Michael Grunwald is a senior staff writer for Politico Magazine.

Republicans may be divided, but they can still agree that Obamacare is, as Donald Trump likes to put it, “a total disaster.” And in recent weeks, as several insurers have abandoned the Obamacare exchanges and others have jacked up premiums, some of the reform’s Democratic defenders have started speaking out about its problems as well. Minnesota Governor Mark Dayton warned that the Affordable Care Act has “serious blemishes and serious deficiencies.” Bill Clinton actually called its middle-class premium hikes “the craziest thing in the world.”

The problems are undeniably real. But the political debate over Obamacare has been wildly misleading.


That’s because the problems that have dominated the news and made reform seem so troubled—those soaring premiums and fleeing insurers, as well as cancelled policies, failed co-ops, and even the initial website fiasco—haven’t affected the vast majority of the public. The debate has focused almost exclusively on hardships faced by less than 6 percent of Americans who do have insurance but don’t get that insurance directly from their employers or the government, especially the 3 percent covered through the law’s new insurance exchanges, the state-based marketplaces where individuals can comparison-shop for policies. And thanks to Obamacare subsidies, many of those Americans are now covered for the first time.

The debate over what’s wrong with Obamacare matters beyond this political cycle; what happens to the health care system in the next administration will be driven by what Americans think needs fixing. And while the headlines and stump speeches have focused on the struggles of the exchanges, the Affordable Care Act is quietly reshaping the entire system. It’s reining in the spiraling growth of health care costs, cutting by half the ranks of the uninsured, and providing a host of new protections and perks to the insured.

The political debate has been primarily detached from that transformation. Lately, it has focused on insurers who are abandoning the exchanges, jacking up premiums, and forcing consumers to find new policies—a disaster, arguably, but a limited disaster. It’s as if health care only mattered to the 11 million Americans on the exchanges, a population smaller than Ohio’s—or, if you subtract the 85 percent of them who receive subsidies that limit their out-of-pocket costs, a population roughly equivalent to Idaho’s. The exchanges became a laughingstock after the botched rollout of healthcare.gov, but in a 2016 Commonwealth Fund survey, three out of four consumers on the exchanges said they’re satisfied with their insurance.

Most people don’t realize the pain has been so localized; they just hear there has been pain. In the wake of the grumbling from Democrats like her husband, Hillary Clinton offered her most spirited defense of Obamacare at last week’s debate, noting the “big benefits” it has provided to 170 million Americans with employer-based coverage. And President Obama himself has continued to make the case for his signature initiative; he’ll be in Miami on Thursday to promote its progress. But Clinton and Obama both agree that the law needs to be improved. And after six years of bad headlines, they’re finding it hard to correct widespread impressions that the most ambitious health initiative since the creation of Medicare is a mess, even though most Americans oppose its full repeal. The share of the U.S. population that is uninsured is at an all-time low, but only 26 percent of Americans know that, according to a recent Kaiser Family Foundation survey.

“From the very start, Obamacare was a political football,” says Larry Levitt, a health reform expert at the foundation. “The facts have never gotten in the way of the spin.”

That’s partly because much of the political debate has been a proxy for the broader debate over its first three syllables. Republicans who don’t like the president predictably don’t like the centerpiece of his legacy, which they unanimously opposed in Congress. The fourth syllable contributes to the dispute as well; some conservatives just don’t like the idea of taxing the wealthy to provide subsidized care for the less wealthy, which is exactly what Obamacare does. At Trump’s rallies, his pledges to repeal Obamacare get cheers as loud as his pledges to build a wall, and it’s not because his crowds are packed with health care wonks.

To the extent the debate over Obamacare does involve the details of the law and its real-world impact on the system, most of the debate has been about the government-run insurance exchanges and the rest of the market for individuals without employer coverage. The perks of Obamacare—insurance protections for Americans with pre-existing conditions, a ban on insurer caps that limited payouts to expensive patients, delivery reforms that have helped produce the slowest cost growth in half a century—have been mostly uncontroversial and undiscussed.

Even when Clinton defended Obamacare during the debate, she conceded that “premiums have gotten too high,” and that “we’ve got to get costs down.” In fact, for the majority of Americans with employer-based coverage, the average annual premium increase since Obamacare became law in 2010 has declined 40 percent compared to the increases of the previous decade, saving the average family nearly $3,600 a year. Obamacare has also helped rein in the skyrocketing costs of treating more than 100 million Americans covered by Medicare and Medicaid, which has dramatically reduced the most dire threat to the U.S. government’s fiscal outlook, extending the expected solvency of Medicare by 11 years.

So when Trump scoffed to Clinton that “everything’s broken about it,” he was ignoring a lot of what it has done. Still, the exchanges were a key element of reform, designed to help Americans without employer-provided health benefits to buy competitively priced insurance, and they do look broken. Health experts do worry about the stability of those markets in the long run. Maybe their struggles get disproportionate attention, but they do matter.

The basic problem is that the exchanges have attracted fewer consumers and sicker consumers than expected, which has made them less profitable for insurers. That’s why Aetna and United are abandoning the exchanges, why the share of counties with only one insurer serving the exchanges is expected to spike from 7 percent this year to 31 percent next year, and why 1 million consumers may see their policies cancelled. It’s also why most of the insurance cooperatives the law created to create more competition on the exchanges set their prices too low and went out of business. And it’s why some middle-class consumers are now facing premium hikes as high as 70 percent, although there were similar announcements last year that largely fizzled; in the end, the average hike was only 8 percent on the exchanges, and just $4 a month for consumers with incomes modest enough (below $97,000 a year for a family of four) to qualify for at least some subsidies.

