The Affordable Care Act is finally coming online next year, and the debate over how that will go is proceeding along the same channels as the debate over the law itself. Conservatives are unified by overweening certainty that the law’s rollout will be a disaster. Max Baucus’s slightly out-of-context professed fear last month it will be a “train wreck” is currently playing the same role as Nancy Pelosi’s slightly out-of-context 2010 comment that “we have to pass the bill so that you can find out what’s in it.” (Both were expressions of frustration with the administration’s inability to overcome Republican obfuscation, which Republicans have understood as confessions of something much darker.) The liberal reaction is much more cautious, with even the most optimistic pushbacks conceding the potential for serious trouble (“there are still a million things that could go wrong”).
The net effect of this imbalance between the overwrought right and the cautious left is to provide a picture of a probable failure. The midpoint of a debate between “certain disaster” and “probably not a total disaster” is still an uncomfortable place for supporters of the law. It is probably making us all overestimate the potential for a debacle and completely overlook a different possibility — that it could actually build a constituency for Obamacare.
Scanning over the right’s Implementation Train Wreck drumbeat, the striking thing is that, just as when the law was passed, how few conservatives understand even vaguely how the law works. John Stossel’s contribution here is typical — his argument does not involve any deeper analysis than Obamacare-is-government, government-is-bad. Most conservatives seem to be under the impression that the law would rip apart existing insurance arrangements, which explains their bizarre, muddled attempt to “apply” Obamacare to Congress, which already has employer-provided insurance and like most Americans should not be affected by the law.
It is certainly true that implementing the law is going to be complicated. It’s not just that new government programs are complex — any new large initiative is complex. Rolling out a new product is hard, and it would be harder if half the retail managers were working for a rival firm. Insurance is also inherently complicated. Signing up for employer insurance is a pain in the neck, and it will also be a pain when the government is doing it. Republicans will be able to exploit all these pains, snafus, and breakdowns, and possibly create a drumbeat of failure and disorganization in the news media.
But what I don’t think they realize is that the constituency they’re mobilizing consists almost entirely of people that Obamacare is trying to help: uninsured people whom the government is trying to enroll in subsidized exchanges. The Obamacare debate has mainly centered on the people or groups that will give something up to pay for the new coverage — Medicare providers, people with very high cost insurance plans, and so on. It has ignored the interests of the uninsured, which is typical — the uninsured are a politically disorganized and powerless constituency, which is one reason why they have had such a rough go of it.
To the extent that the implementation brouhaha comes into any focus, it will shine a light on those people’s struggle to get needed help from the government. Republicans aren’t trying to get those people better help. They’re trying to screw them.
The best thing Republicans have going for them is that most Americans have little idea what the law does, which is why its specific provisions always poll way better than the overall impression of the law itself. Forty-two percent of Americans don’t even know the law is in place. That underscores the difficulty of carrying out implementation — it’s harder to enroll people for a benefit when they don’t know it exists.
But that same reality underscores the opportunity that implementation offers. Actually getting people health insurance they couldn’t afford will help build a constituency for keeping it in place. People may not trust or understand new government programs, but they really don’t like having government programs they rely on taken away.
That’s why Republicans have always assumed that they had to stop the law before it takes effect. For all the mess and confusion that will accompany the law, you’ll also have something happen that advocates of universal health insurance wanted, and opponents of it feared: actual people getting access to subsidized medical care.