As America’s love-hate relationship with healthcare reform approaches its first anniversary, the law is proving just as divisive now as it was during the midterm elections. Fittingly, the Patient Protection and Affordable Care Act of 2010 (ACA), which has polarized the country, is moving forward along three separate tracks.
“Usually, at this point of the game one would only be worrying about the implementation,” says Leighton Ku, a health-policy analyst at George Washington University. “But, obviously, there’s been enough discord that the political route and the legal route are now equally important.”
Here’s a look at where the ACA stands from practical, political, and legal standpoints, along with the major players involved in the ongoing tussle.
The Battle of Public Perception
America is hopelessly divided. Despite pollsters’ best efforts to break the stalemate, the collective numbers still suggest that roughly equal numbers of respondents favor and oppose healthcare reform (with a slight advantage to opponents). It’s a trend line that has barely budged since the bill’s enactment last March.
In January, the Republican-led House of Representatives voted to repeal the entire reform act in what analysts have called a largely symbolic gesture, given that the repeal effort subsequently failed in the Democratic-controlled Senate. Even so, Ku says, the vote fulfills a Republican campaign promise and sends a strong signal to the party’s political base. “What’s driving the Republicans is that their constituencies really don’t like it,” agrees Robert J. Blendon, a professor of health policy and political analysis at the Harvard School of Public Health. “Almost all Republican congressmen who ran had on their website, ‘I will repeal this bill if elected.’ ”
But opposition doesn’t necessarily mean voters want everything repealed, a caveat also borne out by recent polling. “Where the public stands is a little more ambiguous than what the campaign rhetoric is,” Ku says. That ambiguity could present an opportunity for both parties to reframe the debate in the coming months in an effort to win over a clear majority of the public. With the economy of paramount concern, Republicans have cast healthcare reform as a “job-destroying” act that will speed the country’s descent into bankruptcy.
If the economy improves, however, opposition to the law is likely to soften. And with their “no” vote behind them, Republicans in the House will be expected to craft a coherent alternative to the legislation. “Now comes the tough part,” Ku says.
Democrats, meanwhile, have largely regrouped and are being more vocal about the law’s necessity—after a campaign season in which many conservative Democrats largely avoided talking about it, or even touted their opposition to it, and were beaten anyway.
In the absence of wholesale repeal, a few individual provisions might be stripped away. Most key elements cannot be defunded, although Republicans could cut funding streams to Health and Human Services (HHS) or the IRS to hamper implementation. Congress also could choose not to appropriate money to the estimated $106 billion worth of new spending authorizations. A sizable percentage of that pool covers popular pre-existing programs, however, which makes a “no” vote politically more risky.
A Matter of Time
The nonpartisan Congressional Budget Office has predicted that repealing the healthcare reform legislation would increase the federal deficit by $230 billion over the next decade. Even so, the law’s supporters are finding little traction among voters who have heard repeated claims by Republicans that the act itself will push the country deeper into debt (many Republicans say the CBO estimate is based on faulty numbers provided by the law’s supporters). One big reason why: The tanking economy has eroded public trust in the government. “The ratings of trust in the federal government are so low,” Blendon says, “you need a stethoscope to try to hear them.”