Debate and the Affordable Care Act is no new combination. Signed into law by President Barack Obama in March 2010, the healthcare reform law passed the House of Representatives and the Senate without a single vote from a Republican lawmaker, setting up Obamacare to be the most divisive issue of his administration. Over the reform’s four-plus-year transformation from a campaign promise and healthcare theories to political reality, the Affordable Care Act has played a major role in deepening the rift between Republicans and Democrats. The law’s complexity has lent itself to over-exaggerations by both parties, which, even after the cornerstone provision of the reform — the insurance marketplaces launched last October — has left the American public unsure of its ramifications. The Congressional Budget Office is also unable to fully calculate how the reform will impact the country’s finances in coming years, mostly because so many details of the Affordable Care Act, including the employer insurance mandate, are still in flux. That reality leaves voters largely pessimistic and more open to a barrage of campaign literature both bashing and lauding the reform’s impact on American healthcare system.
To be a success, the Affordable Care Act depends on the proper functioning of essential cogs that, together, make up the massive and complex system of reform. Early measures of the effectiveness of the insurance exchanges at reducing the number of unemployed Americans have showed positive results. But quantifiable measures of performance pillars of the reform have yet to come together to form a coherent narrative of how the Affordable Care Act has improved (or hurt) the American healthcare system. Unanswered questions remain; namely, how sustainable is the individual insurance mandate over the long-term? The budgetary impacts of Obamacare, and its ability to lower overall healthcare costs in America, are still subjects of much debate. As always, the Obamacare debate is not limited to concerns raised by healthcare policy wonks.
Noting that the Obamacare debate has cast a dark shadow over American politics may seem unnecessary, but it is still important to examine how the reform will inform the campaigns of incumbents and challengers, Republicans and Democrats, and representatives and senators. The 2014 congressional midterm elections will be an important checkpoint in the life of the Affordable Care Act. True, analysts will not be able to wake up the Wednesday following election day and say unequivocally that the American cast their ballots in support of the healthcare reform, or to oppose it. However, Obamacare is an important strand in the American political narrative.
Obamacare may not occupy the same position in the national consciousness as it did last fall when the faulty launch of the insurance exchanges created great public outrage, but the broad-based dissatisfaction in the federal government expressed by the American electorate has been profoundly colored by the fight over the healthcare reform. So the main story of November’s elections may be that loss of confidence. Yet, the impact of Obamacare on voters can not be discounted. After all, it is the greatest reform to the American healthcare system since the 1960s when President Lyndon Johnson signed Medicare and Medicaid into existence.
1. Midterms Will Be More About Obama Than Obamacare
Pew Research found that approximately half of all voters say Obama’s performance as president will influence how they will cast their ballots come November; 29 percent of those respondents noted that they consider their ballot a vote against Obama, while 19 percent said they consider it to be a vote of confidence for the president, who has seen his approval rating run in the low 40 percent range so far this year.
Important moments in the history of the Affordable Care Act have been linked to dips in the public’s approval of his job performance; Obama saw the lowest job approval rating of his presidency during the 16-day shutdown of the federal government, a crisis brought about by the inability of Republican and Democratic lawmakers to agree to the funding of Obamacare. On October 1, both the insurance exchanges launched and the government’s fiscal year began, giving Republican lawmakers what they thought was an opportunity to derail implementation. Implementation proceeded, although not smoothly.
With both the political posturing that characterized the fight over the implementation of the Affordable Care Act and the technical flaws that prevented possible insurance consumers from enrolling for exchange insurance through the federal government’s healthcare website, the Affordable Care Act — Obama’s pet reform — did little to win the public’s approval. As October waned, Obama’s approval rating continued to drop, hitting 40 percent during the week of November 18, according to Gallup, nearly the lowest the firm has recorded.
