Whisper it not, but the beleaguered Barack Obama may have a success on his hands, in a distinctly unexpected quarter. Remember Obamacare, his health reform approved by Congress in March 2010 amid much contention and without a single Republican vote? It now looks as if it's going to work, after all.
Traditionally, most Americans have had health insurance through their employers. And if you're covered by the system, it works very well indeed, as I can personally testify. A month ago, I was diagnosed with cancer. A fortnight later, I underwent surgery and, touch wood, that will now be the end of it. The speed and quality of the care were terrific. With the exception of a few co-pays of $15, everything was covered by my wife's health insurance from work. Would the treatment have been as swift and efficient under the NHS? One can but hope so.
But if you were among the 45 million uninsured Americans, or the millions more whose coverage was inadequate, it was a different story. Hence President Obama's reforms, aimed at both lowering healthcare costs that are the highest of any major Western economy, and introducing something close to universal coverage.
The scheme has three key elements: the so-called "individual mandate", requiring everyone to purchase coverage – if needs be, with help from the government; a system of healthcare exchanges, where newcomers could buy the coverage best suited to them; and a major expansion of Medicaid, the federal healthcare programme for the poor. But the 1 October launch of the government website explaining the exchanges was an unmitigated disaster. HealthCare.gov couldn't cope with the traffic and crashed repeatedly. Republicans had a field day and the President's job approval ratings plunged to Bush-like levels.
But, six months on, the mood is changing. One reason was last week's announcement that the government's sign-up target of seven million people by the end of March had been met (even though the figure may have been massaged). But, more broadly, public opinion seems to be shifting. Albeit by a tiny margin, supporters of the 2010 law now outnumber opponents, and a recent poll showed that six out of ten Americans want the scheme to be improved, not scrapped as Republicans continue to demand. One thing is becoming clear. Love it or loathe it, Obamacare is here to stay.
The measure is anything but perfect. If you set out to build a healthcare system from scratch, the Obama reforms are the last way you would go. Ideally, this president would almost certainly have preferred some form of government-run single-payer system. But he wasn't building a system from scratch; he was seeking to modify one that, in 2012, represented 17 per cent of the national economy – or $2.8trn, more than Britain's entire GDP – and with vested interests to match. So he kept the existing structure of employer-based coverage and for-profit insurance companies and hospitals, abandoning early on any notion of a government-run "public option" to compete with private insurers.
The Patient Protection and Affordable Care Act, to give Obamacare its formal title, is unwieldy and desperately complicated, and will continue to require fine-tuning. Even at full throttle, it won't cover everyone. Huge questions remain: have enough healthy young people signed up – or will the newcomers be the old and infirm, leading insurers to increase premiums further? Even Obamacare's impact on federal spending is lost in a fog of conflicting statistics. And although the Supreme Court in 2012 upheld the "individual mandate", the law's most controversial provision, legal challenges are continuing.
But despite the undiminished drumbeat of Republican criticism, something psychologically has changed. The law is now part of the landscape. It may not quite match the great welfare advances of the 20th century under earlier Democratic presidents: Franklin Roosevelt's introduction of social security, and the creation of Medicare for the elderly, and Medicaid by the Johnson administration in 1965. But it most certainly builds on them. Indeed, Obamacare may contain the seeds of the demise of employer-based insurance, as companies encourage workers to switch to the exchanges.
As were social security, Medicare and Medicaid in earlier days, the Affordable Care Act has been lambasted by the right as creeping socialism, and as another step towards a despised European-style nanny state. This time, however, Republican behaviour has been especially disgraceful. No serious alternative has been put forward: just scorched-earth opposition, and mendacious hysteria over "death panels" and the like.
This implacable hatred has seen Republican-run states refuse to implement the expansion of Medicaid – despite the fact that the federal government would pick up the entire bill. More than 40 times, the Republican-controlled House of Representatives has voted to repeal the law (including the individual mandate which was a Republican idea in the first place).
But, with every extra day Obamacare is up and running, that becomes less likely, even if a Republican wins the White House in 2016, and (rather more probable) his or her party controls the Senate as well as the House. Huff and puff they surely will, but Republicans won't tamper with Obamacare's most popular elements, such as the coverage for children on their parents' policies up to the age of 26, and bans on insurance companies rejecting people for pre-existing conditions, and imposing limits on lifetime payments to an individual. And the larger the health exchanges grow, the more market forces will promote competition and lower premiums. Isn't that what being a Republican is all about?
A lame duck pallor may be settling over the Obama presidency. But, just possibly, healthcare reform is set to be his monument for the ages. Who would have said that six months ago?