For a hundred years, every Democratic administration—and most Republican ones, including President Trump's—came to Washington vowing to overhaul the healthcare system. The goal was always the same: shield Americans from the crushing costs of illness. But amid the noise of today's political battles, many missed the quiet truth: the Affordable Care Act (ACA) has already finished that long quest.
The ACA is far from perfect. It has plenty of flaws, and critics on both sides have pointed them out for years. Yet, for the first time, future leaders have a real option to reach near-universal coverage by building on what already exists. That's far simpler than designing a new system from scratch, and it can be done through budget reconciliation, bypassing the Senate filibuster. The mix of Medicare, expanded Medicaid, ACA marketplaces, and employer plans makes it possible to cover all Americans step by step.
When the ACA finally emerged after years of repeal attempts and legal challenges, it brought an end to a long-running political kabuki. Democrats would propose health reforms; Republicans would cry socialism and offer modest alternatives—less government, more markets. Under President Obama, Democrats tried a version of the old Republican alternative, hoping for bipartisan support. Republicans again shouted socialism, and the cycle repeated. Now, the GOP has run out of rope.
There have been few real proposals to counter the ACA. For one thing, there's little room for a government program to the right of the Heritage Foundation's blueprint that inspired the reform—originally offered as a counter to the Clinton plan in 1993. More importantly, a new spirit from the conservative grassroots demanded all-out war on Democrats and their healthcare schemes. Republican officials joined the chorus. But perhaps all that no longer matters.
The quiet, decades-long collaboration between the parties has been hard to see because each episode sparked fierce debate. Theodore Roosevelt first proposed national health insurance in 1912 as a third-party candidate. Over the next decade, the battle played out in states like California, where it was defeated by referendum, and New York, where it died in committee. The fight hit Washington under Franklin Roosevelt, who planned a new crusade for national health insurance as World War II ended. But he died before his plan was ready, and it landed on Harry Truman's desk—a liberal message from the grave. Truman made it his life's cause.
That battle helped define the modern parties: liberals championed a right to healthcare, conservatives fought government overreach. The arguments, metaphors, and insults on both sides have barely changed in decades. Now, for the first time, the foundations for a healthcare program are in place.
Perhaps the ACA's odd design obscures the end of the 100-year war. Barack Obama himself called it “Jerry-rigged” and a “Rube Goldberg.” Comedian Jon Stewart threw up his hands in comic exasperation as Kathleen Sebelius explained the plan's intricacies, asking, “Am I a stupid man?” The program needs more work—the ACA isn't very affordable, good coverage costs a lot, private markets need steady oversight to avoid cutting access for profits, and administrative costs are out of control.
But here, finally, stands a foundation. A full century after the debate began, the health insurance basics are in place. The Biden administration used them to bring national uninsurance levels down to just over 7 percent—a historic low. Many states have achieved uninsurance rates in the low single digits. Future leaders could toss it aside and try another fundamental rethink, as every administration eventually faces demands for reform. But now, for the first time, leaders—Democrats and Republicans alike—have the option to tinker their way to universal coverage.
