When the US Supreme Court, in a narrow five to four decision, upheld President Barack Obama’s 2010 health reform law in June, many Republicans, though disappointed with the ruling, felt the court had handed them a winning election issue.
The law, the Patient Protection and Affordable Care Act (ACA), remains unpopular with many voters, and Republicans saw the court’s decision as an opportunity to make the upcoming election a referendum on the act, which they had dubbed derisively as Obamacare.
“If we want to get rid of Obamacare, we will have to get rid of Obama,” said Mitt Romney, the Republican candidate for president, after the court’s decision. Romney has repeatedly promised to act to repeal the law on the day he takes office, should he be elected.
Since the court’s decision, the Republican strategy has been “to just hammer on the unpopular aspects of the ACA and deflect any questions about what they would do in place of the law,” said Bradley Herring, associate professor in the Johns Hopkins Bloomberg School of Public Health’s department of health policy and management in Baltimore. “You talk about the law taking money out of Medicare; you talk about death panels; you talk about the unpopular individual mandate.”
The Democrats’ defense had been hampered because the law is complicated and because many of its important provisions that Democrats believe will be popular do not come into effect until 2014.
In the meantime, the Democrats’ strategy has been to focus on the popular provisions that have been implemented, said Herring, such as provisions that guarantee coverage for children with pre-existing conditions, allow young adults to remain on their parents’ health plans until they turn 26, and give patients on Medicare, the federal health insurance plan for seniors, substantial savings on prescription drugs.
The Ryan effect
The debate shifted, however, when on 11 August, Romney announced his vice presidential running mate would be Republican Paul Ryan.
Ryan, a congressman from Wisconsin, is the architect of a budget plan that would slash federal spending, including spending for Medicaid, the federal-state health insurance plan for poor and disabled people, and would convert Medicare from a defined benefit plan, which currently pays for most essential health services, to a defined contribution plan, which would provide seniors with a voucher to help them purchase coverage from private insurers. The voucher would cover the cost of lower cost plans, but seniors would have to pay for higher cost plans themselves.
Ryan argued the voucher plan would help slow the rise in Medicare costs by encouraging insurers to compete for the seniors’ business. Democrats contend that it will merely shift the cost of care to seniors, who will have to pay more and more out of pocket as the costs of care rise over time.
The problem for the Republicans is that both Medicare and Medicaid are extremely popular. In a poll taken by the Kaiser Family Foundation shortly before the Republican national convention, for example, 58% of respondents said they thought Medicare should “continue as it is today, with the government guaranteeing all seniors the same set of health insurance benefits.”
Even among Republicans, support for the status quo was strong, at 55%. Among people aged 65 and older, a crucial voting block that has been leaning towards the Republicans in recent elections, support for the status quo ran at 71%.
The Democrats saw their opening, says Herring, and they “pivoted to an attack on Congressman Ryan’s Medicare proposal . . . scaring people with how terrible his reforms will be.”
Although Romney says he has his own plan, he has warmly endorsed the Ryan budget and, according to his campaign’s website, Ryan’s Medicare proposal “almost precisely mirrors” his own.
Given the Republican commitment to drastically reduce the size of the federal budget, there is no doubt that, if elected, they would substantially cut Medicaid and “voucherize” Medicaid, said Joseph White, chair of the department of political science at Case Western Reserve University in Cleveland, Ohio. “This election is as much about Medicare and Medicaid as it is about the Affordable Care Act,” White said.
The Republicans had a Medicare attack of their own, charging that the Democrats had cut $716bn (£440bn; €551bn) from Medicare to pay for Obamacare, a charge the Democrats have called dishonest because the savings in the law come from reductions in payments to hospitals and providers and do not affect the benefits that seniors receive.
Going into their national conventions, Obama and Romney were running neck and neck in most major polls. At their convention last month, the Republicans repeated their attacks on the ACA, though Romney in his acceptance speech made only one specific reference to the act—promising to repeal and replace Obamacare—and repeated the charge that the Democrats had cut $716bn from Medicare. However, he made no mention of his plans to reform the program.
The following week, the Democrats came out strongly in defense of the law, even embracing the term Obamacare, and savaged the Republicans for having a plan to “end Medicare as we know it.”
In his acceptance speech, Obama hit the “Romney-Ryan” Medicare plan hard: “Yes, we will reform and strengthen Medicare for the long haul, but we’ll do it by reducing the cost of healthcare—not by asking seniors to pay thousands of dollars more,” he said.
Unlike Romney, who saw little or no bounce in his poll numbers after the convention, Obama saw his support increase by as much as 6% in some post-convention polls. Although Romney’s pollster and senior strategist, Neil Newhouse, dismissed the Obama surge as a transient “sugar high” in a 10 September memo, the president seems to have pulled ahead of Romney in most polls, at least for now.
Surveys reported last week indicate Obama maintaining or extending his lead, nationally and in key states. An average of available surveys compiled on 21 September by the political news website Real Clear Politics shows Obama leading 49.4% to 44.9% nationwide as well as in crucial swing states, such as Florida, where he leads 48.1% to 46%; Iowa, 48.1% to 46.3%; and Colorado, 48% to 45.9%.
Most of these surveys were taken before news broke about the speech Romney gave to wealthy donors at a $50 000 a person fundraiser in May in which he spoke disparagingly about the 47% of Americans who do not pay federal income tax, many of whom are working poor, elderly people, or soldiers serving in combat who pay other federal and state taxes.
