The Politics Of Obamacare After King v. Burwell

In the wake of the latest Supreme Court decision, the Affordable Care Act seems to have become even more firmly established than it was before last week, and the prospect of repeal has become even less likely.

congress-healthcare

As the dust has begun to settle after the Supreme Court’s ruling in King v. Burwell, there seem to be at least some perception that Republicans on Capitol Hill and elsewhere are breathing a sigh of relief:

Even as Republicans rose in a chorus of outrage Thursday over the Supreme Court’s refusal to gut the Affordable Care Act, party leaders were privately relieved.

Republicans were spared the challenge of having to come up with a solution for the 6.4 million Americans — most of them in conservative states — who might have found their health insurance unaffordable had the court gone the other way.

And as it moves into a presidential election season, the party can continue to galvanize the conservative base by railing against both the law and the high court.

“Every GOP candidate for the Republican nomination should know that this decision makes the 2016 election a referendum on the full repeal of Obamacare,” said Sen. Ted Cruz (Tex.), one of the 13 Republicans who have declared they are running.

At the same time, the court’s second ruling in favor of the five-year-old law has increased the pressure on Republicans to tell the country how they would fix the health-care system.

A Republican nominee for president will have to have a plan to replace the law,” said former Republican National Committee chairman Ed Gillespie, who in his failed Senate campaign in Virginia last year was virtually the only nationally prominent member of his party to come up with one.

David Winston, a pollster who advises the GOP congressional leadership, said, “Ultimately, the challenge for Republicans is not just how to deal with this law, but where’s the direction? Where are the alternatives?”

Republicans do have some ideas. They support, for example, the law’s provision preventing insurance companies from denying coverage to people with preexisting conditions and requiring them to allow parents to carry their young adult offspring on their policies. Most also argue for allowing insurers to sell policies across state lines.

Winston also pointed to a bipartisan proposal, advanced by House Energy and Commerce Committee Chairman Fred Upton (R-Mich.) and ranking committee Democrat Diana DeGette (D-Colo.), that aims to accelerate the pace of medical breakthroughs.

But none of the GOP proposals would go as far as the Affordable Care Act has in guaranteeing coverage, and many health experts say that a piecemeal approach would send health-care costs soaring.

One thing that is certain: The issue will not go away.

“ObamaCare is fundamentally broken, increasing health-care costs for millions of Americans,” House Speaker John A. Boehner (R-Ohio) said in a statement issued by his office. “Today’s ruling doesn’t change that fact.”‘

Indeed, the initial round of rhetoric after the court decision suggested that the ruling had further inflamed the right and given the growing field of Republican presidential contenders a new battle cry.

“Our Founding Fathers didn’t create a ‘do-over’ provision in our Constitution that allows unelected, Supreme Court justices the power to circumvent Congress and rewrite bad laws,” former Arkansas governor Mike Huckabee said in a statement while campaigning in southern Iowa.

“The decision turns both the rule of law and common sense on its head,” Sen. Rand Paul (R-Ky.) said in a statement. “As president, I would make it my mission to repeal it, and propose real solutions to our health care system.”‘

While the legal issues surrounding the law are, with the exception of a few minor issues, largely resolved the issue of the Affordable Care Act specifically, and how the health care and health insurance industries in this country are structured is most assuredly not going to go away any time soon. From the Democratic point of view, the fact that the PPACA even has it is structured leaves millions of people uninsured and without access to regular health care will still be an issue that candidates and activists talk about on a regular basis. To some degree, we will see that battle manifest itself over the issue of Medicaid and the largely Republican-controlled states that have declined to take part in the expansion of that program under the Affordable Care Act. Beyond that, one can already see movement on the left toward something more than the PPACA although it’s generally a topic you only hear from the likes of Vermont Senator Bernie Sanders.

