Are the worms turning? While cries of repeal are still echoing in some quarters, doubt about the enterprise is beginning to seep through. Senator Bob Corker (R-TN) has publicly argued that repeal is not realistic (later clarifying he meant as long as Obama is in office), and the Chamber of Commerce, one of the interest groups most active in opposing reform, has also said it will turn its attention from repeal to influencing the regulations and pushing amendments. The Chamber is also planning to spend tens of millions of dollars to elect candidates friendly to their positions (which generally means not those who voted for health reform), but there’s little doubt that they would do that with or without passage.

More about the walk backs here and here and here.

Essentially, repeal is a nonstarter unless Republicans control both the White House and 60 Senate seats (or are close enough to 60 to make a deal with conservative Democrats). Threatening to “defund health care reform” if they take control of Congress is similarly hollow (Wonk Room says why.)

As we said last week, repeal isn’t in the interest of most of the health care industry (they’re helping to back Enroll America) or that of the employers (who doth protest too much.) Repeal is, at bottom, the rallying cry of  ideological extremists and their financial backers who oppose a set of policies embraced by many Republicans in the 1990s at Mitt Romney just a few years back-–policies well to the right of Richard Nixon. (For the record, it gave me the CREEPS to write that.)

Although the repeal caucus is becoming more marginal, the walk back from repeal doesn’t in any way mean smooth sailing for reform. (Speaking of sailing, watch our video valentine to health reform advocates.) Along with the Chamber, insurers are suiting up for the implementation game. The industry sent over 1,500 representatives to a recent meeting of the National Association of Insurance Commissioners (who number 50). The NAIC will have a major role in structuring the Exchange and the law’s insurance reform provisions.

And big employers are already squawking about the fact that the law closes a loophole in the Medicare Part D statute that allowed them previously to deduct from their taxable earnings the portion of retiree health benefits cost subsidized by the federal government.

This is the brave new world of our next four years: powerful special interests focusing their fire on specific provisions that they find objectionable, while repeal remains “red meat” to rile up the far-right voters. Better get used to it and dig in for a long fight.

A closer look at public opinion post-reform: Is there a bump from this Baby? (Maybe, but it’s not really showing yet.)

On his recent trip to Maine, President Obama chided the media for their obsessive focus on the popularity of health reform, saying the new law must be given time to work.

But, if anything, the importance of public opinion is growing post-passage. During the legislative cycle that just finished, public opinion mattered, but was only one among many factors that influenced the outcome. The real decision makers were Congressmembers, who are influenced not only by voters, but by donors, advisors, party leaders and other folks who want stuff.

In the election (spin) cycle we are entering, voters are the decision makers. And what they think about health reform in 2010 and 2012 will, in part, determine who is in a position to make the key decisions about implementation. Right now, voters are pretty evenly split on the question of whether passage was a good thing for the country. On balance, they believe that reform will help someone other than themselves and are worried that that help will come at their expense.

The public also holds internally inconsistent views about the role of government in health care, with majorities simultaneously believing that there is too much government involvement in health care, that health care reform didn’t do enough to check the power and potential abuses of insurers, and that there should be a public insurance option available.

One factor in public opinion that could have big mid-term consequences is the age divide. The majority of younger voters support reform, but older voters, who tend to be a relatively larger fraction of the mid-term electorate, are more negative on reform.    And while younger voters are more likely to care about other things (e.g. unemployment), health care is a more pressing issue for older voters.

These older voters’ critical role in midterms helps explain why one of the first things out of the box is help for seniors facing high prescription drug costs. Starting this year, Medicare beneficiaries who enter the “doughnut hole” coverage gap in Medicare Part D will receive a $250 rebate—giving seniors a tangible benefit to weigh against the fear of future change that has been stoked by opponents throughout the debate. (Remember the death panels?)

Although it is still a long way from election day, right now it looks likely that Republicans will make big gains in the midterms in both houses, though still fall short of wresting control of either chamber away from the Democrats. With narrower margins to work with at best, we can expect future [positive] tweaks to reform to come via the budget reconciliation process.

Deconstructing the kids pre-existing condition brouhaha In the run up to reform, Democrats touted the elimination of pre-existing condition exclusions for children as one of immediate benefits of reform. Then, shortly after passage, there was a brief argument about what the provision actually meant: Did it mean that insurers could no longer refuse to cover a family based on a child’s pre-existing condition? Or did it only mean that if they covered a child, they could not impose an exclusion? (Prior to passage, there was quiet concern about the ambiguity of the provision, but it did not reach the media). After a stern letter from HHS Secretary Sebelius, insurers—who had briefly asserted the more narrow interpretation—quickly folded their tents and agreed to the more expansive view.

Why? Was the law clearly on the side of the administration, or was something else at play? (If you guessed the latter, give yourself a star.)

First, staging a fight to defend their right to deny coverage to sick kids is a bad PR move for the insurers. Second, insurers don’t really oppose reform overall (Enroll America, remember?)

Third, and most importantly, insurers retain the ability until 2014 to vary premiums based on the “experience,” or expected cost, of enrollees with significant illnesses. Until then, the immediate win for kids with pre-existing conditions is less meaningful than it first appears. So score it as a PR win for the administration and insurers, and a small step forward for children with pre-existing conditions. No Fooling Has Senator Tom Coburn (R-OK)been spending too much time with Congresswoman Michelle Bachman (R-MN)? Last week, Sen. Coburn admitted to being paranoid. “This may be a little paranoid, but I think they know it’s going to fail,” Coburn said. “Then we’ll go to a single payer system like Western Europe.”

(Upon hearing Coburn’s comments, Dennis Kucinich is rumored to have said, “From his mouth to God’s ear.”)

–Michael Miller, director of strategic policy