By far the most effective part of the Affordable Care Act, in terms of helping Americans get care, was simply expanding Medicaid. But what many Democrats and liberals were most excited about was the bill’s many experimental and technocratic attempts to “bend the cost curve”—reduce costs without price controls—and “improve quality,” mainly by encouraging insurers, with incentives, to strive for outcomes that market forces alone weren’t incentivizing them to aim for. The signature example of this may be the “Cadillac tax,” which was designed to nudge companies to force employees onto cheaper insurance plans with greater cost sharing—a tax built on the belief that one of the primary drivers of health care cost inflation was people taking advantage of their too-generous employers and greedily consuming more health care than they needed. The tax never went into effect. The individual mandate, similarly designed to force the healthiest young invincibles to enter the market to bring down costs, is equally dead. And a decade into the ACA, it has become more apparent than ever that the best way to reduce America’s absurd health care costs would simply be a single-payer program.

That is not to say that the ACA did not end up having the significant long-term political ramifications its drafters promised it would. The primary non-Medicaid structure of the ACA, with its means-tested subsidies to purchase private insurance, had the predictable effect of convincing some of its beneficiaries that Obama and the Democratic Party had nothing to do with the government assistance they weren’t sure they were getting. Then, as costs rose and rose over the decade, that structure also had the predictable effect of making people who receive partially subsidized private care resentful of those poor enough to qualify for Medicaid.

Much of the decade we have just endured has shown how the Democratic addiction to dispensing benefits through the tax code in complicated, indirect ways—combined with the usual insufficiency of these benefits—was nearly perfectly designed to foment mass resentment of others, imagined or not, who might secretly be getting the Good Benefits. The political scientist Suzanne Mettler coined the term “the submerged state” in 2010 to refer to the jungle of hidden government “programs” designed not to call attention to themselves, often perpetuated not because they are still helping the neediest, but because they are lucrative to the finance, insurance, and/or real estate industries. One of her illustrations of the effect of the submerged state is a graph showing how many people who used particular government programs admitted so only after first telling researchers they’d received no assistance.

That nearly 40 percent of people on Medicare claimed this is likely attributable to ideology (and the fact that Medicare, like Social Security, was designed to make retirees feel like they had “paid into it”). But when 60 percent of people who used tax-advantaged higher education savings accounts claim they received no government benefits, as they did in Mettler’s study, it’s probably because tax-advantaged savings accounts are wholly inadequate to the problem of higher education costs. Now combine this with a persistent belief (memorably described by Ashley C. Ford a few years ago) that minorities—black kids in particular—get to go to college for free by default, and stir in the rise of tuition costs and other expenses due to cutbacks in state investment in education. The result of this cocktail of ignorant biases and inadequate solutions might look something like the year 2019.