In the end, around seven million Americans signed up for Obamacare by the March 31 deadline, either through the federal exchange or through one of the fourteen exchanges set up by states (plus one in Washington, D.C.) that chose to run their own. That’s the target administration officials hoped for last fall, and considering the enrollment period’s hideous rollout, it came as quite a surprise to most commentators in Washington that it was reached. Republicans and conservatives spent months predicting that few would sign up, and that the law would simply perish of its own Rube Goldberg weight. But the “death spiral” of the Affordable Care Act, so anticipated on the Fox News Channel, failed to materialize.
There was quite a rush toward the end, particularly among younger, healthier enrollees, coaxed into participation by celebrities such as NBA star Kobe Bryant and the comic actor Zack Galifianakis, whose hilarious, deadpan interview with an obliging Obama on the comedy website Funny or Die went viral and led to a surge in visits to healthcare.gov. (“Where are you planning on building your presidential library, in Hawaii or your home country of Kenya?” Galifianakis asked the president.)
These younger people are said to account for 27 percent of all enrollees—not what the administration had hoped for, but enough, according to a Kaiser Family Foundation study from last December, to avoid the substantial hikes in insurance premiums that would result if there were not an adequate number of relatively healthy young people in the insurance pool.1
This is all good news for the administration, but what really matters is not how many people sign up for coverage, but how many actually end up paying for it over an extended period. Any household hit with an unanticipated expense—a major car repair, a sudden need to buy a child a new computer—might skip an insurance payment that month. Or a healthy person might sign up, not use the insurance for a year, and stop paying or cancel. These fluctuations, too, will have an impact on premium rates by 2015, when some fear we’ll be in for substantial rate hikes, even though a provision in the law requires insurers to provide extensive justification for increases greater than 10 percent.
The truth is that we won’t know for years the actual percentage of enrollees who are sick. The reason we won’t know, it’s worth recalling, is embedded in the law itself. Insurers can no longer ask applicants questions about their health or any preexisting conditions they may have. And precisely because the law’s authors knew this little catch-22 would arise, they built “shock absorbers,” or risk mitigation provisions, into the law, by which the government would share some of the risk of loss that insurance companies assume (and conversely would be rewarded a portion of excess profits).
In sum, while reaching the enrollment target was a good start, much about the law’s impact is up in the air and will remain so for some time. But the self-anointed political experts who fancy themselves to be Washington’s arbiters of the conventional wisdom need judgments and need them now. Among that group, the verdict was long ago rendered. The law is a disaster for Democrats. This has been the view for months, indeed years, and it congealed fully in early March after the special congressional election in a Florida swing district near Tampa Bay, where the Republican, David Jolly, defeated Democrat Alex Sink by less than 2 percent (a libertarian third candidate took nearly 5 percent).
Inevitably, this narrow win in a low-turnout race was declared “a referendum on Obamacare.” But if you looked closely, some data suggested that the health care issue actually helped Sink marginally and made the result a little closer than it might have been. Geoff Garin, Sink’s pollster, told me afterward that Jolly’s “repeal Obamacare” position was more unpopular than Sink’s “keep it and fix it” position. Sink’s support improved when respondents were reminded of the specific consequences of repeal—i.e., that insurers could use preexisting health status to refuse to issue a policy, reimpose lifetime caps, charge women more than men, and so on.
It has been said for months now that Obamacare will be the most important factor in this fall’s elections. Certainly, Republicans have vowed to make it so (the House took its fifty-second vote to repeal the law in March). Far from forcing Republicans to reconsider their approach, the meeting of the enrollment target merely led them to dismiss the numbers as phony.
They do so in part because when it comes to Senate elections they are benefiting from a very promising map. Democrats must defend incumbencies in Louisiana, North Carolina, Alaska, and Arkansas, while trying to compete in three other red states, West Virginia, Montana, and South Dakota, where incumbent Democrats are retiring. In all seven of those states, Obamacare’s approval ratings, not to mention those of Obama himself, are well below the national average. So it probably makes a certain sense for the GOP, and outside groups funded by the Koch brothers and others, to inveigh against big-government socialism as much as possible.
But the odd thing about Obamacare is this: while people dislike the word and the abstract idea of it, they favor most of its particular provisions in large numbers. This seeming contradiction is, of course, an old reality in American politics. We might recall that Bill Clinton was fond of saying that the American people are “rhetorically conservative and operationally progressive.” Clinton was leaning on the research of Lloyd Free and Hadley Cantrill, the political scientists who identified this tendency back in 1967. Most people are seduced by conservative rhetoric—about cutting back spending, taxes, and government generally, say—but when they’re presented with a list of programs and asked which ones they’d cut, it turns out they kind of like many liberal programs.
