DOUTHAT: Failing to fix U.S. health care, Obamacare limps on

As Republicans have fallen silent about Obamacare, the law’s struggles have actually increased.

For the first six years of the Obama era, many Republicans made an apocalyptic case against the president’s health care law. It was unconstitutional, immoral, borderline tyrannical. It wouldn’t just fail. It would fail disastrously, in a death spiral that would take down most of U.S. health care as we know it.

Then the apocalypse failed to arrive. The law survived two Supreme Court challenges, the website fiasco during its rollout, and the wave of cancellations and premium increases. It successfully enrolled millions of the uninsured.

At which point Republicans, never particularly eager to grapple with the actual details of health care policy, began talking about the issue less and less. Since the government shutdown in 2013 failed to stop the law from taking effect, the word “Obamacare” has lost pride of place in Republican talking points.

On the 2016 campaign trail, terrorism and immigration are the hot-button topics, tax cuts once again the big domestic policy promise, and it’s clear that any real health care talk will wait until the general election (if it shows up then). The party’s base just isn’t that excited by the issue anymore.

For a while after the HealthCare.gov website righted itself and enrollment picked up, liberals had fun mocking the GOP’s predictions of disaster and began talking as though Obama’s legacy was established. But you hear a lot less of that talk nowadays.

After the initial surge, Obamacare’s enrollment numbers have mostly disappointed. The law has knocked down the U.S. uninsured rate to about 11-12 percent, compared to a pre-Great Recession level of 14-15 percent. But it looks like the Obamacare exchanges will fall at least 4 million enrollees short of the target for 2016.

Moreover, the people who are enrolling are sicker and more heavily-subsidized than either the White House or the participating insurers had hoped; the healthy uninsured are often choosing to pay the fine/tax and go without coverage. That means the initially lower-than-expected premiums charged on the exchanges are headed upward, and major insurers may end up following UnitedHealthcare for the exits.

Also, the excited liberal claim that Obamacare has bent the overall health care cost curve downward looks premature. After five years of slower-than-expected growth, cost growth spiked higher in 2014—driven, in part, by Obamacare’s coverage expansion.

All of this disappointing news, however, does not prove that we’re headed for an apocalypse after all. Obamacare’s lower-than-expected enrollment, for instance, means that the law’s subsidies will cost less than anticipated. And the budget-busting scenario feared by some conservatives (myself included), in which employers find a way to dump their sickest or poorest employees onto the exchanges is unlikely.

So despite their problems, the exchanges could stagger along for quite a while as a kind of high-premium, high-risk pool attached to our shrinking employer-based and expanding single-payer (Medicare and Medicaid) systems. Which would let both sides claim a modest sort of vindication: Liberals because many of the most sympathetic cases will have access to insurance, conservatives because everyone else’s costs will have risen and the larger system’s underlying problems will linger unaddressed.

In a well-functioning republic, these problems would be addressed in a new debate about health care reform.

Maybe that debate will happen. But it seems just as likely that Obamacare is neither fixed nor fully paid for nor furiously opposed but simply limps along with the rest of our health care system for as long as both can limp.•

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Douthat is a New York Times columnist. Send comments on this column to ibjedit@ibj.com.