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. 
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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.