Obama's own political legacy is on the line with health care. He needs the law to work in the long run, and even innocuous-seeming political concessions now can create bigger problems down the road. Even a change as minor as extending the law's enrollment window, as Sen. Jeanne Shaheen, D-N.H., has proposed, could have unintended consequences. It's the defined enrollment period that stops healthy people from taking their chances without insurance and signing up on their way to the emergency room if they need it.
"Our starting point has to be that anything you do right now makes the policy worse," said Jonathan Gruber, a health care economist at MIT who helped design the law. "I think the policy will work if we leave it alone."
That's an increasingly hard sell, though, for congressional Democrats who have already followed Obama this far down the road, only to end up with a broken website and a raging controversy over canceled insurance plans.
Democrats essentially gave up years ago trying to reverse the law's stubbornly ambivalent polling, saying the law would work once it was in place and everything would be fine. But that strategy hinged on the White House implementing the law well, and instead the administration delivered a bungled website whose high-profile failure made the inevitable stories about plan cancellations worse.
Now, negative perceptions are being cemented and rank-and-file lawmakers want to show their constituents either an improvement or a vote in favor of an improvement. A detailed explanation of the best ways to structure an insurance market won't cut it.
Obama tried to deliver, but Democrats left their options open even after he announced his administrative "fix" for canceled plans, with in-cycle Senate Democrat Mary Landrieu, D-La., saying legislation was needed to make the change stick.
Policy-minded supporters of the health care law are unhappy too and worried about Obama's willingness to wade into the issue. The way Obama addressed the issue was the "least bad thing you could do," Gruber said, but going any further "“ as many congressional Democrats want to do "“ would only further perpetuate the two-tiered system that Obamacare is trying to equalize.
On its face, the tradeoff underlying the Affordable Care Act seems simple: Guarantee coverage to sick people, and bring healthy people into the system to offset the cost. The execution of that balance, though, is complicated. It relies on a web of specific policies that work together. Many of those specific tools "“ such as pushing healthy people off of their inexpensive plans "“ are unpopular on their own.
But pulling on any one of those threads — and there are no fewer than four Democratic plans that would do just that — could upset the law's built-in efforts to get people covered and avoid major premium hikes next year. Letting more people keep old health care plans would upset that balance. So would delaying the individual mandate, as Sen. Joe Manchin, D-W. Va., has proposed. Even Shaheen's innocuous-looking proposal to extend the window to buy coverage is making insurance companies nervous.
All of those bills would chip away, to some extent, at policies designed to push young, healthy people into Obamacare's marketplaces. And getting young people to sign up is the key to the law's ultimate success.
"I would really hope that there would be some fortitude in the face of all this "¦ I can understand that they're nervous, but I hope they can keep a longer perspective on things," Jost said.