No one likes Obamacare

People are always interested to know, when I tell them I write about health care, what I think of Obamacare.

My answer usually is this: “The Affordable Care Act is so massive, it's just about impossible, if you know what’s in the law, to entirely love it or hate it."

I could just as easily say this: "No one is happy with this law."

We all know conservatives don’t like Obamacare. Republicans have been warning about Obamacare-induced death panels, death spirals and the death of America as we know it since before the law was passed. And after it was passed, the Republican-led House has staged 40-some votes to repeal all or part of Obamacare.

“Obamacare will destroy the private-insurance market, incentivize businesses to cancel current health coverage for their employees, create physician shortages, and force Americans and states into total dependency on the federal government,” wrote Jim DeMint and Mike Needham, both of the Heritage Foundation, in a Wall Street Journal op-ed that encouraged shutting down the government to stop funding for the law.

Perhaps more surprising is that liberals don’t like Obamacare either. Many of them wanted Obama to push for a national, Medicare-for-all health insurance program. At the very least they wanted a public option insurance plan to give the health insurance industry some real competition. But that provision didn’t make it into the final version of Obamacare.

“Obamacare is awful,” wrote liberal filmmaker Michael Moore in a New Year’s Day op-ed in the New York Times. “The Affordable Care Act is a pro-insurance-industry plan implemented by a president who knew in his heart that a single-payer, Medicare-for-all model was the true way to go.”

Indeed, looking back nearly four years after Congressional debate over Obamacare, I see lots of ways in which critics of the law got a better deal than they thought (or said) they would, while many proponents of the law are now disappointed.

Consider that health insurers like Indianapolis-based WellPoint Inc., which in general worked against the law, now enjoy a government decree for nearly all Americans to buy their product. (I can tell you the newspaper industry would kill for a mandate for all Americans to buy its product. And I suspect every other industry would, too.). Obamacare gives its insurance mandate teeth by taxes on those who don’t buy insurance and by fairly sizable tax subsidies for many who do. Those subsidies are set to total $100 million a year by 2017, Moore noted.

Consider that hospitals, who thought they would see a flood of newly insured patients, are now trying to cut their expenses to deal with Obamacare’s slower-than-expected growth in reimbursements from the Medicare program. (Other factors hurting hospitals right now are federal sequestration, Indiana’s decision not to expand Medicaid eligibility, as called for by Obamacare, and a decline in patient visits, which appears to be induced by the nation’s long bout of joblessness and by the rise in high-deductible insurance plans.)

Consider that hospitals, doctors and even drug companies like Eli Lilly and Co.—all of which supported Obamacare because of its expansion of insurance coverage—are now seeing their services and products cut out of some insurance plans, as insurers switch to narrow networks and narrow formularies.

Consider that health savings accounts and high-deductible health plans—which were marked for extinction by the incoming Obama administration—are now, thanks to the bronze plans on the Obamacare exchanges and Obamacare’s Cadillac tax on employers, on their way to becoming the dominant type of health insurance plan across the country.

Consider that labor unions, some of Obama’s staunchest supporters, will likely not be able to keep their health plans going in the future. Some unions have even called for the outright repeal of the Affordable Care Act.

Why does all this discontentment matter? Because it means that health reform is by no means done. If anything, the Jan. 1 implementation of the bulk of Obamacare is just the beginning of health reform.

I don’t ever expect a repeal of the Affordable Care Act—even if Republicans take control of the Senate and the White House by 2017. Instead, I expect liberals and conservatives to engage in a pitched battle to twist Obamacare’s basic architecture into something more to their liking.

Liberals will still find it hard to attack Obamacare outright. But they could certainly re-start their anti-insurance rhetoric, blasting health insurance companies for the real-world effects of their narrow networks, high deductibles and high premiums. That could give them traction on introducing a public option.

Conservatives will find it hard to stop predicting Obamacare’s impending doom. If they did, however, they would discover that the bill has given them a chunk of what they wanted—proliferation of health savings accounts, the extension of tax breaks to individuals (not just companies) for buying insurance. They could try to scale back the highly prescriptive nature of the regulations on the Obamacare exchanges and open those marketplaces across state lines—both in the name of expanding choice and competition. They could also take a shot at repealing Obamacare’s individual mandate tax.

I also expect conservatives to try to extend the logic of Obamacare—tax subsidies for private insurance—to Medicare (as Rep. Paul Ryan has already proposed). In response, I expect liberals to try to keep the program roughly as it is, while expanding Obamacare's modest provisions for reducing health care spending and, possibly, giving Medicare the power to negotiate prices with drug and device companies.

Obamacare, for all it changes, leaves a lot of things the same in American health care. Both liberals and conservatives can find things in the law they will fight to preserve, and other things they will fight to overturn.

So, now that Obamacare is here, let the real health reform debate begin.