The Health Care Reform War Without End

The battle over Obamacare is running into overtime, with risks for both parties — and the country.

UNITED STATES - CIRCA 1937: US Politico "Alf" M. Landon.  Former presidential hopful Alf Landon. 
Time Life Pictures/Getty Images
Ronald Brownstein
April 3, 2014, 5 p.m.

In the 1936 elec­tion, one year after Pres­id­ent Roosevelt signed the law cre­at­ing So­cial Se­cur­ity, his Re­pub­lic­an op­pon­ent Alf Landon called it a “cruel hoax” and prom­ised to re­peal it.

Landon won just two states — and, four years later, Re­pub­lic­an nom­in­ee Wendell Willkie ran on ex­pand­ing So­cial Se­cur­ity. Al­though con­gres­sion­al Re­pub­lic­ans con­tin­ued guer­rilla war­fare against the pro­gram in­to the 1950s, the pro­spect of full-scale re­peal sank with Landon.

In 1964, Re­pub­lic­an pres­id­en­tial nom­in­ee Barry Gold­wa­ter staunchly op­posed the cre­ation of Medi­care, the health pro­gram for the eld­erly pro­posed by Pres­id­ent John­son. But after John­son routed Gold­wa­ter and then pushed Medi­care through Con­gress in 1965, op­pos­i­tion col­lapsed. By 1968, Re­pub­lic­an pres­id­en­tial nom­in­ee Richard Nix­on ac­cep­ted it as settled law.

Al­though the skir­mish­ing around So­cial Se­cur­ity of­fers some par­al­lel, the struggle over health re­form is burn­ing longer and hot­ter than the scuff­ling over any pre­vi­ous ex­pan­sion of Amer­ica’s safety net. It was em­blem­at­ic earli­er this week that just hours be­fore Pres­id­ent Obama an­nounced that the Af­ford­able Care Act had ex­ceeded its ori­gin­al en­roll­ment goal of 7 mil­lion, Rep. Paul Ry­an for the fourth con­sec­ut­ive year re­leased a House Re­pub­lic­an budget that would re­peal the law.

Factors from in­creased po­lar­iz­a­tion in Con­gress to the widen­ing ra­cial, gen­er­a­tion­al, and geo­graph­ic di­ver­gence in each party’s co­ali­tion ex­plain this per­sist­ence. More im­port­ant are the con­sequences. This elong­ated con­flict is ex­pos­ing each side to un­pre­dict­able polit­ic­al risks and deny­ing the coun­try a mean­ing­ful de­bate over ad­dress­ing the law’s in­ev­it­able flaws and mis­cal­cu­la­tions.

Ry­an’s de­fi­ant budget — com­ing im­me­di­ately after the rush that pro­duced more than 7 mil­lion en­roll­ments on the health care ex­changes, plus at least an­oth­er 4 mil­lion sign-ups un­der Medi­caid — cap­tured how much mo­mentum the re­peal cause re­tains in the GOP. How far apart are the two sides? Ry­an’s plan would not only undo the in­sur­ance ex­pan­sions un­der Obama­care but also im­pose fur­ther sharp cuts on Medi­caid, even­tu­ally elim­in­at­ing ex­ist­ing cov­er­age for an ad­di­tion­al 15 mil­lion to 20 mil­lion people.

The skir­mish­ing will only in­tensi­fy if Re­pub­lic­ans win the Sen­ate this fall (even if Obama can still block any re­peal le­gis­la­tion with his veto). And that in turn would in­crease pres­sure on the 2016 GOP pres­id­en­tial con­tenders to cam­paign on re­peal­ing the health law (as Mitt Rom­ney did in 2012). As Ben Dome­nech, a lead­ing young con­ser­vat­ive ana­lyst, wrote this week, “The Re­pub­lic­an Party is wed­ded to the re­peal of Obama­care for the fore­see­able fu­ture. There will not be a single vi­able can­did­ate in 2016 who is not in fa­vor of re­peal or avoids the chal­lenge of put­ting for­ward a health care policy de­signed to re­place Obama­care should they be elec­ted.”

While the late sign-up crush has im­proved over­all at­ti­tudes to­ward Obama­care, the risk for Demo­crats in this war without end is that many Amer­ic­ans will blame the law for every glitch in the health care sys­tem. That danger is evid­ent in sur­veys show­ing that most Amer­ic­ans, par­tic­u­larly whites, view Obama­care more as a trans­fer pro­gram for the poor than something that will help them per­son­ally. Like­wise, a re­cent sur­vey by Demo­crat Peter Hart and Re­pub­lic­an Bill McIn­turff found that while two-thirds of Amer­ic­ans say the law has not af­fected their qual­ity of care, nearly half be­lieve it is in­creas­ing their costs. Com­bined with ideo­lo­gic­al res­ist­ance, such at­ti­tudes will threaten Demo­crats this fall in red-lean­ing con­gres­sion­al dis­tricts and in key Sen­ate races, des­pite the im­proved en­roll­ment pic­ture.

