Over the last four years, President Barack Obama’s most significant bill was the 2010 Affordable Care Act (ACA), which introduced a major reform of the U.S. health care system. Although most provisions of the bill were affirmed by the U.S. Supreme Court in summer 2012, Republican opposition to the bill has been significant. The Republican majority in the U.S. House of Representatives has voted thirty-three times since its signing to repeal the ACA, but the House’s efforts have been stymied by the Democratic-controlled Senate. Not surprisingly, health care reform plays a significant role in the U.S. election campaign in 2012.

The design of the health care system in the U.S. is fundamentally a question about the role of government. The debate focuses not only on the role of citizens versus the federal government, but also about the rights of the individual states versus Washington. The ACA has become the watershed between the different camps and this has characterized the first two Presidential debates as well. President Obama sees the ACA as a governmental tool to support and aid citizens; additionally, he and Democrats believe that the ACA is an important step to begin to limit health care costs, which have exponentially risen over the last decades and thus have impacted the U.S. economy. Governor Mitt Romney and Republicans, who understand the ACA as on overreach by the government, argue that the law increases the federal budget deficit and reduces the rights of the individual citizen as well as the states. In a debate between Republican candidates, Governor Romney called the ACA “a huge power grab by the federal government. It’s going to be massively expensive, raising taxes, cutting Medicare.”[1] Arguing that the ACA burdens U.S. workers, insurers, and manufacturers of medical products with new taxes, a recent Heritage study estimates that these costs will reach $1 trillion over the next decade, resulting in higher prices and a loss of jobs.[2] Governor Romney has pledged to allow states to opt out of ACA provisions and to work together with Congress to repeal the law. He has advocated for strengthening state’s rights and for allowing each state to come up with solutions to rising health care costs on their own. Additionally, he prefers market dynamics to play out, which he asserts will improve the health care system.[3]

Public Opinion

Most Americans agree with the Republican opposition to the individual mandate. A Kaiser Family Foundation poll from April 2012 found that only 30 percent of Americans favor the individual mandate. Yet, the other components of the ACA are much more popular: for example, 60 percent of respondents supported the requirement for insurance companies to provide coverage even to people with pre-existing conditions, 61 percent support the prohibition of gender rating, and 66 percent favor the expansion of Medicaid.[4]