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Obamacare isn't dying. What now?

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(Bloomberg) — Imagine that someone had told you a year ago what Obamacare would look like in April 2014.

Let’s say he predicted that the number of people with health insurance would rise, but by much less than the Congressional Budget Office was projecting.

Much of this increase would come from putting more people on Medicaid rather than from the commercial “qualified health plans” (QHPs) sold through the public exchanges, which were supposed to be the centerpiece of the Patient Protection and Affordable Care Act (PPACA).

He went on to predict that President Barack Obama would feel compelled to let people stay in insurance plans that don’t comply with PPACA’s regulations, and he would decide to delay several parts of the law. That the law would turn out to discourage work, in part by making it pay less. That it would remain unclear how many states were going to have stable exchanges. And that Obamacare, already unpopular, would get a little more so.

That would have been seen as a pessimistic forecast. But that’s what happened.

My point isn’t to take away from the administration’s achievement in recovering from the disastrous rollout of the online insurance exchanges, which is genuinely impressive and a real boost for the White House in terms of both politics and policy. It’s to provide some perspective on that achievement.

This is not a success story. It’s a survival story.

It looks like more than that only because, for a few weeks in October and November, the rollout made Obamacare’s collapse seem like a possibility. The website fiasco was a development that almost no one, on either side of the debate, had predicted.

Now that it’s resolved, the debate continues basically along the same lines that everyone expected a year ago. The law will continue to be implemented, with the administration making whatever revisions it thinks necessary. Opponents will continue to criticize it but be unable to repeal or significantly change it as long as Democrats hold the White House. Supporters will hope that it gets more popular, or at least more entrenched, as more people receive benefits from it.

A year ago, when almost everyone expected the law to expand coverage, there were reasons to doubt it would become popular as a result. Those reasons still apply. A lot of people are going to lose access to their doctors, another round of premium increases is likely, and some employers will drop coverage. Obamacare won’t be responsible in all cases, but it will be responsible in many and blamed in many.

As it becomes clear to opponents that the law is not going to implode on its own, they’ll have to come up with proposals to replace it when they have the power. This is already happening. Last week, Louisiana Gov. Bobby Jindal became the latest Republican to outline a plan.

Some Republicans, however, think proposing their own health-care ideas is a mistake because it distracts from the case against Obamacare. And even those who think it’s important to advance alternatives are divided on a key question: How important is it that a replacement plan increase coverage?

More people would have coverage under Jindal’s plan than under the pre-Obamacare system. But compared to Obamacare, people would lose coverage. Does that matter?

Jindal notes that Medicaid may not improve physical health outcomes for its recipients. Insurance coverage does, however, yield a measure of financial security. For many years, federal policy has suppressed the emergence of a market that would enable almost everyone to purchase protection from catastrophic medical expenses. Undoing those policies — especially by redeploying existing federal tax breaks to help the uninsured — would allow such a market to develop. A proposal by Republican Senators Tom Coburn, Orrin Hatch and Richard Burr that uses this approach could cover more people than Obamacare does.

The higher-coverage alternative seems like a better bet for the law’s opponents, both from the perspective of winning the 2016 elections and that of actually enacting an alternative. It seems unlikely that Congress would pass legislation to strip coverage from millions of people.

Even if opponents of Obamacare eventually agree on that point, devising an alternative is only the beginning. It will still be necessary to strike at the Affordable Care Act’s weak points. The tax on people who don’t buy insurance is one of them. It is both the law’s least popular feature and a window into its coercive heart. Congressional Republicans should keep pressing on this issue.

One way of doing so: Replacement plans should make sure to include an amnesty for anyone who runs afoul of that tax. That’s my advice, free of charge, for Obamacare opponents in politics – - especially any of them who are thinking about running for president.

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