On the Republican side, things are a bit more complicated. For the time being at least, it is going to be impossible for pretty much any Republican to take anything other than a “repeal” position on the Affordable Care Act for the foreseeable future, at least through the 2016 election cycle. One need only look at the example of John Kaisch, who managed to win election and re-election in the vastly important (from the perspective of Presidential politics) state of Ohio, and before that has a record on fiscal issues that made him a star on the right, but who know is largely derided on the right because he chose to support Medicaid expansion. It’s simply politically impossible for a Republican to take any position on the PPACA other than “repeal,” even though it seems exceedingly unlikely to happen. Even if a Republican wins the White House in 2016, any bill that fully repeals the Affordable Care Act will have to somehow get past the filibuster rules in the Senate. Given the state of play of Senate races in 2016, the odds of the GOP winning a filibuster proof majority are fairly low, so I wouldn’t put much hope in that possibility. There’s been some suggestion that Republicans may be willing to end the legislative filibuster altogether if the GOP wins the White House, but that seems unlikely for many reasons not the least of them being the fact that even Ted Cruz is against the idea. If Republicans don’t win the White House, then they would need to hold the House of Representatives and  a win veto-proof majority in the Senate in 2016. Since that’s unlikely to happen, you can pretty much write-off complete repeal off the table. What might be more likely would be a Republican sponsored bill that reforms significant parts of the PPACA while living much of the basic structure intact, but even that will require at least winning the White House, maintaining control of the Senate and making a deal with incoming Democratic leader in the Senate Chuck Schumer that convinces him not to lead a filibuster among his fellow Democrats. The most likely outcome it seems to me, though, is that eventually Republicans will shift from the position of trying to repeal the PPACA altogether, because they won’t be able to do it, and begin talking about reform of a law that even many of its proponents will admit could use some reforming. In that regard, I suspect that we will be seeing major Republicans advocating PPACA reform by the 2020 election, if not sooner than that.

In reality, of course, the political battle over Obamacare was over when President Obama won re-election in November 2012. At that point it was clear that Republican efforts to repeal the law before it went into effect in October 2013 would not succeed, meaning that millions of people would be signed up and receiving something from the programs established under the law well before the next opportunity to nullify the law would present itself. It’s also worth noting that the business community has largely accepted the law and adjusted to it, and the insurance and health care industries are strong supporters. Given all of that, it seems unlikely that a campaign centered around the repeal of a law that will have been in full operation for three years by the time the 2016 General Election takes place is going to be much of a winning message for Republicans. Perhaps I’ll be proven wrong about that, but it’s worth noting that the gap in the polls between those who approve of the law and those who disapprove has been shrinking in recently. That’s not to say that people are pleased with the state of health care, or that there aren’t serious issues on the horizon such as rising health care costs that will become issues in future campaigns. What it does suggest, though, is that a position of complete repeal and return to the status quo in March 2010 is not a winning political message in a General Election even if it might be one that is essentially required for anyone running in a primary in the Republican Party. Eventually, something is going to have to give in the inherent contradiction between those two truths, the only question is when it will happen and how Republicans will adapt to the new reality.

 

FILED UNDER: Barack Obama, Campaign 2016, Congress, Health Care, Hillary Clinton, Politicians, US Politics, , ,
Doug Mataconis
About Doug Mataconis
Doug holds a B.A. in Political Science from Rutgers University and J.D. from George Mason University School of Law. He joined the staff of OTB in May 2010. Before joining OTB, he wrote at Below The BeltwayThe Liberty Papers, and United Liberty Follow Doug on Twitter | Facebook

Comments

  1. sam says:

    “The most likely outcome it seems to me, though, is that eventually Republicans will shift from the position of trying to repeal the PPACA altogether”

    Sign seen at 2024 Tea Party rally: “Keep Your Government Hands off My Obamacare.”

  2. Scott says:

    As president, I would make it my mission to repeal it, and propose real solutions to our health care system.”‘

    Propose first, then we’ll see.

  3. Ron Beasley says:

    @sam: Good one Sam

  4. gVOR08 says:

    @Scott: Why wait. He has sixteen months of campaigning left. What do you you suppose the odds are he’ll make a serious proposal? Me too.