In the surreptitiously recorded video released by the magazine Mother Jones, Romney said this 47% was made up of people who are “dependent upon government, who believe that they are victims, who believe that government has a responsibility to care for them, who believe that they are entitled to health care, to food, to housing, to you name it.”
These people will vote for Obama, no matter what, Romney went on to say, “so my job is not to worry about those people—I’ll never convince them that they should take personal responsibility and care for their lives.”
His comments, which have been widely perceived as damaging, have been denounced by the Democrats and even disavowed by many members of his own party.
Down ticket races
Polling trends in the “down ticket” Senate and House races also appear to be looking up for the Democrats, including in several swing states.
Going into the election, Republicans felt confident they could keep their majority in the House of Representatives and that they had a good chance at capturing the Senate.
In the Senate, the Democrats, who hold only a three vote majority, have to defend 23 Democratic seats, while the Republicans have only 10 seats to defend. A shift of just four Senate seats could give the Republicans control of both chambers.
Prospects for a Senate takeover have dimmed for the Republicans somewhat, however. In Arkansas, support for Republican representative Todd Akin, who was challenging Senator Claire McCaskill, a vulnerable incumbent Democrat, plummeted when he said in a radio interview women do not get pregnant as the result of “legitimate rape.”
In Maine, Angus King, a former independent governor who is likely to vote with the Democrats, is doing well in a race to fill a seat left vacant when Senator Olympia Snow, a moderate Republican, chose not to run again. And in Massachusetts, a recent poll put Democratic challenger Elizabeth Warren ahead of Republican Scott Brown, a first term senator.
Democrats are so buoyed by the recent polls that some party leaders are even claiming that they might take back the House of Representatives, and House minority leader, Nancy Pelosi, a Democrat from California, credits voters’ concerns over the “Romney-Ryan” Medicare plan for the turnaround.
“We have been saying there are three important issues in this campaign,” Pelosi said in a recent CNN television interview. “And in alphabetical order, they are Medicare, Medicare, Medicare.”
Most analysts, however, believe it is unlikely that the Democrats can win the 25 seats they would need to reclaim the majority, and given that there are still eight weeks of campaigning and three presidential debates, the race is far from over.
Should the Democrats sweep the election, implementation of the Affordable Care Act will go forward smoothly, says Professor Charles Zeldon, an expert on American legal and constitutional history at NOVA Southeastern University in Fort Lauderdale, Florida, but if the Republicans hold onto the House, they will fight implementation “tooth and nail.”
Even if Romney were to win the presidential election and tried to move to the center, he would find his “hands tied” by congressional Republicans, who have taken an ideological position that brooks no compromise, Zeldon said.
Opposition is also likely to continue at the state level. Several governors said they will not set up health insurance exchanges, which will create marketplaces for individuals and small businesses to purchase health insurance, or expand Medicaid to cover more of the uninsured, even though the federal government is picking up most of the tab for the expansion.
But Patricia Gray, director of research and external affairs of the University of Houston Law Center and a former Texas state legislator, thinks even her conservative governor, Rick Perry, will eventually fall into line.
The law has just too many provisions that are popular with consumers and providers for the Republicans to repeal it, said Gray. “This train has left the station.”
Indeed, in what appeared to be an attempt to move to the center after the election, Romney said he’d keep many of the popular provisions of Obamacare. The comment caused an uproar among conservatives, and Romney’s staff tried to walk the comment back the next day.
But if the Republicans do repeal the law, said Gray, “then they own healthcare in this country and they’ve got to figure out a way to fix it—and you can’t do it with vouchers.”
Overview of the Affordable Care Act
The Patient Protection and Affordable Care Act of 2010 seeks to reduce the number of Americans without health insurance as well as reorganize the US healthcare delivery system to improve quality and cost effectiveness.
Provisions of the law roll-out over several years. Elements already put into place include provisions that:
Forbid insurers from denying coverage to children with pre-existing conditions
Allow young adults to stay on their parents’ health plans until they turn 26
Fund “high risk” insurance pools for adults who have difficulty finding coverage because of pre-existing conditions
Create a program to help businesses subsidize high cost retired people aged 55-64, who are not yet eligible for Medicare.
The most important changes under the law, however, come into effect in 2014. These include:
Subsidies and tax incentives to encourage businesses to provide health insurance for their employees and for individuals without employment based coverage to obtain their own
Creation of health insurance “exchanges” to serve as market places where individuals and small businesses can easily shop for a variety of plans
Expansion of Medicaid to allow non-elderly people whose income is less than 133% of the federal poverty level ($24 352 for a family of three in 2010) to enroll.
Under the law, all Americans would be required to obtain insurance or pay a fine. This “individual mandate” provision is highly unpopular and a key element of the lawsuit challenging the law’s constitutionality.
In a five to four decision last June, however, the US Supreme Court ruled the fine was not a penalty, which it would have considered unconstitutional, but a tax, which was constitutional.
However, the court did rule unconstitutional a provision of the law that would have denied Medicaid funds to states that did not implement the Medicaid expansion as mandated by the act. Several state governors have said that their states will not participate in the Medicaid expansion program.
Cite this as: BMJ 2012;345:e6413
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; externally peer reviewed.