The Obama administration has spent the last few months insisting that the trains will run, more or less on time. But it hasn’t managed to generate force behind its narrative. Liberal activists disappointed that reform didn’t produce a single-payer or public option never developed a passion for the law. The policy wonks who most closely share the administration’s worldview—analysts like Ezra Klein, Jonathan Cohn, and Sarah Kliff—have acted like real wonks, weighing the bad alongside the good, re-creating the Nate Silver–versus–unskewedpolls.com imbalance of assuredness. Nobody can honestly argue the law is certain to succeed. You can’t honestly argue it’s certain to fail, either, but that hasn’t stopped some from doing so.
Just as in the 2012 campaign, the bad news, while often exaggerated, has been real enough. The administration has carried out its implementation in the face of unplanned adversity. The law allowed states to set up their own health-insurance exchanges, and expected nearly all to do so, but provided for the federal government to step in for those that failed. Most red states decided to boycott, and the paradoxical result—Republican governors got a Washington-run system rather than one they created—was an acceptable price for maintaining the Obamacare boycott; it also created vastly more work for Sebelius and her department. The legal challenge likewise gave Republican states an excuse to put off any decision at all.
In the face of unexpectedly tight deadlines and shrinking budgets, Obamacare’s implementation has largely consisted of triage: identifying the essential pieces of the law and delaying or jettisoning everything else. Yet every trim or delay has produced more howls of outrage and more Obamacare-chaos coverage. Among the American public, the loyalists have dwindled to the most hard-core Democrats, with the softest supporters of the president increasingly joining the skeptical opposition. A Washington Post–ABC News poll found that the 74 percent of moderate and conservative Democrats who approved of the law at the time of its passage had shrunk to 46 percent by this summer. Another poll found that just since Obama’s reelection, overall Democratic approval for the law has dropped from 72 percent to 57 percent.
You might think that this all represents nothing more than another episode of conservative self-delusion of the sort that ended in a dumbfounded Mitt Romney campaign beholding the election returns last November and Karl Rove bleating helplessly at the Fox News decision desk. But unlike with the election, perception and reality cannot be so neatly separated. The final, decisive stage of the Obamacare wars is one in which perception can create its own reality. The predictions of a train wreck are intended to precipitate one.
On October 1, the most important piece of Obamacare, the health-insurance exchanges, will open up for customers. The exchanges are Obama’s answer, borrowed from Governor Mitt Romney, to the problem of the broken individual-health-insurance market. Insurers want to avoid getting stuck with sick customers, so they either screen out anybody with a high health risk, charge sky-high rates to those without a perfect health history, or impose conditions (like lifetime caps on what the insurer has to pay) that foist the costs onto consumers who need a lot of medical care. Because of that, the people who can get individual health insurance are the ones who need it least, most of them young and healthy. Historically, the only way for Americans to get decent health insurance is to have a job, since insurers will cover a whole company, where they can pool together all the employees, sick and healthy alike.
The exchanges will create a workable market for people who can’t get insurance through their job—at least in theory, and in practice in Massachusetts. The successful operation of the model in the Bay State suggests, at the very least, that the design of the program is not conceptually unworkable. And if it does work, it will be a lifeline for the millions of Americans locked out of the insurance market. Of course, their care isn’t free. The money to insure people too poor or sick to find insurance on their own will come from a combination of higher taxes on the rich, savings from Medicare, and getting young, healthy people to enroll in the system.
That vast transfer of wealth—from rich to poor, and from healthy to sick—is Obamacare’s most socially radical element, and it is that political transformation that has captured the attention of the right. Once uninsured Americans have a program that provides them access to medical care, the political system will no longer be able to disregard their plight. As conservative writer Byron York has put it, “Once those payments begin, repealing Obamacare will no longer be an abstract question of removing legislation not yet in effect. Instead, it will be a very real matter of taking money away from people. It’s very, very hard to do that.”