The healthcare industry heaved a collective sigh of relief last week after the U.S. Supreme Court upheld insurance subsidies in states using federally run exchanges. The 6-3 decision effectively puts an end to legal challenges to the Affordable Care Act.
And while the political war over the ACA is far from over, Democrats defending the law now hold the upper hand.
In the short run, Republican leaders on both sides of Capitol Hill have few political levers for changing the law. Anything major is certain to draw a veto from President Barack Obama. In his Rose Garden statement shortly after the high court decision, the president said his signature achievement is now “woven into the fabric of America.”
There is plenty of evidence to justify that statement. The uninsured rate for adults under age 65 in the U.S. has fallen to its lowest level on record, according to the Centers for Disease Control and Prevention, and it will fall even farther after the next enrollment season. Even with 21 states refusing to expand Medicaid, the reality is that Obamacare is working.
Getting a bill to the president's desk to undo that progress would require overcoming a filibuster in the Senate. And while Senate Majority Leader Mitch McConnell of Kentucky could use the reconciliation process to force through legislation, that process is reserved for tax and spending bills.
In the next few months, we might see McConnell lead a move to repeal the ACA's medical-device tax or the so-called Cadillac plan tax on high-cost employer health plans (many Democrats and their union supporters back those efforts). But other than increasing the federal budget deficit, neither would undermine the insurance exchanges or Medicaid expansion, which are the defining elements of Obamacare's coverage expansion.
As we head into the 2016 election cycle, it isn't clear what slogans will resonate with the American electorate. Every announced Republican presidential candidate and many unannounced ones attacked the high court's decision. They repeated the GOP's pledge to repeal and replace the law should they win the White House and maintain control of Congress in the 2016 elections.
But here is where the GOP rhetoric runs into the stubborn realities behind the ACA. The law always was and still remains the conservative approach to universal health insurance.
The premium subsidies in the law are necessary to preserve the role of private insurance as the primary way of providing coverage to the tens of millions of low- and moderate-income working Americans whose employers do not offer health insurance. To make that market work while also covering people with pre-existing medical conditions, the law mandates that individuals and businesses buy and provide coverage, respectively, and it fines those who ignore the mandates.
Absent those mandates, the individual insurance market would enter a death spiral where healthy individuals would drop coverage, sicker people would remain in the pool and rates would skyrocket. Chief Justice John Roberts highlighted that reality in his decision.
Yet the mandates are what the GOP has placed highest on its list of things to repeal. Politically, it's not a stupid move. A February HealthDay/Harris Poll that drilled down into the specifics of the ACA found the American public rejected the individual coverage mandate by a 52% to 28% margin.
But public support for the rest of the legislation remains strong, proving once again that Americans are politically conservative yet operationally liberal.
The public supports the employer mandate by a 52% to 27% margin, almost the exact inverse of the individual mandate. It supports guaranteed issue of insurance by a 70% to 15% margin. It supports keeping the exchanges by a 59% to 18% margin. It supports keeping subsidies for low-income people by a 58% to 22% margin. It supports expanding Medicaid by a 42% to 28% margin.
The inside-the-Beltway wisdom continues to assert that the American people are opposed to the ACA, largely because of amorphous political questions in Kaiser Family Foundation and Gallup polls that ask whether people support the law or not without giving specifics. Yet even here, the results are trending in favor of the law.
Given last week's court decision and the likelihood that another 10 million uninsured people will be added to the insured ranks by the time next winter's primaries roll around, there's reason to be hopeful that the weave of Obama's fabric—no matter what the outcome of the 2016 elections—will become a lot tighter in the years ahead.