« November 2014 Issue

The Mid-Terms and the ACA: Implications for Health Care Advocacy

As the dust begins to settle on the 2014 elections, consumer health advocates are taking a moment to reflect on the role that health care played in the outcome, as well as the implications for federal and state health policy going forward.

Voter Attitudes on Health Care

It is pretty clear health care was a minor factor in terms of influencing the election outcome. Both the composition of the mid-term electorate—smaller, older and less racially and ethnically diverse than in 2012—and the geography of many of the contests account for much (though not all) of the electoral gains made by the Republican Party. In terms of issues, health care trailed far behind the economy as an area of voter concern. Some might have expected the rebounding economy would play to the advantage of Democrats. But persistent weakness in the labor market and stagnant wages have contributed to a much more negative outlook on the economy than you might expect if you just look at numbers like Gross Domestic Product growth or job creation. The majority of voters feel that the economy doesn't work for “people like them,” and they expect the future to be worse, not better.

When it comes to health care itself, voters attitudes are complex. A majority still has a negative view of the law, but most of the major provisions are still popular. Even though they don't like the ACA, a majority also opposes repeal (perhaps explained in part by the fact that a portion of ACA critics think that the problem is it doesn't go far enough). Generally, attitudes toward “Obamacare” and toward President Obama are very strongly correlated. 

Relatively few voters thought the ACA was a top issue, but among those who did, opponents outnumbered supporters by 2-1, reflecting a general difference in intensity between supporters and opponents. Finally, the problems of the initial Healthcare.gov launch (and perhaps the controversy over plan cancellations) appear to have done lasting damage to the president's popularity, which made him a marginal figure in the election as most incumbent Democrats sought to distance themselves from their party leader. Certainly the president was not able to mobilize voters the way he did when he appeared on the ticket in 2012.

Impact on Federal Policy: Is ACA repeal possible?

Although health care was not a large driver of the electoral outcome, the election could still have significant consequences for federal and state health policy. It is more likely that the shift will occur in the content of the political debate than in actual policy outcomes.

With regard to the ACA, we can expect the Senate to join the House in passing an ACA repeal bill or something very close to it. This will likely happen through the mechanism of budget reconciliation since the Republican majority will not have the 60 votes necessary to move a bill through the normal process. Notwithstanding the shift in party control of the Senate, ACA repeal has no more chance going forward than it had in the last Congress. However, specific provisions of the law, such as the medical device tax and some others, could be overturned.

Proposals to reshape other federal health programs such as Medicare and Medicaid could also advance through the budget process. Like proposals to repeal the ACA, such proposals can only become law with the cooperation of the Obama administration. In the past, the administration has shown itself willing to entertain changes to health benefit programs, but only in the context of a “grand bargain” that also included new tax revenue, a step that Republican lawmakers have been unwilling to take. If both the president's position and that of Congressional Republicans remain unchanged, there will be no major changes in health benefit programs.

In the States: Impact on Medicaid Expansion and Marketplaces

Finally in terms of states, persuading states to extend Medicaid to all low-income adults has become less likely in a few places, but prospects remain unchanged or have even improved in others. How incoming Republican governors in states like Maryland and Massachusetts will try to change the course set by their predecessors is a big unanswered question. But it is unlikely that new governors will abandon their state-based Marketplaces where they already exist, and a few are contemplating setting up their own Marketplaces.

Another Critical Supreme Court Decision

Finally, the biggest wildcard in health politics for the year ahead comes not from the election, but from the Supreme Court decision to consider King v. Burwell, which, if overturned, would prohibit people from obtaining tax subsidies in the federal Marketplace operating in 30 states. A ruling against the administration in King would almost certainly touch off chaos in insurance markets and a political firestorm as well.

Looking to 2016

While the outcome of the 2014 election was certainly disapointing to ACA supporters, it is more likely to result in the continuation of the status quo than to usher in any new direction in health policy. At the same time, given that both houses of Congress are now committed to repeal, we have to assume the ACA will not become accepted as a permanent part of the U.S. health system until after the 2016 election.

Michael Miller, Director of Strategic Policy