  5. Ron Beasley says:

    The popularity of the ACA is increasing even faster than Medicare did. In fact when people were asked about individual parts of the law they liked them from the beginning The Repuublicans feared the law because they were terrified that it would work and become a part of American society. Just look what happened when Bush43 tried to privatize Social Security – even most Republicans knew that wasn’t a place they wanted to go. By 2016 there will be 3 third rails in US politics, Social Security, Medicare and the ACA.

  6. Stan says:

    If I remember correctly, the New York Times used to discuss policy as much as it did politics. I wish the Times, the Post, or somebody, would study the ACA in detail rather than just report on how popular it is and how a few individuals, who may or may not be representative, are affected by the law. Here are some questions worth considering.

    1) How is the law financed?
    2) Not counting the Medicaid expansion, what is the additional tax bite per taxpayer due to enactment of the law broken down by income segments?
    3) In states that expanded Medicaid enrollment, what is the additional tax bite per taxpayer?
    4) How many people suffered financially due to the coverage requirements on procedures and medications mandated by the law?
    5) Did the law result in a shift from full time to part time work caused by businesses trying to escape the employer mandate?
    6) Have studies been made of the health and financial effects of the precursor of the ACA passed into law in Massachusetts under Governor Romney?
    7) What do hospitals and health care providers think about the law?

    Have studies of the type outlined above already been carried out? I have in mind a well known internet article by Ezra Klein reporting on the academic research of Uwe Reinhardt and colleagues on why medical costs are so much higher here than in Europe (Google “It’s the prices, stupid”). Is anybody doing reporting like that now?

  7. LaMont says:

    If the GOP were politically competent, knowing that the writing is on the wall concerning their current stance on Obamacare, they would pull the “switch-a-roo” and support single payer, call it something else that fixes Obamacare, and claim as much credit as possible for “fixing” the healthcare “crisis” Obama resided over in this country. In the process, they would look like bipartisan geniuses as the Democrats aren’t nearly as spiteful as the GOP is. Heck, their minions are so fixed on arguing on all that is wrong with Obamacare that they are practically supporting single payer today! The GOP has the propaganda machine well oiled. They could literally steal the show. It’s just too bad they have political simpletons for representatives – incapable of thinking ahead. They’re trying to play checkers during a chess tournament!

  8. J-Dub says:

    “Every GOP candidate for the Republican nomination should know that this decision makes the 2016 election a referendum on the full repeal of Obamacare,” said Sen. Ted Cruz (Tex.),

    So when Hillary wins, then Cruz will back down, right, since they lost the referendum?

  9. J-Dub says:

    @LaMont: Trump basically endorsed a single-payer system during his announcement speech when he said he would repeal Obamacare and replace it with affordable health care for all.

    Unfortunately he may have also promised that Mexico would pay for it somehow…

  10. J-Dub says:

    But none of the GOP proposals would go as far as the Affordable Care Act has in guaranteeing coverage, and many health experts say that a piecemeal approach would send health-care costs soaring.

    Leading to the new Republican tag line “I’m not a mathematician”

  11. stonetools says:

