How to End the Obamacare Debate

With the GOP opposition showing no signs of abating, the Obama administration has to start showing that the health care law is working.

Linda Norman, right, and Joanna Galt, both from Florida, hold their banners during a "Exempt America from Obamacare" rally on the West Lawn of the Capitol in Washington, Tuesday, Sept. 10, 2013. 
Ronald Brownstein
Sept. 19, 2013, 4:05 p.m.

Even amid the high-stakes man­euv­er­ing over Syr­ia and the fed­er­al budget, White House Chief of Staff Denis Mc­Donough has a cal­en­dar on his of­fice door that counts down the days un­til open en­roll­ment for the un­in­sured be­gins Oct. 1 un­der Pres­id­ent Obama’s health care law.

It’s a re­mind­er that noth­ing will shape Obama’s leg­acy more than wheth­er he can suc­cess­fully im­ple­ment, and polit­ic­ally en­trench, his massive health re­form plan. Obama has three years to for­ti­fy the law with enough sup­port to make re­peal dif­fi­cult, even if Re­pub­lic­ans win uni­fied con­trol of Wash­ing­ton in 2016.

The pres­id­ent has a long road to travel. Polls show that most Amer­ic­ans doubt the Af­ford­able Care Act will im­prove con­di­tions for their fam­ily or the coun­try. Im­ple­ment­a­tion of the law’s many pieces has cre­ated com­plex lo­gist­ic­al and com­puter chal­lenges that have already forced the ad­min­is­tra­tion to delay some com­pon­ents. And, most im­port­ant, op­pos­i­tion from Re­pub­lic­ans is blaz­ing un­di­min­ished — and is now flar­ing in­to es­cal­at­ing threats to shut down the gov­ern­ment or de­fault on the fed­er­al debt rather than fund the pro­gram.

No oth­er fed­er­al en­ti­tle­ment has faced such fe­ro­cious op­pos­i­tion after pas­sage. Al­though many con­ser­vat­ives ini­tially raged against Medi­care, that fire ex­tin­guished quickly when be­ne­fits star­ted flow­ing in 1966. Medi­caid, the joint state-fed­er­al health pro­gram for the poor, pro­voked stur­di­er op­pos­i­tion, but two years after its pas­sage in 1965, all but 13 states had signed onto it. (With­in five years, all but two states were par­ti­cip­at­ing.) Re­pub­lic­an res­ist­ance to So­cial Se­cur­ity lingered longer; but after 1936 pres­id­en­tial nom­in­ee Alf Landon won only two states while pledging its re­peal, the party con­fined it­self to guer­rilla snip­ing against the pro­gram, be­fore sur­ren­der­ing en­tirely un­der Pres­id­ent Eis­en­hower.

All of that pales be­side today’s cru­sade against the health care law. This cam­paign ex­tends from the con­gres­sion­al Re­pub­lic­ans’ de­fund­ing de­mands, to the wide­spread re­fus­al of GOP-con­trolled states to ex­pand Medi­caid eli­gib­il­ity, to the pas­sage of laws in states such as Geor­gia and Ohio im­ped­ing “nav­ig­at­ors” work­ing to en­roll people on the in­sur­ance ex­changes. “The mag­nitude of res­ist­ance is un­pre­ced­en­ted,” says Prin­ceton Uni­versity so­ci­olo­gist Paul Starr, au­thor of an ac­claimed his­tory of the Amer­ic­an health care sys­tem.

Without draw­ing mor­al equi­val­ence, it’s fair to say the health care law is fa­cing more wide­spread de­fi­ance than any fed­er­al ini­ti­at­ive since the Su­preme Court ordered pub­lic schools to de­seg­reg­ate in its 1954 Brown v. Board of Edu­ca­tion de­cision. Obama is un­likely to fold against con­gres­sion­al Re­pub­lic­an de­mands for delay. But, even so, some two dozen states — all but two with Re­pub­lic­an gov­ernors — are re­fus­ing to ex­pand Medi­caid (which was ini­tially ex­pec­ted to provide about half the law’s cov­er­age in­crease) and to es­tab­lish the on­line ex­changes for those un­in­sured people with slightly high­er in­comes. Mean­while, al­most all Demo­crat­ic-lean­ing states are em­bra­cing the law.

This con­trast cre­ates two power­ful dy­nam­ics that will shape the un­fold­ing de­bate. First, it means that with half the states in­hib­it­ing it, the pro­gram won’t en­roll as many people na­tion­ally as Obama hoped. Be­cause many of the res­ist­ing states have big un­in­sured pop­u­la­tions and skimpy safety nets, 8 mil­lion of the 13 mil­lion people po­ten­tially eli­gible un­der the law’s Medi­caid ex­pan­sion live in states that are not in­creas­ing cov­er­age, the Urb­an In­sti­tute cal­cu­lates. Without state out­reach, sign-up on those states’ ex­changes also could slip, again de­press­ing the na­tion­al res­ults.

That pro­spect frames a second, po­ten­tially de­cis­ive, ques­tion: Can the law’s sup­port­ers pro­duce suc­cess in the states that are wel­com­ing it? If Cali­for­nia, Col­or­ado, Min­nesota, and oth­er states that are im­ple­ment­ing the law most en­thu­si­ast­ic­ally can en­roll large num­bers of the un­in­sured, avoid big lo­gist­ic­al snafus, and at­tract enough healthy young people to re­strain premi­um rates, that would strengthen Obama’s hand na­tion­ally — and in­crease pop­u­lar de­mands to par­ti­cip­ate in the res­ist­ing states. If it be­comes “clear that in many of the states that are whole­heartedly im­ple­ment­ing it, it is work­ing well, the in­ter­est­ing ques­tion is, what kind of pres­sure will that put on the “˜re­fusenik’ states?” says Har­vard Uni­versity so­ci­olo­gist Theda Skoc­pol, who stud­ies the safety net. In par­tic­u­lar, suc­cess in par­ti­cip­at­ing states could in­spire grow­ing agit­a­tion from health care pro­viders in the re­fusenik states, which are re­noun­cing nearly $500 bil­lion in fed­er­al money through 2022 (at small state cost) by re­ject­ing the Medi­caid ex­pan­sion, the Urb­an In­sti­tute pro­jects.

In this pro­cess, Cali­for­nia could fig­ure largest be­cause its huge, di­verse, and heav­ily un­in­sured pop­u­la­tion presents a tough­er test than more-ho­mo­gen­ous co­oper­at­ing states such as Min­nesota and Mas­sachu­setts. If Cali­for­nia suc­ceeds, notes An­thony Wright of the ad­vocacy group Health Ac­cess Cali­for­nia, “we can show it can work in a state where the prob­lem is “¦ on the scale of Texas and Flor­ida,” the two largest res­ist­ing states. Cali­for­nia has already ne­go­ti­ated ag­gress­ively to lim­it premi­um rates for in­surers selling through its ex­changes and has en­rolled (through an early-start waiver) about half of those eli­gible for the law’s Medi­caid ex­pan­sion. But, Wright ac­know­ledges, the state con­fronts su­per­sized ver­sions of the same “daunt­ing” lo­gist­ic­al chal­lenges loom­ing else­where as en­roll­ment be­gins. Obama’s best chance of de­fend­ing health care re­form against its en­emies is to en­sure that it works for its friends.