Tough slog ahead for implementing affordable care

If Barack Obama is re-elected as president, the overriding purpose of his second term will be the implementation of the Affordable Care Act. Implementation and the use of executive power have not been Obama’s strengths, but he is going to have to get better very quickly. A powerful presidency mixes the “bully pulpit” with a maximum use of the president’s authority, from conception of a policy to its implementation.

It will be a brutal slog, with inevitable battles between the White House and Republican governors, particularly in the South. There will be conflicts with Republicans in Congress over funding. The rhetoric will be heated. Republicans will say that Democrats want to impose a tyrannical socialism; Democrats will say that Republicans don’t care whether vulnerable Americans die.

But the health care battle is more than just a means to provide insurance to a large number of Americans; it is also a metaphor for the role of government in the midst of very hard times for the public sector. The private sector is slowly but steadily recovering from the recession (the root of the president’s unfortunate comment that the private sector is “doing fine”), while the public sector has been rocked by austerity and cutbacks throughout. To alter government’s role in health care would be a big change.

This high-intensity conflict is critical to both parties. To Democrats, health care is the long-missing piece of the social insurance contract that began with Social Security and Medicare. To Republicans, health care represents a historic overreach of government, and they believe its success would become a serious threat to their party’s political survival. Democrats want to add a third piece to their legacy; Republicans want to roll back parts of the first two.

If Obama can sink the roots of the health care law into American life, he will have completed a historic piece of the Democratic Party’s mission. Republicans are fearful that voters will overcome their initial distaste for the law and come to like it. Democrats wonder if the voters will learn to love it.

This health care program will lack the appealing simplicity of Medicare and Social Security, as the proportion of Americans who already have health insurance is far greater than those seniors who had retirement or medical care when those historic programs were enacted. But many Americans have family or friends who are uninsured, or have pre-existing conditions, or whose children have already benefited from the ability to stay on their parents’ policies until age 26. And, notably, the fact that hospitals will want federal aid to pay for the care of the uninsured will help the president win the battle in the states regarding the expansion of Medicaid.

There are two selling points in the president’s favor. One is that except for the mandate to buy insurance, the individual components of the law already are popular. But the other is that the overall plan is built on a moral philosophy that has yet to be stated clearly: No American should be without the umbrella of health care because he or she does not have enough money, or the right job, or live in the right place.

For too long, the president has argued for his policies on the ground that they “make sense.” The most powerful argument is a much deeper one, that the policy is right. If the president can make that case, and if the voters agree, the path to implementation and enduring change will be brightly lit.

Raphael J. Sonenshein is executive director of the Pat Brown Institute of Public Affairs at California State University, Los Angeles.