    Obama originally wanted Republican buy-in on universal health insurance, because he knew that it would very difficult to pass a big, complex program that changed one sixth of the economy.He wanted the Republicans to share the work of getting it passed, and also to share the credit.So he proposed a program modelled on conservative ideas of how to achieve universal health insurance , and why he made a deal with Big Pharma( we won’t pressure you on prices so long as you sit out the political struggle).
    Liberals howled, “Sell out!” about all this and and as late as December 2009 were calling on Democrats to “kill the bill.”Fortunately, Obama managed to get everyone on his side marching and firing guns in the right direction, and (just barely) passed the bill into law.
    Republicans responded to all this with scorched earth opposition, figuring that by calling it “Obamacare” ( code for “N!&&ercare”) and making up stories about how the ACA would undermine Medicare they would scare older whites into forgotting their economic mismanagement and voting Republican again. It worked at first. They swept the 2010 elections and gerrymandered themselves into a decade long House majority. They also did their best to sabotage the economy,screw up the government, and generally set the table for a Republican Presidential win in 2012.
    Fortunately for the good guys, Obama won in 2012 and Roberts couldn’t quite bring himself to ignore a century of constitutional law and kill the ACA in its cradle. Obama then shot himself in the foot with the botched ACA launch, but recovered and got the ACA up and running. Since then, the ACA has worked like the proverbial charm and has been such a success that by the time the second legal challenge came to SCOTUS, all but the truly pyschopathic right wanted to keep it going.
    At this point it looks like Obama’s decision to for universal health insurance and keep pushing for it, despite all opposition, has worked.The Republicans’ gamble of all out opposition looks like a failure. Obama and the Democrats get all the credit and the bragging rights for instituting the successor and complement to Social Security and Medicare, and the Republicans will be stuck opposing what is likely to be an increasingly successful and popular program.
    Well played, Mr. President .

  12. stonetools says:

    @Stan:

    Ezekiel Emmanuel wrote a book:

    Reinventing American Health Care: How the Affordable Care Act will Improve our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System

    LINK

  13. Tyrell says:

    @Ron Beasley: Repeal – no, repair – yes, and I’m not just talking about a new fan belt and oil change.
    Eliminate the penalty, tax, fee, fine, chains and whips, thumbscrews : whatever Judge Roberts calls it. Instead, use incentives such as discounts, free tickets, and special free coverages such as contacts and gym memberships.
    Offer more choices in terms of plans and deductibles. The federal employees have over 200 options. Certainly they can offer more than three plans.
    Get a better website and customer service. Evidently they have a requirement that you have to be handed off to no less than six telephone reps when you call.
    If this plan is what is requiring doctors to spend their day looking at a laptop instead of their patients, then they need to go back to paper instead of a laptop, or no more then five questions: name, address, phone #, ss #, and regular or decaf. Why do I have to check off on 37 questions about my parents health ? I am the patient in here, Doc, not them !
    Medicare popular ? I will let you know about that next year when I am on Medicare, relaxing on a sunny beach in Cuba taking advantage of Obama’s new Cuban policy.

  14. OzarkHillbilly says:

    @Stan:

    The answers are all out there if you care to look.

  15. Jeremy R says:

    Republicans do have some ideas. They support, for example, the law’s provision preventing insurance companies from denying coverage to people with preexisting conditions …

    One of the more disingenuous aspects of the post-ACA GOP healthcare “ideas” is they continue to pretend they can offer community rating with guaranteed issue, scrap any sort of individual mandate and not have premiums skyrocket. I don’t think I’ve ever seen a reporter call them on it.

  16. Stan says:

    @stonetools: “Ezekiel Emmanuel wrote a book:

    Reinventing American Health Care: How the Affordable Care Act will Improve our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System”

    Notice the word “will”. The law’s been in effect now for a few years. How has it worked out in practice? I’m a supporter of the ACA, but I’d still like to see a comprehensive study of how it’s worked out in practice.

  17. OzarkHillbilly says:

    Doug,

    What might be more likely would be a Republican sponsored bill that reformsSCREWS UP significant parts of the PPACA while living much of the basic structure intact, so that later on they can say, “SEE??? We told you it was a mistake from the get go!” You know that’s what they want to do and that’s what they will do given the chance.

    Also:

    or that there aren’t serious issues on the horizon such as rising health care costs that will become issues in future campaigns.

    Health care inflation has fallen off a cliff since the full implementation of the ACA. It is still early and time will tell if that holds but don’t be buying into all the Republican scare talk about policies doubling in cost. The insurers just submitted their proposed rate changes to the regulatory agencies and as they have always done they are asking for the moon and the sun and the stars. The process will sort things out, as it always has.

