By John Reichard, CQ HealthBeat Editor
September 27, 2013 -- For those who have complained that President Barack Obama has allowed his critics to dominate what the public hears about the health care law for months, if not years, his recent appearance at Prince George's Community College in Maryland was no doubt music to their ears.
Two days earlier, Obama began talking at length about the overhaul, perhaps addressing critics who accuse him of sitting on the sidelines for too long. But at the conversation with former President Bill Clinton in New York City, Obama was professorial and at times halting in long explanations of its policy basis of the law before an arguably odd target audience—international leaders.
But last week, Obama was the down-to-earth and impassioned politician, displaying the style that helped him win the White House twice. No longer was he keeping the health care law (PL 111-148, PL 111-152) at arm's length. Rather, he fully embraced it in remarks going right at the demographic—young adults, many of them of color—that will be crucial to whether the insurance exchanges opening this week will succeed in the long run.
But if Obama's spirited remarks suggest he is getting back in campaign mode and becoming re-energized in support of the law, Republicans also appear to be increasingly confident that in the coming week they will have they have a shot at derailing it.
Former Bush administration budget official James Capretta suggests in a column in the Weekly Standard that Republicans can build on the implementation delays the Obama administration has already announced and continue to push for a broader delay of the overhaul.
It's debatable whether, over time, having a polarizing figure like Obama pitching the exchanges is going to help or hurt turnout at marketplaces across the country, particularly in red states.
But without such an effort by top Democrats, it's unclear what else would begin bringing people to the exchanges in large enough numbers to assure the success of the marketplaces as the law's popularity slumps further amid withering Republican attacks.
In Prince George's County, Obama sought to redirect that negative energy back on his attackers by joking that they'll stop using the term "Obamacare" if the exchanges work. And he talked at length about the chance the marketplaces give millions of people for the first time to be part of big groups that get better, more affordable coverage.
Safety in Numbers
"If you're not part of a group, you're either uninsurable, or you need to spend a small fortune on insurance that oftentimes is not very good," he said. "That's what's happening right now. The Affordable Care Act was designed to solve that problem."
Maryland's exchange is drawing attractive bids from insurers because it is creating a big pool, he said. "Here in Maryland, [the] average 25-year-old making $25,000 a year could end up getting covered for as little as $80 a month, $80 a month." Insurers "proposed these prices because they want to get in with these big groups, with all these new customers.
"Think about that," he added. "Good health insurance for the price of your cell phone bill, or less."
"If you buy health care through the marketplace, your plan has to cover free checkups, flu shots, contraceptive care. So you might end up getting more health care each month than you're paying for the premiums," Obama said.
"We created a new market—basically a big group plan—for folks without health insurance so that they get a better deal, and then we're providing tax credits to help folks afford it," Obama said.
"You would think that would not be so controversial," Obama said, drawing laughter.
"Here is a prediction for you," Obama added. "A few years from now, when people are using this to get coverage and everybody is feeling pretty good about all the choices and competition that they've got, there are going to be a whole bunch of folks who say, yes, I always thought this provision was excellent. I voted for that thing. You watch. It will not be called Obamacare.
"But we need you to spread the word," Obama exhorted. "Tell your friends, tell your classmates, tell your family members about the new health care choices. Talk to folks at your church, in your classroom. You're going to a football game, basketball game -- talk to them. Tell them what the law means. "
No Sale
But Republicans have leverage of their own in the current budget battles. And they see growing support within the party for a strategy that focuses not on a government shutdown to stop the health law, but a delay. That could prevent Obama's vision of a vibrant health care law marketplace from ever coming to pass.
Obama will soon weary of funding government through small stopgap measures, Capretta predicted in his Weekly Standard column.
"At some point, therefore, the president will want to cut a deal with House and Senate Republican leaders to take budget uncertainty off the table for at least one year," Capretta wrote.
"So the question is, when that time comes—probably in the days leading up to the holiday season in December—what should be the top priority of the GOP? Both for substantive and political reasons, Republicans should make it clear that their main objective is to delay as much of Obamacare as possible."
Capretta said the strategy is an attractive one because of delays that already have occurred, such as the employer mandate and the limits related to out of pocket spending. The idea of delaying other aspects of the law, given what he says is a growing sense that the overhaul is not ready for prime time, will not be seen as "politicized" but reasonable, he argues.
"If all or crucial parts of Obamacare are delayed, then the signature legislation of Obama's presidency will look anything but inevitable—and if it can be delayed once, it can be delayed again and again, and then repealed," Capretta said.
Early stumbles in the start of exchanges "could be more than just glitches," says Scott Gottlieb, a scholar with the American Enterprise Institute. "We could have the specter of some really significant data security issues," he said in an AEI-sponsored telephone press briefing last week.
If there are a lot of revelations that people have lost private data in trying to shop on exchanges, people "are going to start pulling away" from the marketplaces, he said. Other aspects of exchanges could prove unpopular, he suggested. Gottlieb also said that many of the plans offered on exchanges are narrow network plans, and predicted that this limited network model could migrate out into the broader marketplace.
But Gottlieb and AEI analysts Tom Miller and Joseph Antos downplayed the chances that exchanges won't ultimately get up and running, at least for a while, or that major parts of the law will be delayed. Absent big data security problems, Gottlieb said he expects the exchanges "will be self-sustaining."
Gottlieb suggested that with gains in future elections Republicans could focus on changes, such as having a broader array of plans on exchanges, eliminating the individual mandate, and scaling back subsidies.
Miller said that if exchanges are still around in 2105 and 2016 there will be a push to liberalize rules on what benefits plans can offer in exchanges.
Antos said exchanges can be expected "to limp along. The fact is that insurance companies have a lot at stake. They want something to work." But over time subsidies will not keep up with rising premiums, he said. And he forecast that those rates will rise sharply in 2015 and that companies will drop out of exchanges.