2. The Big Obamacare Battle Has Already Been Fought
During the government shutdown crisis, when 46 percent of Americans thought the healthcare reform to be a poor policy, Republican lawmakers cited constituents’ disapproval of Obamacare as the reason they refused to approve any spending bill that “funded” the Affordable Care Act. In an interview with CNN last September, Texas Senator Ted Cruz, who had campaigned vigorously for fellow Republican lawmakers to vote against any spending proposal that funded Obamacare, said that what he wanted was “to keep the government running and at the same time to deal with the harms, the millions of Americans who are … at risk of losing their healthcare, are facing skyrocketing insurance premiums.” Now, more than eight months after Obamacare insurance policies have gone into effect, with fears of premium price hikes and budgetary problems remaining, it would seem the midterm elections should be a moment of reckoning for Congress. Yet, it appears, that midterms will not be another battleground.
3. Midterm Voters Have Already Made Up Their Minds About Obamacare
Of course, as measures of public sentiment, midterm elections are inherently flawed; typically, voters in congressional midterms tend to be older, more conservative, whiter, and more passionate about the issues. This year, Pew has found that voters are even less engaged than usual. July survey results revealed that while 40 percent of voters say they are more enthusiastic to cast their ballots than in previous midterm elections, 45 percent said they are less enthusiastic — a measure that has not been so high since 1998, when the scandal surrounding Bill Clinton’s affair with Monica Lewinsky was dominating the news. Still, 34 percent did say that national issues — rather than local issues or a candidate’s character and experience — will make the biggest difference in their vote for Congress. Only 7 percent of voters said that their November choice will be primarily based on a candidate’s political party. Together, low voter enthusiasm, anti-incumbent sentiment, and concerns over national issues suggest voters are not merely looking through Obamacare goggles.
It is true that Obamacare has not been drawing headlines as it did last October and November when the website’s malfunctions produced outcry (and a congressional inquiry), and the government shut down for 16 days. Headlines are now split between fears of coming premium rate hikes and the steadily declining uninsured rate. But while affordability and accessibility that the Obamacare insurance exchanges brought to the individual market have decreased — the uninsured rate in the United States dropped from its third-quarter 2013 peak of 18.0 percent to 13.4 percent in the second-quarter of this year — that is not the full story of how the Affordable Care Act has changed the American healthcare system. Research conducted by Kaiser Family Foundation for its July Health Tracking Poll showed that over half the public has an unfavorable view of the Affordable Care Act, an increase of eight percentage points since June, while the share of Americans who view the law favorably held steady less than 40 percent. The constant stream of negative press the Affordable Care Act has left its mark, as survey data shows. A statistic, like the dropping uninsured rate, cannot combat fears of rising costs for many Americans.
“The ACA starts from a place of wanting to make sure that all individuals can obtain affordable insurance, even if they have a prior medical condition,” wrote Aaron Carroll MD, MS, director of Indiana University’s Center for Health Policy and Professionalism Research in a 2012 blog post. “But if you guarantee access to insurance to everyone and mandate that people with preexisting conditions can’t be charged higher rates than their healthier peers, you need to prevent adverse selection (having relatively sicker individuals more likely to buy insurance coverage rather than relatively healthy people) and people gaming the insurance market (forgoing coverage and enrolling only when they become ill) — thus, the mandate that everyone must purchase insurance or pay a penalty. And if you demand that people buy insurance, then you have to make sure they can afford it. That’s why you have subsidies,” he argued. “The plus is that many more people get access. The negative is that it costs people and the government money. That’s the trade-off.”
That trade-off is not justifiable to many lawmakers and voters. Yet, these issues are by no means new additions to the debate.
4. Voters Want Congress to Do Something, Not Bicker
The July Health Tracking Poll showed that large shares of the American public would prefer Congress to pay more attention to other issues like the economy and jobs, the federal budget deficit, education, and immigration. But at the same time, the popularity of the healthcare reform has ticked down in recent weeks, largely because the public hears more criticisms of the Affordable Care Act than praise in both political advertisements and personal conversations, and that gives GOP candidates ammunition. Since Obamacare is one of the key issues that defines Republicans from Democrats in the current highly polarized political environment, the reform will still play a role in campaigns for November’s elections. Even though voters have shown themselves to be broadly pessimistic and anti-incumbent, and the healthcare reform’s popularity has stabilized at around 40 percent, Republicans remain focused on attacking the Affordable Care Act because it appeals to a portion of the party’s voter base.
