Year Four of the Obamacare Era
Why conservatives will win the health-care debates of the future.


Avik Roy

Three years ago last week — March 23, 2010 — President Obama signed the Patient Protection and Affordable Care Act into law. In the intervening period, conservatives have worked tirelessly to build the case for repealing Obamacare, by calling attention to the law’s broken promises and policy flaws. But Obamacare’s third year was unkind to the law’s opponents. First, the Supreme Court upheld its constitutionality, by a margin of one vote, that of Chief Justice John Roberts. Then, last November, Americans voted to reelect President Obama, taking repeal off the table until at least 2017, and possibly forever. So the core question facing conservatives today is: What should we do now? Should we continue to fight for repeal, despite the long political odds? Or is there another path forward, one that will expand freedom and bring our entitlement state under control?

Some of Obamacare’s tax increases and Medicare cuts have already been implemented, but it is on January 1, 2014, that the bulk of its regulations, mandates, and subsidies go into effect. And it is that last item — subsidies — that is the most politically potent. In a little over nine months, as many as 30 million Americans will become eligible for Obamacare’s insurance subsidies. By 2017, according to estimates by the Congressional Budget Office, 25 million people will be enrolled in Obamacare’s private-insurance exchanges, with an additional 10 million newly enrolled in the Medicaid program.

If the next Republican nominee for president promises to repeal Obamacare, the unfortunate truth is that he will be promising — at best — to disrupt health-care coverage for these 35 million Americans. To put that number in context, 12 million Hispanics voted in the 2012 election. Is a party that may embrace citizenship for illegal immigrants prepared to discard a much larger bloc of voters?

On the other hand, those who still seek repeal have hope. As Jay Cost points out in a thought-provoking piece, the politics of Medicare, say, and those of Obamacare are somewhat different. Medicare was a financial windfall for the older people who received nearly free health care as a result, and thereby also for the providers of health-care services, like doctors and hospitals, who got rich off the program. The cost of Medicare to average taxpayers has, by contrast, remained opaque. That has given opponents of Medicare reform a substantial degree of political leverage over the supporters of reform. Even Paul Ryan’s controversial premium-support plan promises to make no changes to the program for Americans who are ten years or less away from becoming eligible.

By contrast, while Obamacare will subsidize health insurance for tens of millions of currently uninsured voters, the law will impose significant — and visible — costs on the rest of the population. It will impose steep fines on medium-sized and large employers that do not provide health insurance to every full-time employee. It will dramatically raise the cost of health insurance for young people who aren’t insured through their employer — by as much as 100 percent — and it will make coverage costlier for every American, through an array of taxes and benefit mandates. It will force many seniors out of the popular Medicare Advantage program. Most infamously, it will require that most Americans purchase government-certified health insurance or pay a fine: the “individual mandate.”

So, the question that repeal advocates must unsentimentally and rigorously answer is whether the constituency of people most harmed by Obamacare will be larger, and more passionate, than the constituency of people who most benefit.

The 2014 midterm elections will be an opportunity to find out. Will young people — who have voted overwhelmingly for Democrats in recent years — put social issues aside and protest their rising insurance costs? Will seniors on Medicare Advantage — who already favor Republicans — vote in even larger numbers for conservative candidates? Because 2014 will be the year in which premium “rate shock” will be at its sharpest, it will be the year in which Republicans will have their best opportunity to illustrate the law’s worst flaws.

It is likely that Obamacare’s subsidized insurance exchanges will have some initial difficulties. Earlier this month, an Obama-administration official said he was “pretty nervous” about whether the exchanges would be ready on time. “The time for debating about the size of the text on the screen, or the color, or is it a world-class user experience —  that’s what we used to talk about two years ago,” he said. “Let’s just make sure it’s not a Third World experience.”