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What does the Democrats' Election Day "shellacking" tell us about the future of Obamacare?

Peter Suderman
Medical Progress Today
November 11, 2010

How much did the passage of the Patient Protection and Affordable Care Act hurt Democrats at the polls this year? And how will the changes brought on by the November election shape health care policy debates in the years to come?

As President Obama said the day after the vote, Democrats took a "shellacking" in the midterm election, losing 60 seats in the House and at least six seats in the Senate. Those losses came as poll after poll showed that more Americans opposed the health care overhaul—arguably the party's most significant legislative achievement—than supported it. Exit polls suggested that it was the second-most important issue for voters, after jobs and the economy. While it's always tricky to definitively isolate the effect of a single policy, even President Obama admitted, in a post-election interview on 60 Minutes, that the health care law had been "politically costly" for Democrats.

That wasn't what was supposed to happen. Prior to the health law’s passage, Democratic leadership confidently predicted that it would prove a political winner. A few days before the law passed, White House communications staffer Dan Pfieffer was quoted by The New York Times saying that "if and when this is passed, Democrats will run aggressively on this." President Obama's lead pollster took to The Washington Post to argue that critics of the law were misreading polls, and that evidence suggested that support for the law would turn around. "When it comes to health care and insurance, once reform passes, the tangible benefits Americans will realize will trump the fear-mongering rhetoric opponents are stoking today," he wrote. Even former President Bill Clinton, long hailed as a master of careful political judgment, argued that "the minute the president signs the health care reform bill, approval will go up."

But as we now know, the approval numbers didn't rise. Indeed, in recent months, approval across polls has dropped slightly. And a Kaiser Family Foundation Health Tracking Poll released the week following the election reported that just 25 percent of respondents believed they and their families would be better off under the law—the lowest number since Kaiser began the tracking opinions about the health care overhaul in February 2009.

So it's no surprise that Democrats didn’t run on the law either. Quite the opposite: In the mid-September, Politico reported that Democrats had spent more than three times as much touting their opposition to the law as advertising their support. The law's backers pointed out that a number of Democrats who voted against the law lost their elections too, but that hardly makes the case in its favor. In the end, pinpointing the precise effect of the law on the election remains difficult. But it's probably safe to say that Democrats who predicted that it would push the party toward political victory were wrong.

Predictable or not, though, those Democratic losses are now set to shape the health law's future. In particular, Republican victories at the state level will make implementing the law more difficult. Republicans strongly opposed to the health care law won governor's races in Pennsylvania, Wisconsin, Ohio, and Florida.

Republican governors could prove to be crucial players in the fight over the implementation of the law. That's because the law relies heavily on state governments to build and run its health exchanges—the government-run insurance marketplaces that each state is expected to build and run. Those exchanges are to be built under strict federal supervision, and because they will be responsible for determining whether an individual is eligible for publicly funded insurance subsidies, they could pose an enormous technical challenge. Governors in many states have already complained about the complexity involved in designing the exchanges. The law gives states the options to decline to build an exchange, but the alternative is to let the federal government step in and run it instead. Yet there may be a third option: Design exchanges that don't meet the strict federal standards, and then challenge the administration to shut them down. The theory is that if states can create successful, popular exchanges based on their own designs rather than federal rules, the Obama administration won’t risk political backlash by meddling with them.

Governors may also be instrumental in determining how the PPACA's Medicaid expansion proceeds. The law is projected to add 16 million individuals to the joint federal-state health insurance program. And although the federal government will pay for a large share of the expansion costs, the additional expense to states is still expected to be a burden; estimates put the cost to Texas alone at $27 billion by 2023. That's why Lone Star state officials are already reportedly considering a radical alternative: drop out of Medicaid, which remains a voluntary program, entirely. Instead, the state might pick up some of the slack with a state-run program. And after 2014, it could push many would-be Medicaid enrollees onto an exchange, where they would receive federal subsidies.

Meanwhile, a national-level debate will continue in Congress as well. Rep. John Boehner, who is expected to take over as Speaker of the House, has indicated that he will lead House Republicans in a tough procedural fight over the details of implementation. Sen. Tom Coburn has suggested that the way to oppose the bill is simply to bring repeal to a vote, repeatedly, and thereby force Democrats to stand by an unpopular law. Others have suggested that Republicans might attack the law's bankroll: Senate Minority Leader Mitch McConnell said that his office "is looking for the various parts of [the law] that are subject to funding."

McConnell also admitted, however, that legislative proposals to repeal or significantly alter the law would face a serious barrier in President Obama's veto. And Rep. Paul Ryan, the ranking Republican on the House Budget Committee, has said much the same thing, warning that, thanks to Obama's veto power, pushing too hard on the law's funding could lead to "stalemate." And a budget showdown could lead to a (likely unpopular) government shutdown, as happened in 1994.

Most Republicans, then, know that there are limits to how much they can affect the law. But they also know that Democrats passed the health care overhaul despite its consistent unpopularity, and took a "shellacking" at the polls later in the year. Expect the GOP to do its best to push those limits without risking a political shellacking for itself.

Peter Suderman is an associate editor at Reason magazine and a 2010 Robert Novak journalism fellow.

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