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With enrollment over, real debate can begin

There’s going to be a lot of arguing about Obamacare in the coming days and weeks – even more so than usual, that is. Monday was the last day for people to sign up for health insurance for this year.

Supporters will claim that the late surge in enrollment proves the Affordable Care Act is a success, while opponents will counter that continued technical glitches and last-minute changes show the law to be a failure.

As much as this tedious debate deserves to end, it’s unlikely to as long as Democrats and Republicans live and breathe (and need health care). It’s possible, however, that the end of open enrollment will allow for the start of a better, more important debate: about how the new law works and how it can be improved upon.

Now that the rush of enrollment has passed, the challenge is to identify and respond to at least three kinds of concerns.

The first involves relatively narrow problems with the law itself. For example, many state-run exchanges are poorly run; states such as Maryland and Massachusetts need help to fix them in time for the next open enrollment period, which starts in November.

The law’s programs to cushion insurers from excess risk may also need reinforcement – if not enough young people sign up for insurance – to lessen any shocks to premiums next year.

That leads to the second kind of problem – with the health care system generally.

This includes persuading still more young people to sign up next time; getting more doctors and hospitals to coordinate care, making good on the promise to make medicine more affordable; and smoothing the transition from employer-based coverage for people who lose it.

None of this occurs in a political vacuum, of course, and this is the last and most expansive challenge. (It’s also one reason that the debate about Obamacare is not going away.) If the Affordable Care Act could be said to have a single purpose, it would be to extend health care insurance to people who cannot afford it. That it does so in such a convoluted way is not a bug, as they say in computer science, but a feature: It’s the politics that enabled the law’s very existence.

That said, it has proved difficult – to put it mildly – to expand coverage to poor people in states that reject the law. Some states may well follow New Hampshire’s lead, reversing their initial opposition to the expansion of Medicaid.

But if the federal government’s current strategy of exemptions and semantic dodges proves unequal to the task of gaining Obamacare purchase in states such as Texas or North Carolina, its architects will need to look for an alternative. Spending $1.3 trillion in health care subsidies for the middle class while leaving many poorer Americans with no options threatens the moral basis for the whole undertaking.

There’ll be time enough for that debate. The Affordable Care Act isn’t a gambit that wins or loses – certainly not yet.

It’s a long-term and complicated response to a longer-term and more complicated problem, the solution to which cannot be found through the tiresome debate about Obamacare’s numbers.

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