  18. stonetools says:

    @Stan:

    Nobody has written that book,but Ezra Klein and his crowd at Vox cover the ACA obsessively. Might want to follow them.

  19. Stan says:

    @OzarkHillbilly: “The answers are all out there if you care to look.”

    I do care to look, but fining informative articles isn’t easy. It strikes me as incomprehensible that a law as important as the ACA has been reported so poorly. I remember using my newly acquired literacy to read about World War II as it was happening in our family newspaper and talking about it with my parents. If it had been reported the way journalists are writing about the Affordable Care Act we’d find out what the public thought about FDR’s leadership and how happy Pierre DuPont in Bangor, Maine was about the Germans being kicked out of France. But we’d have no idea about what was happening on the battlefields.

  20. OzarkHillbilly says:

    @Stan: I just read this short piece from Krugman: Hooray for Obamacare

    It has lots of links that will take you to answers of at least some of your questions.

    This will take you to Vox: 7 charts that show what Obamacare critics are getting wrong

    This is from Think Progress: 5 Embarrassing Predictions About What Obamacare Would Do To The Economy

    They all have links to follow for more info.

  21. stonetools says:

    Here is a good Jonathon Chait article on why you can’t get much news on the ACA:

    In his remarks at the White House today hailing the Supreme Court’s denial of a right-wing nuisance lawsuit designed to cripple his health-care law, President Obama mused over why the public did not overwhelmingly approve of it. After all, the law is not only working as intended, but in some of the most crucial metrics — premium levels, federal budget costs — it is working considerably better than projected. Yet public approval has remained mediocre. The president settled on the fact that there are people benefiting from the law and they don’t even know it. There’s no card that says Obamacare.

    But there is another possible explanation. The law’s critics have consistently presented a much louder and more certain attack, and its supporters a more cautious and muted defense, and this has remained the case even though, on virtually every point, the critics have been wrong and the supporters right.

    If there is one thing Obama and liberals have earned a resounding F on , it’s messaging. They really could not have been worse-and not just on the ACA.

  22. Kylopod says:

    To do a full-scale repeal would mean immediately throwing millions of Americans off their health insurance, including millions of Republican voters. I simply don’t believe the GOP is stupid enough to do such a thing even if they win the trifecta in 2016. We already saw how panicked many Republican officials became when King v. Burwell was being decided. And that was only a partial repeal in roughly half of the states. And it would have happened while Obama was still president, when there was still some possibility of blaming it on Obama and getting at least some voters to agree. If they do it when a Republican is president, they’ll automatically own it in the eyes of the public.

    Some liberals I’ve been talking to over the past week act like I’m being naive, but that misses the point. I’m not saying Republican politicians aren’t draconian enough to do something like this. They most certainly are. What I’m saying is that they’re just not that stupid. If there’s anything the Republicans in power care about, it’s big business, and immediate repeal would have a devastating effect on the insurance companies. The only way they could possibly proceed is through some kind of gradual phase-out, but even than the companies would fight it tooth and nail. And that’s not something I believe the GOP is willing to do.

    It’s a little like the debt ceiling: they can talk a good talk but in the end they’re not going to deliberately blow up the whole economy to get their way. There are a core of Republicans who would do so, but they’re not the ones in front of the controls.

    In a way, all this talk of repeal is a distraction, since Republicans do still potentially have the power to do significant damage to health care. If they win in 2016, I’m sure they will do things causing many Americans (especially poorer ones) to lose their health care, and making it harder for others to gain access, all in the name of “reform.” Furthermore, what Doug mentioned before–how few Democrats are talking about ways to expand on the law (possibly even eventually creating a single-payer system)–is in part a result of their having been on the defensive in the last several years against the GOP’s attempts at repeal. That’s one of the more understated ways in which the GOP’s strategy has met with some success, even if it falls way short of their ultimate goal.

  23. Stan says:

    @OzarkHillbilly: Thanks.

