into something as annoying and frustrating as tangling with an insurance claims agent? Or will they want to move on, let the ACA be settled law, and argue around the margins on the implementation complications that are sure to arise?

My money is on the latter. That doesn't mean Republicans won't fight it, and keep fighting it. Heck, we're still relitigating the 1973 Supreme Court decisions legalizing abortion nearly 40 years later. But abortion also still remains legal, even if access has been severely restricted in some areas, and that's also an issue about which there is deep moral passion. The moral passion to strip people under 26 of the ability to be on their parent's insurance and to prevent people from getting insurance despite pre-existing conditions will be much thinner. In Washington, it is hard to undo what has been done.

That's a central understanding we can see underlying some of Obama's recent other moves, as well.

In issuing an executive order allowing prosecutors to use their discretion to stop deportation proceedings against young illegal immigrants raised in this country, Obama has created another set of facts on the ground. Not only does the order help win over Hispanic voters in advance of the 2012 election, but it creates a policy that Republicans will either have to keep or overturn should Obama lose the election. It will be much harder for Republicans to undo his policy without even further alienating Hispanics than it would have been to simply fumble on comprehensive immigration reform. The new policy creates facts on the ground that strengthen the inertial forces to continue it.

You might even call that a legacy.

Read The Atlantic's full coverage of the Supreme Court's health-care decision.

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Garance Franke-Ruta is a former senior editor covering national politics at The Atlantic.

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