Health-care reform: speed bump or road kill?

Obama at the Wall Street Journal CEO Council annual meeting on November 19.

Implementation of health-care reform continues to suck all the oxygen out of the Washington media echo chamber, where even the 150th anniversary of Abraham Lincoln's Gettysburg Address can become a political football.

The debate is whether 'Obamacare' is fixable or in a death spiral.

Given the current media frenzy, conservative commentators are having the easier time of it.

Megan McArdle of Bloomberg View lays out two reasons why she thinks the future of health care reform is so tenuous.

First, in order for Mr Obama's programme to work, the public must have faith in the government-run "exchanges," where they can choose from a range of private-sector insurance offerings. If people lose this trust, they'll stay away, and a lack of participation will cause the reforms to fail.

Second, she notes, Democratic legislators and insurance companies need to co-operate to hold the system together. If one side bolts - either voting to repeal key portions of the law (Democrats) or refusing to offer plans on the exchanges (insurers) - things could fall apart quickly.

But like that staple of game theory, "the prisoner's dilemma," both parties have a compelling incentive to be the first to jump ship.

"If insurers stand strong but politicians end up repealing the mandate, then they will have lost a bunch of money for nothing," she writes. "If politicians stand strong but insurers raise prices and/or exit the market, they'll get slaughtered at the polls."

Many conservative commentators also are predicting another round of the kind of turmoil that struck the individual insurance marketplace, where some policies have been cancelled because they do not meet federal minimum coverage standards. This time, the employer-based insurance market will be disrupted, affecting a significantly larger portion of the American public.

Cue more dominoes falling, as employers either pass along cost increases or cancel coverage entirely.

"Millions, then, will not only get herded into the ObamaCare exchanges; they will also lose the benefit of their employer sharing the cost of their health insurance premiums," writes John Nolte for

As things get progressively worse, writes Josh Kraushaar in National Journal, Democrats who up to this point have shown "unfailing loyalty to the president" will break ranks to save their political hides.

"More than anything, politics is about self-preservation, and the last two weeks provided numerous examples of how public opinion has turned so hard against the law that even its most ardent supporters are running for the hills," he writes.

Meanwhile, on the left, most arguments in defence of the reform programme are predicated on a big "if": If the Federal health care exchange (and the troubled state exchanges, like Maryland's) are operating soon, the government and insurance companies will be able to start their massive planned advertising campaign to get people to sign up for insurance.

"This is still all about money," writes Greg Sargent in the Washington Post. "If the administration can make the website more or less functional, expect insurers to resume their huge push to entice people to enroll."

As more people sign up, it will be harder to roll back the reforms. Brian Beutler in Salon writes that this is already happening in states that have successfully operating exchanges.

Democratic legislators who already may find it difficult to turn their backs on a programme to which they will be inextricably tied, whether they abandon it now or not, then decide to weather the current political storm. By the time elections roll around in November 2014, the law will be established.

"Modifications to the legislation will surely occur in the future, but major steps toward repeal such as rolling back the Medicaid expansion, withdrawing insurance subsidies, shuttering the exchanges or allowing insurance companies to again deny coverage to consumers with pre-existing conditions seem improbable absent catastrophic, years-long failures far beyond what we've seen to date," writes Brendan Nyhan for Columbia Journalism Review.

Two sides. Two very different views on what happens next.