The danger is that low demand and high prices on the exchanges could create a “death spiral,” with younger and healthier consumers dropping their coverage, leading to even higher prices and even lower demand, and so forth. In 2010, the Congressional Budget Office predicted that 21 million Americans would be on the exchanges by now; barely half that many have enrolled, and conservative health care expert Avik Roy recently spoke for many skeptics in a Vox column warning “that gap between hype and reality is likely to further expand over time.”

But one reason fewer consumers than expected have joined the exchanges is that fewer employers than expected have stopped providing health insurance, which is a good thing. Harvard economist David Cutler, a key architect of Obamacare, says that while the numbers of enrollees are not growing as quickly as the administration had hoped, they are not shrinking, which suggests a death spiral is not yet happening. In 2010, Cutler wrote a harsh memo warning that Obama’s health aides were incapable of executing his vision—Roy quoted the memo to buttress his case that administration officials were “ignorant and arrogant”—but today, Cutler says that Obamacare’s growing pains have been relatively mild. For all the complaints about premiums on the exchanges, including complaints from both Clintons, they’re still 20 percent below the levels the CBO predicted back in 2010.

“There’s concern about what could happen, but not really about what has happened,” Cutler said. “Yes, we’re seeing a correction of the initial prices, but how much did people suffer because the prices were too low? We’re happy when grocery stores sell cheap bananas or airlines sell cheap flights. Why is insurance different?”

The fear is that the exchanges will get much less cheap in the future, especially in states that used to let insurers cherry-pick healthy consumers and cut off coverage of the sick. The market for non-employer-based coverage has always been messy and volatile; now that insurers must provide a minimum suite of benefits under Obamacare, and can no longer discriminate against consumers with pre-existing conditions, there will be upward pressure on prices. Until this year, though, that pressure has been mostly offset by the unprecedented slowdown in medical cost growth throughout the system, as well as a surprisingly ruthless determination by consumers to switch to cheaper plans even when that has meant staying within narrower networks of doctors and hospitals. Many large insurers with broader networks have struggled to make money in that lower-margin environment, although their employer-based businesses have continued to thrive.

Obamacare’s authors did anticipate this kind of problem, which is why the law included “risk corridor payments” to compensate insurers whose consumers turned out to be unexpectedly unhealthy. But Republican critics of Obamacare, led by Senator Marco Rubio, attacked those risk payments as bailouts, and managed to insert a provision eliminating them into a must-pass government funding bill. That made the exchanges an even tougher business proposition for insurers—and when some of those insurers subsequently left the exchanges, Republicans who helped made it happen portrayed their departures as proof Obamacare is fatally flawed. It’s like the old joke about the defendant who kills his parents and then begs for mercy because he’s an orphan—except in this case it’s more like he’s citing the unresponsiveness of his dead parents as evidence that they deserved to be killed.

The administration can’t blame all the problems with the exchanges on political opponents. For example, Obamacare’s rules prevent insurers from charging older consumers more than three times what they charge younger ones, when older consumers tend to use six times as much health care. Even some staunch defenders of the law now believe that onerous ratio should be adjusted from 3:1 to 4:1 to make insurance more attractive to the young and healthy, who don’t seem to be cowed by Obamacare’s tax penalties for uninsured. And while Obamacare’s income-based subsidies for insurance on the exchanges are quite generous, covering about 75 percent of the cost of the average premium, they would have been even more generous if Democrats hadn’t been so eager for the CBO to certify that the law would save money for the government. Clinton has proposed to increase the subsidies, which would reduce out-of-pocket costs even further.

Clinton is also pushing a “public option,” a government-run plan that could help hold down costs by competing with private insurers—but could also end up chasing more insurers out of the exchanges. And while her proposal to offer states new financial incentives to accept Obamacare’s Medicaid expansion would further reduce the uninsured rolls, it could also shrink the market for the exchanges, which could make that market even more volatile. Her proposal to allow Americans over 55 to buy into Medicare could draw even more consumers away from exchanges, although not the kind of young consumers who could create a death spiral.

Health insurance is a complex business, and the exchanges are a particularly complex segment of it. But they’re just part of it. And health insurance is just part of health reform, which is also aiming to transform a “fee-for-service” medical system that pays providers according to the volume of care to a value-based system that rewards quality instead of quantity. There is already evidence that those changes are reducing unnecessary readmissions and hospital-acquired infections—and they’re just getting started. At the same time, the abrupt slowdown in the growth of health care spending growth is quietly saving enormous amounts of money for consumers, companies and taxpayers. The CBO now projects that Medicare spending in 2019 will be about $160 billion less than it projected back in 2010—even though 20 million previously uninsured Americans now have coverage.

But even though overall premium increases were at a historic low last year, they received a huge chunk of Obamacare’s media attention, and a Kaiser poll in June found that 88 percent of Americans were concerned about them. Only 10 percent realized the headlines were limited to the exchanges. And politically, the public’s opinions about Obamacare are evenly split, breaking down almost entirely along partisan lines. It’s not because Republicans care more about adverse selection and risk pools and age-banding in the exchanges. It’s because that’s America in 2016.