Political Battle Over Health Law Starts Next Chapter

In the three years since the Affordable Care Act became law, public opinion has remained deeply divided with as many Americans opposing the law as supporting it. When Americans begin signing up for health insurance under the act, opinion may finally begin to shake loose. Some people without access to insurance gain it and others encounter new bureaucracies.

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It's one of the basic lessons in school - how a bill becomes a law - sounds so finite. Of course the part they don't always teach is how the political debate over a law can just keep going. The Affordable Care Act, or Obamacare, is now the law of the land. The Supreme Court ruled it constitutional.

But as NPR national political correspondent Mara Liasson reports, the fight of the law will likely just intensify ahead of the next elections.

MARA LIASSON, BYLINE: The political battle over Obamacare isn't over, says Drew Altman, the president of the Kaiser Family Foundation. It's just starting a new chapter.

DREW ALTMAN: We're finishing the World War III political phase and entering a new phase, where Obamacare moves from an ideological war zone and a symbol of the differences between left and right to a reality for the American people.

LIASSON: The Affordable Care Act has already gone into effect for everyone who already has health insurance. Starting this fall, people without health insurance can begin signing up for coverage - and tax subsidies - on the state and federal insurance exchanges. To get the enrollment process up and running is a huge operation with high political stakes as President Obama acknowledged this week.

PRESIDENT BARACK OBAMA: The challenge is that, you know, setting up a market-based system, basically an online marketplace where you can go on and sign up and figure out what kind of insurance you can afford and figuring out how to get the subsidies - that's still a big, complicated piece of business.

LIASSON: And it's made more complicated by the fact that 33 states have chosen not to set up their own exchanges - leaving that job to the federal government - and half the states have decided not to expand Medicaid, the program for low income Americans.

OBAMA: Even if we do everything perfectly, there'll still be, you know, glitches and bumps, and there will be stories that can be written that says, oh, look, this thing is, you know, not working the way it's supposed to.

LIASSON: Republicans are counting on a backlash. Brad Dayspring, with the National Republican Senatorial Committee, says if Obamacare was a nightmare for Democrats in the 2010 elections, it will be a tsunami for them in 2014.

BRAD DAYSPRING: If you look at 2010, the country had very strong feelings about Obamacare and it had great ramifications on the election. And that was at a time when the law was intangible; it was just a concept. In 2014, every family is going to feel the changes that are brought upon by Obamacare, whether it's the taxes, the mandates, the bureaucratic red tape that small businesses have to deal with.

LIASSON: One of the hurdles for the administration is the lack of information about the law. In the latest Kaiser health care tracking poll, 42 percent of Americans weren't even sure the law was still on the books. Among the uninsured, says Ron Pollack, whose group Enroll America is trying to get millions of people into the system, the level of ignorance is stunning.

RON POLLACK: Enroll America undertook a national survey, and more than three out of four uninsured people who are eligible for the tax credit premium subsidies - 78 percent - simply didn't know about it and didn't know that they can get significant help. And an even larger percentage - 83 percent of those who are potentially eligible for the Medicaid expansion don't know about it.

LIASSON: That gives Republican opponents of the law a big blank slate to write on, says Democratic strategist Mark Mellman. He says the White House and Democrats have learned a hard lesson from 2010 - the health care law does not sell itself.

MARK MELLMAN: You can't just say tens of millions of people have health insurance and assume that everyone thinks, well, that's great, thank you very much. That's not where people's heads are. People really are concerned about this reform and understandably so. And we can't assume that anybody does know about or understand those benefits. They have to be sold aggressively.

LIASSON: Starting this fall, there will be an aggressive effort by the administration and its allies to showcase the positive effects of the law - from Republican groups there will be an equally fierce attempt to highlight the pitfalls. Republican pollster Bill McInturff says his party should be cautious because the politics could cut either way.

BILL MCINTURFF: When the Medicare drug benefit happened, guess what? The first three to six weeks were pretty rocky. All you read about were stories about confusion, sign up mess. A year later, all that chatter was gone and it totally disappeared as an issue in the election.

We could see some very negative consequences of Obamacare in 2014, but that could be just the reverse.

LIASSON: If the health care law falters, says McInturff, it should fail on its own - not because Republicans pushed it over the cliff.

MCINTURFF: Nothing is less attractive than sitting on the sidelines when what's at stake are people's health care, if in fact what critics have been saying, which is many fewer people than folks imagine get covered and that costs will be too great, and that millions more will lose their coverage in the exchanges and that younger people will pay more. If those two or three things happen in unison, this is not a Republican effort anymore; it will be a substantial majority of Congress trying to figure out how to fix what got broken.

LIASSON: Whatever the political consequences of Obamacare are next year, they will be driven, finally, by Americans' judgment of the actual law, not a hypothetical description. Mara Liasson, NPR News, Washington.

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