The 2010 Patient Protection and Affordable Care Act (PPACA, aka. Obamacare) was enacted over the objections of many who called it a "takeover" and "socialized medicine". Since then, those in opposition have been working to derail, defund, and repeal this federalized-health-insurance train. They may get some unexpected, but welcome help from the inevitable inertia and bickering that accompanies the birth of every large bureaucratic empire.
With the election last Tuesday, pundits have been proclaiming that the issue is finally put to rest. With Obama firmly in office, and the senate in Democrat hands the prospect of repeal is remote. The recent US Supreme Court decision upholding the constitutionality of the "mandate" swept away major doubts about whether the law could move forward. The public perception today is that the matter is settled. "Obamacare" is a done deal.
Nothing could be further from the truth.
Even if the PPACA had broad support, and no focused opposition, the normal process of a "rollout" would encounter institutional roadblocks, and would have to satisfy political interests that would be affected. The bigger the program, the bigger the issues that must be resolved, and this all takes time.
With the PPACA, the stakes are huge, so the institutional resistance will be massive. Because many of the actual rules have not even been issued (also read about delays here), real resistance has not yet appeared. "The secretary" (HHS Secretary Sibelius) is working hard to turn 2700 pages of legislation into detailed rules - an enormous undertaking. Many of the rules will have huge financial and political consequences. Rulemaking may happen, but it will not go smoothly. I will be shocked if Ms. Sibelius issues the PPACA rules anywhere near the required schedule to get everything ready for Jan, 2014.
In the next year, we will see citizens, hospitals, insurance companies, and corporations wrestle with these changes. Contrary to the promises of Mr. Obama that "if you like your insurance plan, you can keep it", thousands of businesses, and millions of Americans will see major changes in their insurance and medical care, and they will not stay silent about the changes they don't like. Corporations that spend hundreds of billions on insurance must come to terms with the many requirements and burdens that will be imposed by the PPACA. They won't go quietly, either.
As usual, others say this better than I do. A list of additional issues can be found here: Obamacare is Still Vulnerable.
Those who got this legislation through Congress are convinced that they are doing the right thing, and have little patience with opposition. They are determined to prevail. Their supporters often think of the PPACA as more of a crusade than a program. Proponents don't speak of costs and tradeoffs, but of rights and dire consequences. Debate often has flavor of a jihad, so I do not expect the PPACA's proponents to "see the light" when things come up in rulemaking that reasonable people might see as a reason to change direction.
On the contrary, I fully expect these "normal" implementation issues to be significant, but not sufficient to stop the PPACA. What I do expect is that all these factors will force the "rollout" of the PPACA to take much longer than expected, and every issue raised and overcome will highlight the inherent contradictions of the PPACA. Throughout the process, the implicit question will be: Do we really want the federal government running our health care?
November 6th, 2012 was a beginning, not and ending. I look forward to November, 2014.