  24. stonetools says:

    @Kylopod:

    If there’s anything the Republicans in power care about, it’s big business, and immediate repeal would have a devastating effect on the insurance companies.

    The best thing Obama ever did was to get buy in from some sections of big business. That, more than anything else saved it at the Supreme Court , IMO, and he did that over heated objection from the left.
    Realistically,defense is the only thing the Democrats can do on health care till the 2020 redistricting( and retaking the House in 2024).They might be able to tweak a few things, but that’s all the House Republicans will allow, and I think they’ll only allow that because the ACA will continue to become more popular over time.
    It’s a pity, because there are probably many things that could be done to improve the ACA. But the Republicans are locked into fighting the ACA to the bitter end. Fortunately, it looks like the end will be bitter for Republicans.
    The biggest applause lines for Clinton during the 2016 campaign will be “I pledge to defend the ACA!”. Republicans, meanwhile, will have to answer questions like “Do you really intend to abolish the ACA and take away health care from millions of Americans?” and “Why haven’t your predictions of doom come true?” Republican governors and legislatures are going to have defend not taking Medicaid expansion, despite there being no good reason for such refusal. Increasingly, its going to look like the Republicans made a big mistake in opposing Obamacare, or the ACA, as they will increasingly begin to call it. Hopefully, the Democrats will make the Republicans pay as big a political price as possible.

  25. stonetools says:

    The first national poll out there measuring reactions to last week’s two big SCOTUS landmark cases is out, from CNN/ORC. Unsurprisingly, it showed a majority of Americans agreeing with Oberkefell v. Hodges, though the percentage was higher than one might have guessed, at 59%. But surprisingly, an even higher percentage—63%—said they agreed with the finding in King v. Burwell that “government assistance for lower-income Americans buying health insurance through both state-operated and federally-operated health insurance exchanges is legal.”

    Yes, part of the reason for this result is that self-identified Democrats were more bullish about the Obamacare than the marriage equality decision. But the percentage for independents—long thought to dislike Obamacare by margins ranging from 2-1 to 3-2—was an identical 63%.

    This is a bag of hurt for the Republicans in 2016. Even the Democrats should be able to take advantage of this.

  26. humanoid.panda says:

    @stonetools: To be sure, it’s possible the support for the King decision is less about the ACA lawsuit, and more about the ridicilousness of using a drafting error to screw things around…

  27. Kylopod says:

    @stonetools:

    The best thing Obama ever did was to get buy in from some sections of big business. That, more than anything else saved it at the Supreme Court , IMO, and he did that over heated objection from the left.

    My impression is that Obama’s strategy for passing the health-care bill was to examine what Clinton did in 1993 and do the opposite. Not only did he keep a low profile during the crafting of the bill, he went to great lengths to make peace with the business community–both things that Bill and Hillary had neglected to do in 1993. It’s a little amazing to reflect that the bill still very nearly didn’t make it, courtesy of the Dems’ failure to keep their eye on the ball of Ted Kennedy’s former seat.

    I don’t think Obama or any of the other Democratic leaders anticipated that it would be challenged in the Supreme Court, let alone multiple times. I also don’t think they anticipated they wouldn’t get a single Republican vote. Otherwise they wouldn’t have wasted all those months trying to woo Olympia Snowe. I think they were expecting the bill to get at least a smidgeon of bipartisan support, and that after it passed the GOP would grumble but move on. It makes sense the Dems would have made all these assumptions; that’s how these things had always worked in the past. Furthermore, they probably accepted the conventional wisdom articulated by Bill Kristol in 1993, that once the government creates a major new social program it quickly grows in popularity and becomes immune to repeal. In short, I don’t think Dems had any idea of the holy war the GOP would wage against Obamacare after its passage.

    None of this is to say that I disagree with your conclusion that making nicey-nice with business ended up saving it in the Supreme Court. I’m just pointing out that the Dems probably weren’t thinking that far ahead when they crafted the bill this way, and were simply focused on the immediate task of getting it through Congress as so many previous administrations had failed to do.