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National Politics|By Amy Walter, April 3, 2013

Washington is currently consumed with guns and immigration, but come 2014 it’s possible that health care will be the more all-consuming issue, and that has lots of Democrats very worried.

After five years of demagoguery, political spin and hyperbole on both sides of the debate, the Affordable Care Act is finally set to go into effect January 1, 2014. Open enrollment begins this October.

Already, however, some health industry groups argue that many Americans should expect to see their premiums rise.

Last week, the Society of Actuaries released a study that predicted that “the overwhelming majority” of those who purchase health care directly on the individual health market “will see double-digit increases.”

America’s Health Insurance Plans, a trade association representing the health insurance industry, contends that “the new health insurance tax, costly benefit requirements and age rating restrictions will drive up the cost of coverage for many consumers and employers. When this happens, many younger and healthier Americans could decide not to get coverage, which would further drive up costs for everyone else.” Robert Zirkelbach, AHIP’s spokesman, says the “success of health care reform depends on whether coverage is affordable and if people choose to get it.”

The Urban Institute, however, pushes back on these claims with their own study that argues that “claims by some in the insurance industry” that the age-rating restrictions will have “dramatic implications for the out-of-pocket costs of young adults are unfounded.” They argue that young people will be insulated from a health care “sticker shock,” noting that most will be able to apply for federal subsidies or will be covered by an expanded Medicaid program.

Even so, there are plenty of Democrats who are worried that the roll-out will fall flat, or worse.

In an informal poll of Democratic insiders, many of whom shepherded Democrats thorough the dismal 2010 elections, almost all voiced concern about the potential for the issue to hurt Democrats in 2014.

“It is a concern that many of us have voiced,” said a prominent Democratic pollster.

“It is the question,” said a Democratic House strategist, “no one really knows.”

Most Americans know little to nothing about the details of the new health care law either. A recent poll by the Kaiser Family Foundation found that more than half (57 percent) of Americans “say they do not have enough information about the ACA to understand how it will affect them.”

In addition, the lack of awareness rises to two-thirds “among some of the key groups the law was designed to help: the uninsured (67 percent) and those with incomes below $40,000 (68 percent).”

The drawn out implementation process and the politicization of the issue for the last few years are contributing factors to the lack of awareness by the public about what the law will and won’t do.

But some of the blame also falls on the Obama Administration. Despite millions spent by HHS in 2012 on TV advertising explaining the benefits of the new law, the Administration has spent very little time preparing Americans for the realities -- and potential bumps in the road -- of the new law. Obama’s win in 2012 was seen as a victory for his health care law. Yet, his campaign spent very little time promoting it.

Elizabeth Wilner, Vice President of Kantar Media's Campaign Media Analysis Group (CMAG) –- and a Contributing Editor of The Cook Political Report -– tracked campaign TV ads in 2012. The Obama campaign, she notes, made almost no mention of the new law in their television advertising. “[U]nless you were watching Spanish-language TV, you wouldn’t have known the ACA existed,” she said. “They used it mainly in ads aimed at Latinos among whom the law is more popular than it is among whites.” In fact, Wilner notes, Obama’s first 60-second spot, “Go,” listed all his big accomplishments except the ACA.

Then there’s the question of whether expectations among those without health care are simply too high to be adequately met. There's also the potential for a very chaotic operational process for consumers.

Cost and implementation are just two of the things on which that voters will judge ACA. Other things include whether the plans are comparable to what many people have (e.g., are people going to find that they are paying more for less), availability of providers, and quality of care.

The silver lining for House Democrats is that even if things do go horribly wrong, few vulnerable Members who voted for the ACA in 2010 are left in Congress. Most of those members were wiped out in the 2010 tea party tsunami. Only ten potentially at risk Democrats who voted for the bill in 2010 are still in the House: Kirkpatrick (AZ-01), Maffei (NY-24), Shea-Porter (NH-01), Bishop (NY-01), Garamendi (CA-03), Owens (NY-21), Perlmutter (CO-07) Rahall (WV-02), Schrader (OR-05), and Tierney (MA-06). Even most of the Blue Dog Democrats who voted against the bill in 2010 are no longer in Congress.

The Senate, however, is a different story. Red state senators like Mark Begich (AK), Mary Landrieu (LA), Mark Pryor (AR), and Kay Hagan (NC) have never had to defend their “yes” votes in an election year.

Will they want the President in their state in 2014 encouraging enrollment? Or would they rather keep him and the issue at bay?

Meanwhile, says Kantar’s Wilner, beyond the basic economic issues of jobs/spending/taxes, “Obamacare” was the single most mentioned issue in Republican TV advertising, not just for president but all the way down the ballot.

Yet, the fact that Republicans lost seats in the House and Senate in 2012 has Democrats like media consultant John Lapp saying that the GOP’s “Obamacare” messaging has run out of gas.

“The more people experience the Affordable Care Act in reality -- as opposed to the fictional bogeyman Republicans created in 2010 -- the better,” says Lapp. “After spending millions on that tired, old playbook in 2012, you’d think they would have retired it by now. Republicans are becoming the chicken little of health care. The sky isn’t falling, and in fact, people are starting to see the benefits of Obamacare. Politically, Republicans are actually vulnerable for trying to take away critical patient protections that hold insurance companies accountable.”

Even some Republicans agree that they have to move beyond knee-jerk calls for “repeal” which can be a turn-off to Hispanics and women voters.

To be sure, even those who are deeply steeped in the ACA are unsure of how the implementation process will go and how Americans will respond to it. There’s likely to be a full-court press by the Administration to educate the public about the new plan. Also expect to see the pro-Obama political organization “Organizing for Action” get into the action. OFA spokesperson Katie Hogan tells us that OFA “will be deeply involved with many other groups around ACA enrollment later this year.” And, of course, those opposed to the law will be doing all they can to draw attention to any and all flaws of the process. For some people, any of these things can trump cost.

But, all agree it is an issue that will be getting a lot more attention -- and should be paid attention to by everyone running in 2014.