Just the beginning

The rollout of the health insurance exchanges last week revealed a reality never mentioned by the Republicans on Capitol Hill who shut down the U.S. government. There is a huge, unmet demand for affordable health insurance in the U.S.

In its first two days of operation, more than 6 million people flocked to the website healthcare.gov to check out their options (See story). Millions more visited websites for the 17 states and the District of Columbia that are operating their own exchanges.

As expected, there were numerous technological glitches in the rollout. Maryland had to use to paper applications for people looking to sign up for one of their newly available options.

These wrinkles will be ironed out. As President Barack Obama said last week, Apple doesn't withdraw its products from the market when things go wrong. It sends out software updates. People who live in the 21st century understand that.

This is only the start of a process that will continue over the next six months and into the future. Crucial questions remain. If those who are initially flocking to the exchanges have huge pent-up healthcare needs—people with pre-existing conditions; people who have ignored routine health maintenance; families with children who have never seen a doctor—then the initial reasonable prices available on the exchanges may not last. The long-term success of the program depends on healthy people, especially so-called young invincibles, signing up for coverage.

Dissecting recent public opinion polls offers some hope that uninsured Americans from all demographic stripes will embrace buying health insurance rather than pay a fine. A Kaiser Family Foundation poll in June found that three-quarters of young people between 18 and 30 believed they need health insurance, and two-thirds worried about how they would pay for a serious illness or accident.

Nor is the evidence strong that the public is opposed to “Obamacare” and will turn up their noses at its offerings. Yes, a Wall Street Journal/NBC News poll last week found 44% of the public thought the reform law was a bad idea compared with only 31% expressing support and 25% offering no opinion.

Yet such polls can be misleading. The same poll showed the public trusted the president more than Republicans in Congress for handling healthcare issues by a 47% to 38% margin, but a share of the opposition came from people who have long advocated for a single-payer healthcare system. Indeed, an early September poll by CNN showed that nearly a third of the 54% of respondents who opposed reform did so because they didn't think the legislation went far enough. That suggests a healthy majority of Americans support expanding insurance coverage.

So what accounts for the virulent opposition on Capitol Hill that has disrupted government services and millions of lives? Do they really believe that requiring people to buy health insurance is unfair? We require people who drive cars to carry insurance. Do they really think it will destroy small business and ruin the economy? A few employers are changing their plans, but most changes in employer coverage such as the switch to high-deductible plans are evolutionary—and were underway long before the reform law came along.

Or is their real fear that this is going to work? If your only goal is keeping what you have—employer-based coverage—that is a legitimate concern. If it works, it is entirely possible that over the next few decades, most Americans will find themselves looking for healthcare coverage on the exchanges.

Skyrocketing costs have already forced a fifth of employers to adopt high-deductible plans that limit their contributions to employee healthcare coverage. Many more are taking advantage of private exchanges run by benefits consultants, where they give their employees a fixed amount of money to buy the plan that best meets their families' needs.

The fact that employers provide their workers with health insurance—a wage taken in the form of tax-exempt benefits—is an artifact of our history. Virtually no other industrialized country follows that model. If the reform law works, it may revolutionize the health insurance marketplace by making it more transparent and more truly a market where insurers compete for the loyalty and dollars of individuals and families.

What true conservative could possibly oppose that?

Merrill Goozner is the editor of Modern Healthcare.

Follow Merrill Goozner on Twitter: @MHgoozner