The Health Care Reform War Without End

The battle over Obamacare is running into overtime, with risks for both parties — and the country.

In the 1936 election, one year after President Roosevelt signed the law creating Social Security, his Republican opponent Alf Landon called it a "cruel hoax" and promised to repeal it.

Landon won just two states — and, four years later, Republican nominee Wendell Willkie ran on expanding Social Security. Although congressional Republicans continued guerrilla warfare against the program into the 1950s, the prospect of full-scale repeal sank with Landon.

In 1964, Republican presidential nominee Barry Goldwater staunchly opposed the creation of Medicare, the health program for the elderly proposed by President Johnson. But after Johnson routed Goldwater and then pushed Medicare through Congress in 1965, opposition collapsed. By 1968, Republican presidential nominee Richard Nixon accepted it as settled law.

Although the skirmishing around Social Security offers some parallel, the struggle over health reform is burning longer and hotter than the scuffling over any previous expansion of America's safety net. It was emblematic earlier this week that just hours before President Obama announced that the Affordable Care Act had exceeded its original enrollment goal of 7 million, Rep. Paul Ryan for the fourth consecutive year released a House Republican budget that would repeal the law.

Factors from increased polarization in Congress to the widening racial, generational, and geographic divergence in each party's coalition explain this persistence. More important are the consequences. This elongated conflict is exposing each side to unpredictable political risks and denying the country a meaningful debate over addressing the law's inevitable flaws and miscalculations.

Ryan's defiant budget — coming immediately after the rush that produced more than 7 million enrollments on the health care exchanges, plus at least another 4 million sign-ups under Medicaid — captured how much momentum the repeal cause retains in the GOP. How far apart are the two sides? Ryan's plan would not only undo the insurance expansions under Obamacare but also impose further sharp cuts on Medicaid, eventually eliminating existing coverage for an additional 15 million to 20 million people.

The skirmishing will only intensify if Republicans win the Senate this fall (even if Obama can still block any repeal legislation with his veto). And that in turn would increase pressure on the 2016 GOP presidential contenders to campaign on repealing the health law (as Mitt Romney did in 2012). As Ben Domenech, a leading young conservative analyst, wrote this week, "The Republican Party is wedded to the repeal of Obamacare for the foreseeable future. There will not be a single viable candidate in 2016 who is not in favor of repeal or avoids the challenge of putting forward a health care policy designed to replace Obamacare should they be elected."

While the late sign-up crush has improved overall attitudes toward Obamacare, the risk for Democrats in this war without end is that many Americans will blame the law for every glitch in the health care system. That danger is evident in surveys showing that most Americans, particularly whites, view Obamacare more as a transfer program for the poor than something that will help them personally. Likewise, a recent survey by Democrat Peter Hart and Republican Bill McInturff found that while two-thirds of Americans say the law has not affected their quality of care, nearly half believe it is increasing their costs. Combined with ideological resistance, such attitudes will threaten Democrats this fall in red-leaning congressional districts and in key Senate races, despite the improved enrollment picture.

But these extended hostilities also risk locking Republicans into a demand for repeal that could appear unrealistic and dogmatic by 2016. Health care is such a charged subject that the law may never enjoy preponderant public support. But as more patients and providers rely on it, the institutional resistance to repeal will almost certainly rise. Theda Skocpol, a Harvard University professor of government who studies the social safety net, says that compared with Social Security, which didn't provide large-scale benefits for decades, Obamacare is "actually moving much faster" to create constituents who gain from it. Her view is that the law already is "not repealable." By the time a Republican president could pursue repeal, Skocpol says, "it will be woven into the life of people, families, and businesses."

Like the program itself, the political consequences of the health care law are complex and precariously balanced. Compared with Social Security or Medicare, Obamacare more explicitly creates losers (such as healthy people previously advantaged by an individual insurance market that excluded the sick) as well as winners. It transfers resources from old to young by slowing Medicare spending to fund subsidies for the working-age uninsured — and in the opposite direction by requiring healthy young people to buy robust coverage that restrains premium costs for those older and sicker.

A course of treatment this intricate inevitably requires reassessments and recalibrations. That's not possible now: Congress can't wield a scalpel while Republicans are still clamoring for the guillotine. But the late enrollment surge, even if it hasn't yet guaranteed the law's survival, has measurably increased the odds that the debate over Obamacare will gradually shift from ending to mending it.

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