- Obamacare and immigration reform could boost Democrats for a generation or more
- Parties in power always try to use policy to secure future voter support
- Ideology aside, Republicans know health care, immigration reforms help Democrats
- GOP attacks focus on the health care law, not just website woes
A "big f***ing deal" has become an equally big fight, with Republicans relentlessly attacking President Barack Obama's signature health care reforms over the new reality they are bringing to the health insurance market.
One reason is the GOP's ideological opposition to big government, as manifested by the health care overhaul intended to hold down rising costs that threaten U.S. fiscal stability.
Another is the long-term political benefit to Obama and Democrats from the sweeping changes intended to give people previously unable to afford health insurance or deemed ineligible the chance to obtain coverage.
Coupled with Obama's stated second-term priority -- proposed immigration reform that would remove the "illegal" label for millions of undocumented aliens -- the legislative power play could provide an electoral boost for Democrats certain to last a generation or longer.
The combination of Obamacare -- as the 2010 Affordable Care Act is known -- and immigration reform "would be a huge boon to the Democratic Party," said Darrell West, the Brookings Institution's vice president and director of governance studies.
"It would provide insurance to millions who don't currently have it, and it brings aboard undocumented people who are very likely to be Democratic supporters," he told CNN.
Wendy Schiller, a political science professor at Brown University, said such an outcome is the goal of all presidents and their congressional allies who seek to "enact policies that will hold their base and attract new voters in successive election cycles."
Republicans know that, which explains their fierce opposition to Obamacare dating back to well before Vice President Joe Biden's off-color description whispered too loudly to Obama as the President prepared to sign the law in 2010.
Now a confluence of factors -- including the overall impact of the reforms as well as major problems in their implementation and continued GOP efforts to derail them -- have further hardened already entrenched partisan positions on the issue.
Effects of Obamacare
It has taken more than three years since the Affordable Care Act became law to begin to understand its effects.
The concept leans heavily on a conservative Republican idea adopted for the Massachusetts state health care program that creates large markets to hold down prices. To work, the program must include less-expensive young people to offset the higher costs of older people, who generally need more health care.
Such a system would provoke competition between insurers for lucrative markets, meaning lower premiums and a minimum standard of benefits to provide security against financial ruin over a major illness or bad accident.
However, an analysis by CNN found that consumer options vary significantly from state to state, and many Americans are discovering they have few options.
For example, West Virginia and New Hampshire have one insurance company offering coverage, meaning no choice between providers, while eight other states -- Alabama, Alaska, Hawaii, Maine, Mississippi, North Carolina, Vermont and Wyoming -- have two.
The Kaiser Family Foundation estimates that 12 million people live in counties with only one insurer, compared with 117 million in counties with more than five insurers. The foundation's Cynthia Cox found that in counties with more than five insurers, the average premium was about $20 a month less than in areas with only one insurer.
In addition, CNN's Tom Foreman reported Thursday that in some cases, the same company will charge more for a policy in a rural area, compared with a big city.
The differences generally reflect the smaller pool of consumers in less populous rural areas, compared with more densely populated urban and suburban areas.
Such disparities also tend to follow a political fault line in many places, with Democrats more prevalent in big cities and suburbs, while Republicans generally get more support in rural areas.
While definitive correlations would be overly simplistic and premature, increased options in urban areas versus rural areas indicate that on a broad level, more Democrats than Republicans are realizing benefits from Obamacare so far in terms of choice and cost.
To Jonathan Gruber, a Massachusetts Institute of Technology professor who helped design the Massachusetts and federal health care laws, it is too early to understand the full effects of Obamacare.
"It's not like Obamacare's chasing insurers out" of rural areas, Gruber told CNN on Thursday. "These are just markets that didn't have many insurers to choose from before, and there hasn't been a lot of entry in the recent times since the law has passed."
In Massachusetts, he said, a major new provider entered the market two years after the reforms took effect.
"You don't need 16 choices. You don't need 12 choices," Gruber said. "It's nice to have that many, but having one or two new entrants, which will happen over time -- it did in Massachusetts -- can really shake up the market in lower prices."
Botched website rollout
Conservative critics long warned that Obamacare amounted to a government takeover of health care that would be too big to manage effectively and deny people the ability to choose their own doctor or coverage.
