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.” 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. 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.
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.
Polls conducted after the U.S. Supreme Court decision in the summer found that the support for the ACA has risen substantially since the spring. An ABC/Washington Post poll in July 2012 found that the U.S. public was equally divided: 47 percent of Americans opposed the law, the same number supported it. However, in April 2012 the same poll found that only 39 percent of Americans supported the law whereas 53 percent of Americans opposed it; thus 14 percent that previously opposed the law supported it in July 2012. Nevertheless, the ACA has never gained the support of the majority of Americans, with all major polls recording less than 50 percent of support since the law was passed. As a CBS News/New York Times poll found in June 2012, the law has satisfied neither the right nor the left. Thirty-seven percent said that the ACA went too far whereas 27 percent found that it did not go far enough, a finding which would explain the overall dissatisfaction with the law.
Polls also analyzed if health care and the reform play an important role in this election. Virtually all major polls find that the economy and the creation of jobs are at the forefront of voters’ minds. An ABC/Washington Post poll in May 2012 asked voters “What is the single most important issue in your choice for president?” The open-ended question was answered by 52 percent of respondents with the economy or jobs. While health care and the repeal of the law came in as the next most important issue, it was a very distant second with 7 percent. A recent analysis on “Understanding Health Care in the 2012 Election,” which appeared in The New England Journal of Medicine in October, looked at health care and the health care reform’s impact on voter preferences. This study found that if a question was not open-ended, but respondents were presented with a choice of issues, 20 percent “named ‘health care and Medicare’ as the most important issue in their 2012 voting choice.” While this is again far behind the economy and jobs (cited by 51 percent as the most important issue), the study also noted that “this is the highest that health care has been ranked as a presidential election issue since 1992.” Additionally, the study also found that 81 percent of voters consider health care to be a very important issue in the election if not their top concern. The polls and study show that while Americans are deeply divided about the health care reform, the economy remains the top concern and deciding factor for a majority of voters. However, the ACA as well as any decisions on the health care system in the U.S. have economic and financial consequences for businesses, citizens, and the federal budget.
Health Care After the Election – The Role of Washington…
Some key provisions of the ACA are phased in only after the presidential election: Barring health care insurance companies from discriminating adults based on pre-existing conditions or gender, for example, will only take effect in 2014. Additionally, the insurance exchanges will also only be established the same year. The insurance exchanges, a major component of the health care law, and other aspects will also only be established between 2013 and 2015.
Thus, the elections in 2012 will be a factor not only in the potential repeal of the health care reform overall, but also in the implementation of further aspects of the law from 2010. The administration and its agencies direct the provisions of the health care reform through rulemaking. But many of the rules on the ACA and even the 2014 implementation phase have already been finalized. Timothy Jost notes in his article “Dismantling the Affordable Care Act: What Could a President Romney and Hill Republicans Do?” that “a new administration could not simply ignore these rules […] [and] it could also not promulgate rules that do not comply with the ACA.” He does point out, however, that any new administration has discretion in issuing guidance. A Romney administration’s guidance for implementing the ACA would differ considerably from a second Obama administration.
Only Congressional action can repeal the ACA. It is therefore important to not only focus on the presidential elections, but also on the Congressional races. RollCall assessed the races in the U.S. Senate and House the following: Nine races for the U.S. Senate, in which a third of the Senators face election every four years, are considered toss-up races: Arizona, Connecticut, Indiana, Massachusetts, Montana, Nevada, North Dakota, Virginia, and Wisconsin. Twenty-four other races can be counted as leaning, likely, or safe for the Democratic or Republican Party, including two independent Senators. Thirty Democratic and thirty-seven Republican Senators do not face an election campaign this year. In the U.S. House, where all Representatives face re-election every two years, twenty-seven races are qualified as toss-up races. Twenty-five races are leaning or will likely go to Democrats, twenty-six races to Republicans. 159 and 198 races are considered safe for Democrats and Republicans, respectively. In the U.S. Senate, fifty-one seats provide a party with the majority, but sixty votes are required to override the President’s veto, as well as for several procedural votes (e.g., to end debate or to override a filibuster). In the U.S. House, 218 seats are needed for the majority. Analysts are predicting that the U.S. House will remain Republican and that the U.S. Senate will continue to have a Democratic majority. However, neither party will most likely surpass sixty votes in the U.S. Senate, making it highly unlikely that the ACA will be repealed even under a President Romney.
