Is it time to give up the fight against Obamacare? That’s a question some conservative health-care experts, pundits, and — more quietly — politicians are asking.
In the first years after its passage, opponents had hoped that the Supreme Court would strike down the law or that a new president would sign its repeal before most of it took effect. But the Supreme Court decided to modify a few of its provisions instead of striking it down, and President Obama was reelected. Repeal is almost certainly off the table for four years. Obamacare will continue to be implemented. Its main provisions will begin to take effect in 2014, even if some deadlines will be missed.
Yet the law still has only weak popular support. According to the exit polls, even the relatively liberal electorate that showed up on Election Day preferred repealing some or all of the president’s health-care law to leaving it as is or expanding it — by a margin of 49 to 44 percent. The election was not a referendum on Obamacare: Mitt Romney did not run on a specific replacement for it, and he felt inhibited in making the case against it because a health-care law he signed in Massachusetts had features in common with it. And still the electorate that reelected Obama registered dissatisfaction.
The public has certainly not moved toward Obamacare since the election. On the contrary, the Kaiser Family Foundation, a strong supporter of the law, has found only slippage in support since November. Its pollsters recently explained the trend by pointing to a significant decline among Democrats — whose support fell from a post-election height of 72 percent to 57 percent in late February. (Only 32 percent of independents and 12 percent of Republicans reported a favorable opinion of the law in that latest poll.)
The public may not be enthusiastic about Obamacare, but it is going to get it anyway. Republicans have not formulated a strategy for this new situation. Senate Republicans have voted to repeal the law, and House Republicans have included repeal in their budget. These moves reaffirm Republican opposition to the law but do not amount to a plan to make that opposition matter. In the absence of such a plan, such expressions of opposition feel a bit ritualistic.
Conservatives have organized significant resistance to Obamacare at the state level. Most states have declined to create the “exchanges” that were to be their main way of working with the new health-care regime. One state, Oklahoma, has filed a lawsuit with a serious chance of dramatically undercutting the law. (Obamacare as written allows only state-run insurance exchanges to funnel subsidies to individuals, yet the administration is intent on providing such subsidies, and the taxes they trigger, in federally run exchanges too.) Some states have even declined to take advantage of Obamacare’s provision to let them expand Medicaid services for their residents, at first almost entirely on the federal tab.
Some Republican governors have, however, accepted the Medicaid funds. Conservatives are furious with them. But expecting the governors to block coverage expansion indefinitely is not a workable strategy to fight Obamacare, in part because it depends on a large group of politicians’ looking past short-term expediency.
Some conservatives are arguing that, given the election results, Republicans should make their peace with Obamacare and seek to improve it. So, for example, some policy wonks on the right argue that the exchanges should be redesigned to encourage high-deductible coverage. Consumers paying out of pocket for routine health-care expenses, they hope, will keep a close eye on prices. Other reformers say the law should be modified so that Medicaid recipients can buy coverage on the exchanges.
Many of the specific ideas these reformers advocate make sense, but they are wrong to think of them as reforms of Obamacare. The law is flawed in its conception and basic design, not just in some of its provisions, and blocking its worst effects would require a rewrite rather than modest modifications. Indeed, the changes these reformers want would amount to that rewrite. Their proponents would therefore have to overcome the advocates of Obamacare — which is another way of saying that enacting these reforms would require assembling the same coalition that repeal would require.