Health Care, Again

During Bill Clinton's first administration, commentators began to condemn the "permanent campaign": Even after an election was over, officials continued to obsess over political positioning and media coverage instead of getting down to the hard business of governing. To see how the health-care reform that was passed earlier this year is talked about, you might think we've entered into a condition of permanent legislating, when even after a bill is signed into law, the battle goes on.

That's because there are now people and organizations on the right that have made it their mission to destroy the Affordable Care Act. Fortunately for them, many of the ACA's most consequential provisions won't take effect for three more years, leaving ample time -- and potentially multiple swings of the political pendulum -- for them to hack away at the act's trunk and limbs in the hopes of felling the entire tree. Their chances of success may be slim, but that the effort is being undertaken at all tells us something about how politics is practiced today.

When the ACA passed in March, many commentators -- myself included -- predicted that because it was now a law, support for it would naturally increase. Instead of being something abstract about which nightmare scenarios could be invented, health-care reform would be an actual set of programs with which people would be interacting. Their own experiences would outweigh whatever new falsehoods Republicans invented.

While I think this will still end up being the case in the long run, it hasn't happened yet for the simple reason that so few people have had any kind of practical interaction with health-care reform. As you no doubt recall, reform's most consequential components -- the requirement that all Americans carry insurance, the establishment of the exchanges where people can purchase it, the subsidies for those with moderate incomes -- don't take effect until 2014. Nevertheless, Sept. 23 will mark six months since the bill was signed, and on that day, some of the most popular provisions will take effect. Insurance companies will no longer be able to deny coverage to children because of pre-existing conditions, and all children will be eligible to stay on their parents' plans until age 26. The despicable practice of "recission," in which insurance companies cancel people's coverage when they get sick, will be outlawed. And the companies will no longer be able to impose "lifetime caps" on coverage (another way they avoid paying for people's care when they get sick).

All these provisions are wonderful, but they affect limited numbers of people. Take the outlawing of lifetime caps, for example. When people reach those caps, it's usually the result of a catastrophic illness or injury, where treatment costs can run up to six or even seven figures. That's an unusual event, which will probably happen once in each of our lifetimes, if at all.

So if you're the White House, you'd like people to view these new restrictions on insurance abuses as a blanket of security under which they're now protected. That is the goal of the Health Information Campaign, a group set up by progressive allies of the administration to continue advocating on behalf of the ACA. The campaign's first ad, called "Not Anymore," reminds people of some of the things insurance companies used to be able to do to you but no longer can.

But they're facing a passel of conservatives advocating that the ACA be repealed. The Heritage Foundation has what it calls a "grassroots" effort to repeal the ACA. Former New York Gov. George Pataki, perhaps contemplating a run for the presidency, has a group called Revere America, which will be targeting members of Congress who voted for the ACA with ads claiming that among the reform's horrors is "your right to pick your own physician taken away." (Sure, it's an outright lie -- but maybe it sounded more plausible than "Obamacare requires you to give your children's blood to illegal-alien vampires.") Meanwhile, Republicans in 40 state legislatures have introduced "nullification" measures saying that the ACA won't apply in their state. Most of the measures have either been voted down or failed to move through the legislative process, but six have passed. And of course, there are the various lawsuits seeking to have the Supreme Court declare the law unconstitutional (see here, and here, and here).

The nullification measures and lawsuits stand on laughably thin legal foundations. But is there really much of a possibility that the ACA will be repealed? The short answer is no. In order to repeal it, Republicans would have to pass a repeal through the House and the Senate (overcoming an inevitable Democratic filibuster), then, once President Barack Obama vetoes the repeal, obtain a two-thirds supermajority in both houses to override the veto. That won't be possible even if they were to take back both houses in this November's election. Even if a Republican were to win the White House in 2012, the GOP would still need to overcome a Senate filibuster to do so.

But most important is that repeal is something the Republican leadership is obviously a bit skittish about. As a consequence, while they will say they favor repeal, in practice they haven't exactly been beating the drums for it. Writing in National Review, the Cato Institute's Michael Tanner lamented that "over in the Senate, a bill by Jim DeMint (R., S.C.) to repeal Obamacare has attracted only 21 cosponsors, meaning that 19 Republican senators have not yet committed to repeal. ... Individual candidates have, of course, made it an issue. But national Republican spokesmen have not invested the issue with a sense of urgency."

That may be because they have been reading the polls carefully. While slightly more people say they oppose the law than say they favor it, the number of those who want to repeal it is significantly smaller than the number of those who say they aren't happy about it. For instance, in the Kaiser Family Foundation's latest health-care tracking poll, 43 percent of respondents said they had a favorable view of reform, and 45 percent said they had an unfavorable view. But when those with unfavorable views were asked whether the law should be repealed or "given a chance to work, with Congress making necessary changes along the way," the number sticking to repeal fell to 30 percent of the total. Other polls have produced similar results, with the proportion of Americans favoring repeal consistently in the 30s -- or, in other words, the size of the Republican base.

If Republicans haven't made repealing the ACA a central component of their electoral strategy, it's in part because repealing the ACA would constitute doing something. Republicans have avoided at all costs any detailed discussion of what they might do if they win back Congress. As a political strategy, it's perfectly reasonable: If this fall's campaign is just about whether people are dissatisfied, Republicans win. But if the campaign involves any kind of extended discussion of the Republican agenda, things look a lot less certain.

Since the beginning of this debate, the greatest fear on the right has always been that health-care reform would not only pass but work. If it did, it would join Social Security and Medicare as not just cornerstones of a progressive social infrastructure but as weapons Democrats can use against Republicans. That's still conservatives' greatest fear, but for now, there's only so far they're willing to go to forestall it.

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