…and of the States
During times of presidential elections, journalists and analysts tend to focus on Washington and politics inside the Beltway, making it easy to forget the role of the states in U.S. politics. While the ACA was a federal law, states play a large role in implementing many of its provisions. Additionally, U.S. states had already been a laboratory for key provisions of the ACA before the health care law was even enacted and many states informed central aspects of the law. Minnesota, for example, is one of the most progressive states when it comes to health care. AICGS’ project on The Potential of Linking Quality of Medical Care with Payment Structures in the German and U.S. Health Care Systems included a discussion on Minnesota, a state at the forefront of implementing managed care. The health care providers in Minnesota are dominated by large, fully-integrated care systems of hospitals and primary and specialty care physicians. Additionally, all health insurers and hospitals have to be a non-profit entity. About 80 percent of providers use electronic medical records in Minnesota and the medical loss ratio is usually exceeded. Regardless of what the outcome of the presidential election is and what the U.S. Congress decides, many states such as Minnesota will continue to focus on initiatives to provide quality health care while lowering costs.
However, other states see the ACA as an overreach into states’ rights. In fact, the Supreme Court case was a suit brought by twenty-six states, led by Florida. While the attempt to strike down the entire law and especially the individual mandate to purchase health insurance, the U.S. Supreme Court did rule in the states’ favor concerning Medicaid. The law had initially included the ability of the federal government to withhold federal payments to states if they did not want to participate in the expansion of Medicaid (a federal-state program for poor and disabled people). The ruling stipulated that the federal government can only withhold funds covering the expansion of the program (if a state decides not to participate), not the entirety of Medicaid funds. Thus, states might option out of ACA’s Medicaid expansion, making this part of the law less effective and leaving some portions of the poor uninsured. If and how this will play out remains to be seen, the Medicaid expansion does not take effect until 2014. Some analysts have predicted that several Republican-governed states will not participate in the expansion, while others have pointed out that pressure by hospital lobbyists to gain access to the federal financial incentives might outweigh partisan preferences.
President Obama points to the ACA as a major achievement, providing all Americans with health insurance and thus addressing the problem of the vast numbers of Americans who are un- or under-insured. His challenger, Governor Romney, argues that the law threatens economic growth and increases the U.S. federal deficit. While most Americans are focused on the economy and job creation in this presidential election, the health care reform has galvanized both parties and ranks as the second most important issue for a majority of voters. Yet it is unclear how much the election and a new make-up of Congress will actually have an impact on the ACA. A Congressional repeal will require a landslide Republican victory in Congress and especially in the Senate. Yet if Governor Romney wins the election, guidance from his administration to the agencies on implementing ACA will be markedly different than under President Obama. Implementing the ACA fully goes beyond Washington, as many states have been at the forefront of health care reform for many decades now. Others see the ACA as governmental overreach infringing on state’s rights. As the debate on health care reform is only one part of the overarching discussion on the role of the federal government versus the states and individual citizens, these issues will continue to play a role in the U.S. even when the presidential election of 2012 is long over.
 Matthew Fleming and David Schultz, “Mitt Romney on Health Care,” Kaiser Health News, 1 August 2012.
 James C. Capretta, “Obamacare Remains a Budgetary and Policy Disaster,” The Heritage Foundation, 2 August 2012.
 Matthew Fleming and David Schultz, “Mitt Romney on Health Care,” Kaiser Health News, 1 August 2012.
 Press Release, “The Supreme Court, Health Care, and Immigration,” CBS News/New York Times Poll, 7 June 2012
 Timothy Jost, “Dismantling the Affordable Care Act: What Could A President Romney and Hill Republicans Do?” Health Affairs Blog, 20 September 2012
 For more on Minnesota’s health care initiatives, see Julie Brunner, “Collaboration in Health Care: Success Wherever You Are,” AICGS, 27 July 2012
 Jonathan Cohn, “Did the Court Undermine the Medical Expansion?” The New Republic, 29 June 2012, http://www.tnr.com/blog/plank/104510/supreme-court-roberts-ruling-on-medicaid-expansion-obamacare-impact
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