The policy consensus, though, is that the status quo is actually the problem, and that it deserves to be threatened, undermined and replaced as expeditiously as possible. Wonks of the left and right disagree on what that replacement should look like. But they’re united in regarding employer-provided coverage as an unsustainable relic: a burden on businesses, a source of perverse incentives for the health care market and an obstacle to more efficient, affordable and universal coverage.

Yet woe betide the politician who dares to publicly agree. That’s what John McCain discovered in 2008, when he proposed a sweeping reform that would have eliminated the tax incentives that undergird employer-provided coverage. Conservative policy types loved the idea (as well they should, being responsible for it), but it cost McCain dearly: the Obama campaign used it to attack him, relentlessly and effectively, as an enemy of the way most middle-class people get health insurance, and thus of the middle class itself.

These attacks, in turn, constrained the Obama White House when it came time to design its own health care reform. Obamacare has an unwieldy, Frankenstein’s monster quality in part because the law is trying to serve both consensuses at once. The core of the bill, the subsidies for the uninsured and the exchanges where they can purchase plans, is designed to offer a center-left alternative to the existing system. But much of the surrounding architecture is designed to prop up existing arrangements — and in the process, protect Obama from exactly the kind of criticisms he once leveled against McCain.