So far, some of the predictions have proved true.
While initial stages of implementation proved relatively uneventful, the biggest single step -- the October 1 launch of exchanges to give people the chance to buy required health coverage -- was badly botched when the government website proved dysfunctional.
The administration scrambled to try to get it working, announcing a "tech surge" with outside experts deployed to bolster the joint government-private sector team that created HealthCare.gov.
In addition, insurers recently began informing some of the relatively small percentage of people who buy their own health coverage, instead of getting it through their employer or government-run Medicare and Medicaid, that their policies were being discontinued or changed because they failed to comply with Obamacare requirements.
The shift undermined Obama's mantra-like pledge in selling the reforms that no one would be forced to change policies or doctors they liked.
Obama "has broken many promises about Obamacare," Republican National Committee Chairman Reince Priebus said in a prepared statement Friday that solicited stories from people about how they were hurt by Obamacare.
On Monday, the RNC announced it was launching a campaign of robocalls and targeted Facebook posts to encourage people to ask why their elected representatives supported what it called "Obama's lie that people could keep their healthcare plans under ObamaCare."
At the White House on Friday, spokesman Jay Carney emphasized that the individual policies being discontinued or changed represented a fraction of the overall U.S. population.
He reiterated the administration line that consumers would get a better deal under Obamacare -- more benefits at what likely will be a lower price than they pay now if they qualify for federal subsidies available under the reforms.
The latest battle line between the parties is about early enrollment figures.
Republicans are pushing the administration to release numbers for how many signed up in the first month of the new exchanges, but Carney and others say complete and reliable information will only be available by mid-November.
Rep. Dave Camp of Michigan, the GOP chairman of the House Ways and Means Committee, has threatened to subpoena information on enrollment figures as soon as this week.
Carney and other officials have said they expect the initial figures to be low, because of the website problems and a cautious approach by consumers in the early days of such programs.
He and others note that the Massachusetts health care plan had most people sign up in the final days before the enrollment deadline, and they expect the same thing to happen with the federal program. That deadline is March 31.
Gruber of MIT called the focus on the early figures premature.
"According to the Congressional Budget Office, it will be about a three-year ramp-up period until Obamacare is fully effective at its full level of functioning," he said. '"That's what we saw in Massachusetts as well. So we need to just calm down and stop worrying about days and weeks and focus instead on months and years."
However, Gruber warned that the HealthCare.gov website must be fully operational by the end of November to ensure that people being forced to change policies have time to enroll by January 1, when their current coverage ends.
The Republican goal in demanding the figures is to depict Obamacare as an immediate failure in order to try to generate public momentum for delaying or dismantling the law.
Some Democrats facing tough re-election battles next year also have proposed a delay to allow people more time to sign up and avoid the fine, but the Obama administration opposes such a step because it would undermine the immediate creation of large new markets needed to keep costs down.
The immigration connection
Even if Obamacare works as planned, Gruber told CNN, about 40% of people currently uninsured would remain without coverage. As many as a half of that group -- 10 million or so -- would be undocumented immigrants living illegally in the country, he said.
"Today, these undocumented immigrants end up in the emergency room. Next year, they'll end up in the emergency room again," he said. "That may be something we want to take on eventually as a society, but we don't seem prepared to do so now."
To West of the Brookings Institute, the Obamacare and immigration issues "do intersect in interesting ways."
He noted the Affordable Care Act specifically excludes undocumented immigrants from getting health insurance under the reforms.
A Senate-passed immigration reform proposal would give temporary legal status to the undocumented, but make them wait 10 years before they could seek citizenship. It is unclear if the plan will get a vote in the Republican-led House.
The decade of waiting to seek citizenship should ease the fears of Republicans over an immediate impact on elections, as only U.S. citizens can vote, West said.
However, any undocumented immigrants who eventually become citizens would probably be Democrats, because "they've seen Democrats have been the people pushing for immigration reform while Republicans have been resistant," he added.
Schiller, the Brown University political science professor, said the issue of Obamacare eligibility could be a sticking point in the immigration reform debate, adding: "Republicans will absolutely insist that (undocumented immigrants) are not eligible for Obamacare during that 10-year-period" before they can seek citizenship.