Tuesday, December 31, 2013

ObamaCare 2014:  Tale of Two Americas

Two Americas have emerged in health care reform: states like California, which have embraced ObamaCare, have enthusiastically implemented its key provisions, and are intent on boosting enrollment and ensuring its success; and states like North Carolina, whose political leaders oppose ObamaCare, resist its implementation, reject Medicaid expansion, and hope that the program collapses.

Jonathon Oberlander and Krista Perreira, “Implementing ObamaCare in a Red State – Dispatch from North Carolina,  New England Journal of Medicine, December 26, 2013

2014 will be the story of two Americas  - Blue states versus Red States,   progressive versus conservatives,  inside the Beltway crowds versus outside the Beltway masses, bicoastals versus inlanders,  Obamacare believers versus nonbelievers.

Given these dualities,  President Obama has two choices: one, compromise with his distractors or confront them.  I predict he will choose that latter course by issuing executive orders and staking out his philosophical differences with the GOP.  Bringing in John Podesta to spell out these differences is one signal of this approach. Another is his history of taking unilateral actions, such as ramming ObamaCare down the GOP’s throat,  changing the law 21 times without consulting Congress,  using the IRS to punish his adversaries by denying them tax-exempt status,  repeatedly deceiving the public with claims that could keep their doctor and health plan,  and charging ahead with healthcare.gov to meet a political deadline after being forewarned it was not ready and might fail.

This is a president that takes inordinate pride in his namesake, ObamaCare.  He is not about to change it because of dropping polls showing distrust in his leadership or its lack of workability.  He will campaign on this issue through a national PR effort, raising money from celebrities, exciting his base with his partisan passion, issuing good news stories about Obamacare benefits.  He will try to work around Congress. He will strike out with executive actions. He wlll demean and ridicule Republicans for failing to cooperate.

But there are big Red Lines obstructing his path to November 2014 electoral glory.   Two obstacles are: one,  the Red States with their 30 GOP governors,   their 680 state legislators,   and the 63 Republican House members and Senators -  all elected in the 2012 midterms; and two, the June 2012 Supreme Court decision allowing states to opt out of Medicaid expansion.   These two events imperil the main intention of ObamaCare dream – to provide coverage for the uninsured and underinsuref and to expand Medicaid.. 

But as the proverb says: the road to hell is paved with good intentions.  And as Joseph Epstein points out in “ObamaCare and the Good Intentions Paving Co” WSJ, December 31, 2013), “ ObamaCare is a nearly perfect example of the Good Intentions Paving Co. at work.  A President and the leadership of his party decide what it would be a fine thing to bring universal health insurance to the nation – what a sweet notion, really – except when they enact the law, it turns out to bring in its train confusion, anxiety, probably loss of employment, added personal and public expense, and aggravation all around. “

Now  the nagging  thought of a repeat of the 2010 midterms in the 2014 midterms haunts the Democratic party. For good reasons.  The IRS scandal punishing conservatives,  the horrendous healthcare.gov rollout,  health plan cancellations exceeding enrollments, and skyrocketing premiums and deductibles,   have aroused the Tea Party, mobilized conservatives,  and sunk Obama in the polls.  Only 16 states have embraced Medicaid expansion, 25 have declined,  and 34 have told the federal government:  “You set up our exchanges. We do not believe in them. You explain this confusing, complex, and controversial law.  It’s your law, not ours.”

Or.  in the words of Oberlander and Perreira in their NEJM piece:  “The ACA is a national law, but its implementation varies substantially across the country.  Two  Americas have emerged.”

The botched ObamaCare rollout, Obama’s known deceptions, and widespread health plan cancellations, have intensified opposition to the health law.  This opposition will grow right up to the November midterms,  barring unforeseen developments, such as a booming economy, sudden  public embrace of ObamaCare’s benefits,  and a perfectly functioning healthcare.gov website.  These events could prevent another midterm nightmare. Meanwhile Obama must figure out how to make the ACA work in states whose governments are rooting for working to ensure its failure.   And he must strive to keep the Good Intentions Paving C. from going out of business. 

Tweet:  America is divided into two countries – one, favoring and embracing Obamacare, and two, the other rooting for its failure.

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