And so it is with the Affordable Care Act. The name itself has become symbolic of the interfering state, so it polls poorly. But when people are asked about its specific provisions, numbers tend to resemble those from a Kaiser poll in mid-March: approval of extension of dependent coverage, 80 percent; of closing the Medicare prescription drug “doughnut hole,” 79 percent; of providing subsidy assistance to help people purchase coverage, 77 percent; of Medicaid expansion, 74 percent; of guaranteed issue, 70 percent. The only major plank that polled below 50 percent in the Kaiser survey was the individual mandate, at 35 percent. The mandate, along with people’s general suspicions that Obamacare is going to increase rates, is the act’s true Achilles heel.
Still, the rest of the provisions should help Democrats, if they’re not afraid to use them. To a Republican candidate thundering about repeal it can easily be said: “So, you want insurers to be able to deny sick people coverage? You want to allow them to throw people off their rolls if their care costs too much?” Another potentially useful rejoinder centers on the expansion of Medicaid. States refusing to accept federal money to operate their own exchanges for the poorer people who qualify for Medicaid are saying good-bye to billions. According to a December 2013 study by the Commonwealth Fund, Texas is sacrificing $9.6 billion; North Carolina, $2.6 billion; Florida, $5 billion; Georgia, $4.9 billion. That’s depriving citizens of a lot of money.
And so, as The Washington Post’s Greg Sargent has reported, it has come to pass in Michigan that the Republican candidate for the open Senate seat created by Democrat Carl Levin’s retirement, Terry Lynn Land, has taken the comical position of wanting to repeal Obamacare while simultaneously endorsing the Medicaid expansion, which is worth $2.6 billion to the state and which the conservative Republican governor is pursuing.2
Republicans have other vulnerabilities when it comes to Obamacare. And they know it, too. This is why three GOP senators—Orrin Hatch of Utah, Richard Burr of North Carolina, and Tom Coburn of Oklahoma—introduced a health care bill in late January. When Democrats pose to Republicans the questions I’ve raised, campaigning Republicans need to say that they’re for something. The bill is an amusing piece of work, coming from Republicans: it retains some of the main features of the same Obamacare law they despise, like barring insurers from imposing lifetime caps on insurance payments; and it imposes what is in essence a tax increase (yes, from Republicans) on people who hold pricey employer-provided coverage by limiting the tax exemptions that individuals are allowed to take for those plans. When they get around to trying to make actual policy, some Republicans see that money is required.
But in fact they’re only trying to make something that looks like actual policy. In the summer of 2010, Republicans, who to that point had been only for repeal of Obamacare, started talking about “repeal and replace.” Then in November they won control of the House, and they promptly dropped the “replace” part. Now that it’s time for another midterm election, they (or some of them) are mentioning “replace” again. They have to seem like they’re offering an alternative. But they also have to keep it vague—apart from Hatch, Burr, and Coburn, few other Republicans can actually endorse their bill, you see, because of the tax increase.
With the enrollment success, Obamacare may well be turning a corner. If Democratic candidates can make the conversation about the act as specific as possible, most of them should be able to fight the issue to a draw. In some states with contested Senate races, Michigan and perhaps Colorado for example, they might even gain an advantage from it.
Still, the Democrats cannot feel relieved about November. It’s likely to be quite bad for them. Senators up for reelection this fall were elected (or reelected) in 2008—a big Democratic year. The party won eight Senate seats in that election, an unusual amount in this day and age. So now, in a nonpresidential year, the bill is coming due. The bright side for Democrats is that 2016 augurs very favorably indeed, because 2010, the year of the Tea Party, was a year in which a number of Republicans won seats that are normally Democratic. If Republicans capture the Senate in 2014, most of the experts on elections appear to think the Democrats may well win it back in 2016.
For this year, Republicans have a strong advantage, and in many cases, they don’t even need to say “Obamacare.” Simply saying “Obama” should work well enough.
Obama’s unpopularity—since last fall, polls have typically found his disapproval number to be six or seven points higher than the approval figure—has a few different sources. Certainly the slow economic recovery, with persistent high unemployment, is the main reason. In a mid-March NBC/Wall Street Journal poll, a staggering 57 percent of respondents said they believed the country was still in a recession (whereas economists say the recession ended five years ago). There was also the screwed-up launch of Obamacare itself; the many millions spent inaccurately attacking the new law; the lack of any dramatic result in foreign policy; and the determination of congressional Republicans to oppose nearly every Obama initiative, resulting in a dysfunction that inevitably leads many average citizens to pin some blame on the president.
1 See Larry Levitt, Gary Claxton, and Anthony Damico, “The Numbers Behind ‘Young Invincibles’ and the Affordable Care Act,” Kaiser Family Foundation, December 17, 2013. ↩
2 See Greg Sargent, “Bleeding Heart Republicans Really Want Health Reform. No, Really,” The Washington Post, February 28, 2014. ↩
See Larry Levitt, Gary Claxton, and Anthony Damico, “The Numbers Behind ‘Young Invincibles’ and the Affordable Care Act,” Kaiser Family Foundation, December 17, 2013. ↩
See Greg Sargent, “Bleeding Heart Republicans Really Want Health Reform. No, Really,” The Washington Post, February 28, 2014. ↩