President Obama gave his longest and most passionate defense of the Affordable Care Act in months on Thursday. The hour-long speech came as a last rallying cry before November’s health insurance open-enrollment period—the last such period of the Obama presidency—and a bit of a valedictory for the law that appears to be his biggest contribution to American policy.
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Obama’s speech sounded the familiar notes in defense of the law: The uninsured rate is at a historic low, young people can stay on their parents’ plans, federal subsidies and Medicaid allow affordable coverage for low-income people, annual spending is capped, and bans for pre-existing conditions are a thing of a past. But it also ventured into detailing some well-publicized issues with Obamacare and providing potential fixes, while striking a defiant tone against the law’s detractors. With just a few months left in his presidency, and a final open-enrollment period taking place right during crunch time in the election, Obama is looking to provide a road map for the future of his cornerstone policy.
For the president, that road map starts with acknowledging the hard-fought gains of Obamacare. “Never in American history has the uninsured rate been lower than it is today,” he noted, “and that’s true across the board. It’s dropped among women. It’s dropped among Latinos and African Americans, every other demographic group. It’s worked.”
Echoing the arguments of some journalists, he attributed the lack of public awareness of the historic gains in coverage to a negativity bias among members of the media and an impulse to place all of the burdens of health-care dysfunction at the feet of his law. Coverage of concepts like health-insurance premium increases—which have risen, sometimes unevenly for some groups of people—has been flawed by a failure to mark the rate of increase, which Obama points out is the lowest in 50 years nationwide.
No matter how much of the continued ambivalence about Obamacare is based on a misunderstanding or negativity bias among the media, it is undoubtedly true that the law hasn’t met many of its own benchmarks, nor the expectations of many of its supporters. As the Clinton campaign and other Democrats on the campaign trail have found, calls to reform the law work better than playing defense, and Obama’s speech turned to that reform work after a victory lap. He mentioned the enduring problem of lack of enthusiasm and sign-ups among young people, an issue that has bedeviled Obamacare for years now; market instability in some areas after major insurers exited exchanges this year; and the continued inability of many families to afford health insurance and health care.
For Obama, the path to fixing those problems is not necessarily through drastic change, but rather through tinkering. Notably, three of his most substantial solutions—all states expanding Medicaid to low-income people, promoting state innovation with insurance and delivery systems, and providing an emergency public health-insurance option in places where insurers pull out of markets—are all restorations of original policy points in the Affordable Care Act that have been whittled away via political or legal decisions. The new reform idea that the president presented Thursday is using the system’s savings to offer more tax credits to young people and families to help them afford insurance on an exchange. That the most radical change to the original framework of Obamacare that he’s pitching is an increase in tax credits is indicative of Obama’s faith in the long-term outcomes of health reform. And he presents a reform vision that is much more modest than even Hillary Clinton’s moderate proposals for a Medicare extension to near-elderly adults and the creation of a public option.
The general Republican strategy of “repealing and replacing” Obamacare has had remarkable staying power even as uninsured rates have plummeted, perhaps reflecting public ambivalence about the law. Obama’s speech took jabs at would-be repealers using a timely quip about replacing Samsung smartphones with rotary phones, but his overall sentiment seemed to be that the endurance of calls to repeal Obamacare is tied as much to him as it is to the actual policy. His speech appeared to concern his legacy: Will politicians be able to make the necessary fixes to the ACA once he leaves office?
President Obama is optimistic on that front, but it is unclear if future fights over health policy will become any less bitter after he leaves office. As the American conservative movement splinters with the rise of Trump, and the Republican Party sees factionalism grow within its ranks, perhaps the most consistent, unifying policy thread among all camps is an ardent refusal to play ball with Obamacare. That refusal was obviously animated by obstructionism and has not been supplemented with many workable replacement policies, but it has been a key issue for Republican voters in three straight elections.
The law still faces a significant public unfavorability rating and rising dissatisfaction about costs, even as the approval rating of the president himself is the highest that it’s been in years. Given that Clinton has positioned herself both as an ideological progenitor and a reformer of Obamacare—and also given her own deep unpopularity—it is unclear whether, if she takes office and rebrands the bill “Hillarycare,” the bitter fight will magically subside. After all, health policy has often been contentious. Nevertheless, Obama is confident that the Affordable Care Act will endure.