Nonpartisan political handicapper Stuart Rothenberg has argued the GOP should not run entirely on a platform against Obamacare. “I think the cake has been baked on the (Affordable Care Act),” Rothenberg said on CNN’s State of the Union several months ago. “I don’t think there are a bunch of people changing their opinions now.” Sure, a number of polls predict Republicans will be able to capture the Senate majority, but as Rothenberg suggested, that might not be the campaign tactic to move the American electorate from its collective lethargy. Obamacare’s ills may be “a fine message,” but candidates and incumbents have to “talk about growth and jobs and what the President does or has not done,” he added.
So Why Is Obamacare Still Part of the Midterm Narrative?
Yet, Republicans continue to follow a pollster-recommended, focus-group-tested script. The message now is more nuanced than the one pushed before millions of Americans gained coverage thanks to the reform. The reality is that Republicans have to bear in mind that now eight million of potential voters enrolled for coverage through the exchanges, and that fact has complicated the party’s repeal efforts. This is not to say that the most fundamental tenant of the healthcare reform debate is changing; Democrats still argue the healthcare reform is the most ambitious social program implemented in the United States since Medicare was passed in the 1960s, while Republicans still say it has put the United States on the slippery slope to socialism and a destroyed healthcare system. Still, Republican lawmakers up for reelection need to appease those voters who want Obamacare repealed without alienating their more moderate constituents. More importantly, the party’s leadership is aware the same arguments against the individual insurance mandate can no longer be made. Instead of concentrating on repeal efforts, Republican candidates are discussing how the law is hurting consumers, government budgets, or the economy.
Anti-Affordable Care Act rhetoric does have value. “Opposing Obamacare is a reinforcing issue that helps re-energize their base of voters but it does not move a lot of new voters to them,” said G. Terry Madonna, director of the Center for Politics & Public Affairs at Franklin & Marshall College, in an interview with the Daily Beast. Generally, most Americans will have made up their minds about the healthcare reform. “The messages that work best are succinct, clear statements about the effects of Obamacare on consumers directly,” including increased insurance costs and taxes, and lost jobs, added Whit Ayres, president of North Star Opinion Research, a Republican polling firm that has surveyed likely voters to determine the best way to campaign against Obamacare. While the message has changed, it is no less critical. “Remember, this is a midterm with low turnout,” said Larry Sabato, director of the Center for Politics at the University of Virginia. “Candidates on both sides are playing to their base and hoping for a large boost from them in fundraising and votes. You don’t accomplish that by watering down the message.”
It is also important to note that the Democrat party has not yet fully recovered from the poor job the administration did conceptualizing and selling the reform, and that includes the botched roll-out of the insurance exchanges. But even while the Republican party message on Obamacare has highlighted the reform’s potential to damage the economy, personal finances, and the healthcare system, some vulnerable Democrats in red states have subtly endorsed Obamacare’s main objective. Take embattled Democratic Senator Mark Pryor of Arkansas for example; an advertisement sponsored by his campaign presented his vote for the reform positively, focusing on one aspect of Obamacare that has really helped many Americans: the rule forcing insurers to no longer deny coverage or charged prohibitively expensive rates to customers with so-called preexisting conditions.
“Mark’s insurance company didn’t want to pay for the treatment that ultimately saved his life,” said the senator’s father, the popular former senator David Pryor, explaining how insurers treated his son after a cancer diagnosis. “No one should be fighting an insurance company while you’re fighting for your life,” noted Mark Pryor. “That’s why I helped pass a law that prevents insurance companies from canceling your policy if you get sick, or deny coverage for preexisting conditions.”
Pryor’s campaign advertisement clarifies several points about Obamacare’s role in the midterms. As Republican pollsters have noted, the Affordable Care Act has been so politicized that any further debate on the subject will do little to sway those who do not directly benefit from the reform — which Gallup’s surveys have show to be a relatively small number. Instead of Obamacare backlash, the story of the midterm elections is the same stagnation impacting Washington. The American public has little confidence the country is on the right direction and voters in both parties express anti-incumbent sentiments. The fights over Obamacare may be a strong example of the political mess that has been the federal government’s status quo over the past several years, but the divisiveness of reform, to some degree, is just a manifestation of greater problems.
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