June 5

The federal government has released new data on Medicaid enrollment showing that with the implementation of the Affordable Care Act, six million Americans were added to the program’s rolls. That’s six million low-income people who now have health coverage, who can see a doctor when they need to and who don’t have to worry about whether an accident or an illness will send them spiraling into utter financial ruin.

The numbers reveal something else, too, something that should horrify conservatives: we’re well on our way to health-care socialism.

Okay, that’s an exaggeration. But only a slight one. And at a time when the press is realizing that Republicans are losing their taste for anti-Obamacare bloviating (more on that in a moment), it shows that Bill Kristol’s nightmare has nearly come true.

Back in 1993, Kristol wrote Republicans an enormously influential memo advising that the best approach to Bill Clinton’s health reform plan was notto do everything they could to kill it outright. If any plan managed to pass, he warned, “it will re-legitimize middle-class dependence for ‘security’ on government spending and regulation. It will revive the reputation of the party that spends and regulates, the Democrats, as the generous protector of middle-class interests. And it will at the same time strike a punishing blow against Republican claims to defend the middle class by restraining government.”

Now let’s look at where we are today. Prior to ACA implementation, there were just under 59 million people enrolled in Medicaid and CHIP, the program that covers poor children. States that accepted the ACA’s expansion of Medicaid signed up a total of 5.2 million new people. The states that rejected the expansion signed up an additional 800,000; these are “woodwork” enrollees, people who were already eligible under their state’s (often absurdly restrictive) rules, but came out of the woodwork to sign up because of all the attention to health care. Add them in, and there are now 64 million Americans on Medicaid and CHIP.

On top of that, there are now over 52 million seniors on Medicare. There are another 9 million veterans enrolled in the Veterans Health Service.

That’s a total of 125 million Americans getting their insurance from the federal government (or, in the case of Medicaid, a federal-state program). The current U.S. population is 318 million. That means that 39 percent of us, or just under two out of every five Americans, are recipients of government health insurance.

As a liberal, of course, I believe that’s a good thing, though just how good varies from program to program (I’ve spent enough time fighting with private insurance companies to wish I could be insured by the government). Conservatives, on the other hand, view this as a disaster. What they’ve only partly come to terms with is the fact that it’s going to be almost impossible for them to do anything about it.

It’s true that Republicans appear to have realized that while the ACA remains unpopular, the idea of repealing it is even less popular. Which is why, as the November election approaches, they’ve almost stopped trying to elevate the issue. As Sam Baker points out, Republicans passed on the opportunity to use the confirmation of Sylvia Burwell to be HHS secretary as a forum to relitigate the law, and the bills circulating around the Hill on health care are now more likely to be small-bore fixes. Notes Baker: “Anyone who’s been around Capitol Hill and health care for the past four years can see it — the anti-Obamacare fire just isn’t burning as hot as it used to.”

Beyond that, as this blog has documented, multiple Republican Senate candidates are now mouthing support for Obamacare’s general goals and have essentially been reduced to gibberish when trying to explain their “repeal and replace” stance.

But the story is bigger than all of this. Republicans may have to accept that while we may not have the single-payer system liberals want, government still dominates American health care, and that isn’t going to change.

It isn’t just that Republicans could stage another fifty ACA repeal votes in the House and accomplish just as little as the last 50 repeal votes did. Rather, it’s that even if Republicans took back the White House and both houses of Congress, moving people off their government insurance would be next to impossible.

One of the most important lessons of the last 20 years of health reform is this: people fear change. That’s what the Clinton administration found out when their attempt at reform crashed and burned, in large part because the Clinton plan would have meant a change in coverage for most Americans. The Obama administration took that lesson to heart in creating its plan, which was designed to give coverage to people who lacked it but offer only new protections to those who already had insurance. That was also the reason for the false but endlessly repeated “if you like your insurance, you can keep it” assurances — they knew that if most Americans, particularly those with somewhat-secure employer plans, thought they’d have to endure some kind of change, then they’d once again be gripped by fear.

Any Republican plan to unwind the ACA is going to run headlong into people’s fear of change and be stopped in its tracks. Are you going to push 64 million Medicaid and CHIP recipients off their current insurance and onto private plans? Are you going to move away from employer-provided coverage? Are you going to privatize Medicare?

Perhaps, given the right circumstances, Republicans could overcome that fear. But I wouldn’t bet on them finding a way to do it.