This explains conservatives’ frantic desire to destroy the exchanges before they come to life. The party’s internal disagreement about which threats Congress should use to halt the law have commanded most of the attention, but the steps the party already agrees upon are equally dramatic. Conservatives have identified the weak point of the exchanges: They require the young and healthy to sign up. If only older, sicker people enroll, the cost of insuring them will rise, causing premiums to go up, causing more healthy customers to drop out—a scenario the industry calls a “death spiral.” Any combination of adversity—mechanical problems with the websites, confusion or distrust of the law—could conceivably leave the exchanges with too few healthy customers, triggering a death spiral that, once under way, probably couldn’t be contained. If that happened, the law’s promise of creating a workable solution for the uninsured without disrupting the employer system would collapse. Obamacare’s remaining political support would fall out, and Democrats in Congress would be far less willing to block the GOP’s unrelenting legislative attacks.
The health-care industry does not expect a death spiral to occur. So far, seventeen states plus the District of Columbia have released the insurance plans on offer in their exchanges, and the premiums are significantly lower than the Congressional Budget Office had forecast. These are real bets being laid down by private companies with money on the line. They expect they will be able to attract a large enough base of customers, enough of them healthy, to charge low rates and still make a profit on the exchanges. The central question over the next few months is whether these companies have underestimated the tenacity of the Republican Party—whether conservatives can mount a campaign of sufficient ruthlessness that even private-sector experts with skin in the game will be surprised.
The right’s actuarial guerrilla war begins with the underlying reality that hardly anybody knows about the exchanges. Polls show that fewer than six in ten Americans even know the law still exists, with the remainder believing it’s been repealed or struck down, or unsure. Of those aware that the law remains in effect, few understand how it works. Yet to succeed, Obamacare requires a critical mass of uninsured Americans not only to grasp what the law does but to act on it.
Republicans in Congress have slashed implementation funding, forcing the Department of Health and Human Services to shift money around merely to keep the law afloat. (This was the source of Baucus’s “train wreck” complaint.) Obama has instead cast about for ways to publicize the exchanges without the assent of Congress. The administration planned to ask the NFL to participate in a public-awareness campaign, based on the Massachusetts campaign that used the Boston Red Sox to advertise that state’s exchanges. In June, Republican leaders fired off letters warning the NFL not to collaborate; the NFL acquiesced.
Obamacare antagonists have also zeroed in on “navigators”—consultants for churches or other charitable organizations, or for state governments, who help walk confused (mainly poor) people through the exchange application process. House Republicans have sent out sweeping demands for documentation to navigators nationwide (sample line: “This request also includes, but is not limited to, any documents provided by [or communications with] representatives from HHS, CMS, CCIIO, Enroll America, or any other entity including federal or state governments discussing individuals to target or solicit for enrollment under the PPACA including discussions or documents related to geographic area”). Numerous Republican-controlled states have imposed unnecessary licensing requirements on navigators who, after all, are not turning a profit. Two such navigator groups—Cincinnati Children’s Hospital Medical Center and West Virginia Parent Training and Information—quickly dropped out in response. You may be old enough to remember the long-ago days of this past May, when conservatives considered burdensome, politically motivated scrutiny emanating from Washington the starkest form of government tyranny.
The heart of the Obamacare resistance is a quasi-campaign to persuade the young and healthy to boycott the exchanges. In recent weeks, the conservative media has developed an obsession with the unfairness and economic drain the exchanges would allegedly impose upon the young and healthy. And it is true that young, healthy individuals who make too much money to qualify for federal tax credits will now have to pay somewhat more for insurance. They may find some consolation in the likelihood that they will one day find themselves no longer young and perfectly healthy, or perhaps sharing a family with somebody with serious medical needs, and thus poised to benefit from a system in which sickness or injury does not subject one to medical deprivation and financial ruin.
The strangest thing about conservatives’ fixation with unfairness is that the redistribution from the healthy to the sick that they decry is already a part of the employer insurance system. If you are a young, healthy person who gets insurance through work, you are getting docked the same amount of money as your older, actuarially more expensive colleagues. What conservatives have now elevated to a principle of the highest moral magnitude has been violated for decades, ignored until its discovery as a weapon against universal health insurance.