Even amid the high-stakes maneuvering over Syria and the federal budget, White House Chief of Staff Denis McDonough has a calendar on his office door that counts down the days until open enrollment for the uninsured begins Oct. 1 under President Obama’s health care law.
It’s a reminder that nothing will shape Obama’s legacy more than whether he can successfully implement, and politically entrench, his massive health reform plan. Obama has three years to fortify the law with enough support to make repeal difficult, even if Republicans win unified control of Washington in 2016.
The president has a long road to travel. Polls show that most Americans doubt the Affordable Care Act will improve conditions for their family or the country. Implementation of the law’s many pieces has created complex logistical and computer challenges that have already forced the administration to delay some components. And, most important, opposition from Republicans is blazing undiminished—and is now flaring into escalating threats to shut down the government or default on the federal debt rather than fund the program.
No other federal entitlement has faced such ferocious opposition after passage. Although many conservatives initially raged against Medicare, that fire extinguished quickly when benefits started flowing in 1966. Medicaid, the joint state-federal health program for the poor, provoked sturdier opposition, but two years after its passage in 1965, all but 13 states had signed onto it. (Within five years, all but two states were participating.) Republican resistance to Social Security lingered longer; but after 1936 presidential nominee Alf Landon won only two states while pledging its repeal, the party confined itself to guerrilla sniping against the program, before surrendering entirely under President Eisenhower.
All of that pales beside today’s crusade against the health care law. This campaign extends from the congressional Republicans’ defunding demands, to the widespread refusal of GOP-controlled states to expand Medicaid eligibility, to the passage of laws in states such as Georgia and Ohio impeding “navigators” working to enroll people on the insurance exchanges. “The magnitude of resistance is unprecedented,” says Princeton University sociologist Paul Starr, author of an acclaimed history of the American health care system.
Without drawing moral equivalence, it’s fair to say the health care law is facing more widespread defiance than any federal initiative since the Supreme Court ordered public schools to desegregate in its 1954 Brown v. Board of Education decision. Obama is unlikely to fold against congressional Republican demands for delay. But, even so, some two dozen states—all but two with Republican governors—are refusing to expand Medicaid (which was initially expected to provide about half the law’s coverage increase) and to establish the online exchanges for those uninsured people with slightly higher incomes. Meanwhile, almost all Democratic-leaning states are embracing the law.
This contrast creates two powerful dynamics that will shape the unfolding debate. First, it means that with half the states inhibiting it, the program won’t enroll as many people nationally as Obama hoped. Because many of the resisting states have big uninsured populations and skimpy safety nets, 8 million of the 13 million people potentially eligible under the law’s Medicaid expansion live in states that are not increasing coverage, the Urban Institute calculates. Without state outreach, sign-up on those states’ exchanges also could slip, again depressing the national results.
That prospect frames a second, potentially decisive, question: Can the law’s supporters produce success in the states that are welcoming it? If California, Colorado, Minnesota, and other states that are implementing the law most enthusiastically can enroll large numbers of the uninsured, avoid big logistical snafus, and attract enough healthy young people to restrain premium rates, that would strengthen Obama’s hand nationally—and increase popular demands to participate in the resisting states. If it becomes “clear that in many of the states that are wholeheartedly implementing it, it is working well, the interesting question is, what kind of pressure will that put on the ‘refusenik’ states?” says Harvard University sociologist Theda Skocpol, who studies the safety net. In particular, success in participating states could inspire growing agitation from health care providers in the refusenik states, which are renouncing nearly $500 billion in federal money through 2022 (at small state cost) by rejecting the Medicaid expansion, the Urban Institute projects.
In this process, California could figure largest because its huge, diverse, and heavily uninsured population presents a tougher test than more-homogenous cooperating states such as Minnesota and Massachusetts. If California succeeds, notes Anthony Wright of the advocacy group Health Access California, “we can show it can work in a state where the problem is … on the scale of Texas and Florida,” the two largest resisting states. California has already negotiated aggressively to limit premium rates for insurers selling through its exchanges and has enrolled (through an early-start waiver) about half of those eligible for the law’s Medicaid expansion. But, Wright acknowledges, the state confronts supersized versions of the same “daunting” logistical challenges looming elsewhere as enrollment begins. Obama’s best chance of defending health care reform against its enemies is to ensure that it works for its friends.