John Boehner says Obamacare is the law of the land, and he’s right. At this point, there is no reasonable prospect that it will be repealed before its full implementation in 2014. At that point, there will be huge additional classes of people dependent on federal subsidies to either (A) be covered by Medicaid or (B) buy health insurance in government-organized markets.
If it is an unpopular program now, in 2014 it will become much more popular with the folks receiving these subsidies. Like Social Security and Medicare, Obamacare clients will come to view it as a right or an entitlement. Anyone who argues for its repeal will be portrayed as a heartless ogre. This is a political reality and Boehner is smart to come to terms with it.
That said, there is one key, politically salient difference between Obamacare and the New Deal/Great Society entitlements: Obamacare creates losers who will be politically impossible to ignore for both Democrats and Republicans alike. This is a complicated subject, but here I’ll focus on two groups of people that will be harmed.
1. The elderly will be hurt – Obamacare cuts a substantial amount of money out of future Medicare expenditures. This is the famous $700 billion cut that go so much attention during the election season. The main way that cuts will be made will be through the newly created Independent Payment Advisory Board (IPAB). Given the constraints that body faces, the most likely strategies they will employ include cutting Medicare Advantage and sharply cutting payments to doctors. For the elderly, the latter will mean that Medicare will become more like Medicaid (the government health insurance program for the poor), as fewer doctors will agree to see Medicare patients.
2. The poor will be hurt – People who are currently insured through Medicaid often cannot find a doctor who will see them. Even if they can find a doctor who takes Medicaid, they face long waits for scheduled care. This is one of the reasons that emergency rooms are so often crowded — they are the only place where Medicaid patients can be guaranteed to see a doctor. Obamacare will greatly expand Medicaid enrollment (by 20+ million people) to the near-poor, but it will do nothing to expand the supply of doctors caring for those patients. This will make it even harder for the poor to find care.
There are others who will be hurt — federal taxpayers and small business owners for instance — but this post is already too long. Democrats will pretend the elderly won’t be hurt. They will respond to the harm to the poor by pushing for expanded funding for Medicaid. Republicans have had mixed success with pointing out the harm to the elderly. Can they make a politically effective, conservative argument about the harm caused to the poor?