But these ex­ten­ded hos­til­it­ies also risk lock­ing Re­pub­lic­ans in­to a de­mand for re­peal that could ap­pear un­real­ist­ic and dog­mat­ic by 2016. Health care is such a charged sub­ject that the law may nev­er en­joy pre­pon­der­ant pub­lic sup­port. But as more pa­tients and pro­viders rely on it, the in­sti­tu­tion­al res­ist­ance to re­peal will al­most cer­tainly rise. Theda Skoc­pol, a Har­vard Uni­versity pro­fess­or of gov­ern­ment who stud­ies the so­cial safety net, says that com­pared with So­cial Se­cur­ity, which didn’t provide large-scale be­ne­fits for dec­ades, Obama­care is “ac­tu­ally mov­ing much faster” to cre­ate con­stitu­ents who gain from it. Her view is that the law already is “not re­peal­able.” By the time a Re­pub­lic­an pres­id­ent could pur­sue re­peal, Skoc­pol says, “it will be woven in­to the life of people, fam­il­ies, and busi­nesses.”

Like the pro­gram it­self, the polit­ic­al con­sequences of the health care law are com­plex and pre­cari­ously bal­anced. Com­pared with So­cial Se­cur­ity or Medi­care, Obama­care more ex­pli­citly cre­ates losers (such as healthy people pre­vi­ously ad­vant­aged by an in­di­vidu­al in­sur­ance mar­ket that ex­cluded the sick) as well as win­ners. It trans­fers re­sources from old to young by slow­ing Medi­care spend­ing to fund sub­sidies for the work­ing-age un­in­sured — and in the op­pos­ite dir­ec­tion by re­quir­ing healthy young people to buy ro­bust cov­er­age that re­strains premi­um costs for those older and sick­er.

A course of treat­ment this in­tric­ate in­ev­it­ably re­quires re­as­sess­ments and re­cal­ib­ra­tions. That’s not pos­sible now: Con­gress can’t wield a scalpel while Re­pub­lic­ans are still clam­or­ing for the guil­lot­ine. But the late en­roll­ment surge, even if it hasn’t yet guar­an­teed the law’s sur­viv­al, has meas­ur­ably in­creased the odds that the de­bate over Obama­care will gradu­ally shift from end­ing to mend­ing it. 

{{ BIZOBJ (video: 4856) }}

What We're Following See More »
Trump Leads Tightly Packed Group Vying for Second
11 hours ago

In one of the last surveys before New Hampshirites actually vote, a Monmouth poll has Donald Trump with a big edge on the Republican field. His 30% leads a cluster of rivals in the low-to-mid teens, including John Kasich (14%), Jeb Bush and Marco Rubio (13% each) and Ted Cruz (12%). On the Democratic side, Bernie Sanders leads Hillary Clinton 52%-42%.

GOP Budget Chiefs Won’t Invite Administration to Testify
9 hours ago

The administration will release its 2017 budget blueprint tomorrow, but the House and Senate budget committees won’t be inviting anyone from the White House to come talk about it. “The chairmen of the House and Senate Budget committees released a joint statement saying it simply wasn’t worth their time” to hear from OMB Director Shaun Donovan. Accusing the members of pulling a “Donald Trump,” White House spokesman Josh Earnest said the move “raises some questions about how confident they are about the kinds of arguments that they could make.”

Bill Goes on the Offensive Against Bernie
9 hours ago

“Bill Clinton uncorked an extended attack on … Bernie Sanders on Sunday, harshly criticizing” the senator “and his supporters for what he described as inaccurate and ‘sexist’ attacks on Hillary Clinton. ‘When you’re making a revolution you can’t be too careful with the facts,’ … Clinton said. … The former president … portrayed his wife’s opponent … as hypocritical, ‘hermetically sealed’ and dishonest.”

Snowstorm Could Impact Primary Turnout
4 hours ago

A snowstorm is supposed to hit New Hampshire today and “linger into Primary Tuesday.” GOP consultant Ron Kaufman said lower turnout should help candidates who have spent a lot of time in the state tending to retail politicking. Donald Trump “has acknowledged that he needs to step up his ground-game, and a heavy snowfall could depress his figures relative to more organized candidates.”