One thing is clear: Obamacare will fail if he doesn’t start paying more attention to the details of implementation, if he doesn’t start demanding action. And, in a larger sense, the notion of activist government will be in peril—despite the demographics flowing the Democrats’ way—if institutions like the VA and Obamacare don’t deliver the goods. Sooner or later, the Republican party may come to understand that its best argument isn’t about tearing down the government we have, but making it run more efficiently.
Matt Yglesias discusses the Republican alternative.
If your priority is to minimize federal expenditures, then obviously giving everyone very low-quality health care is better than giving high-quality health care. But it's like saying that your affordable housing policy is to hand out tents so people can sleep in the park.