Nearly half of Americans think the Patient Protection and Affordable Care Act is a bad idea. While more than 50 percent of Americans supported the law in January, as of September, that number had dropped to the high thirties. And, the midterm elections are mere weeks away. Could Republicans get what they've been asking for where it concerns the PPACA?
While for the average voter, healthcare as an issue has declined in importance since January of this year, it's certainly not irrelevant. When asked specifically about the healthcare law in a July poll, 55 percent of voters would favor a candidate who would keep the PPACA in place to either give it a chance or to make changes. Slightly fewer voters, 43 percent, would support a candidate who favors repealing the law and starting over.
In raw terms, the information could suggest Republicans may do well, very well, as it relates to healthcare in the upcoming November elections.
At the midterm election, little more than one-third of the Senate is up for relection. Currently, the Democrats hold the Senate majority 55-45; however, Republicans could pick up the Senate by maintaining 15 seats and gaining six more. What's more, Republican control of the Senate would mean Republican control of Congress and significantly more power for that party in terms of influencing legislation, in particular the future of the PPACA as we know it today.
So, how would they do it?
A full repeal of the PPACA would be tricky; the legislative machinery needed would require the law to be much more unpopular with Democrats than it actually is. So, a Republican-controlled Congress could turn to appropriations to get the desired modifications, according to an in-depth analysis from healthcare research firm Leavitt Partners.
Discretionary spending cuts to comply with the debt ceiling spending cap are useful tools for killing undesirable provisions. For mandatory spending, like spending on government insurance, reconciliation serves a similar purpose. Such budgetary tools have been used successfully in the past to shape the path of healthcare legislation. And, budgetary legislation would have to be considered at least eventually, because — remember this time last year? — lack of budgetary legislation means government shutdown.
PPACA provisions on the table
Leavitt Partners' analysis shows only three target provisions both repeal-worthy in conservative eyes and politically popular for repeal. These provisions include the medical device tax, the Independent Payment Advisory Board (also known infamously as "death panels") and sustainable growth rate. Even so, only the IPAB has a neutral cost implication.
Repeal of the Federal Medical Assistance Percentage for the Medicaid expansion population and of the healthcare exchange premium subsidies are both in line with conservative ideology and would produce cost savings. However, repeal of these provisions is not politically popular.
Provisions for which repeal is both supported by conservatives but are only semi-politically popular include risk corridors and risk adjustment, definition of the fulltime work week, the employer mandate and the individual mandate.
Indeed, while the above are Medicare and Medicaid provisions that Republicans would like to see repealed, cost implications and political popularity don't seem to overlap favorably, according to Leavitt Partners' analysis.
So, the likelihood that the PPACA will be repealed or modified in a major way is low. However, change may be an inevitability in a Republican Congress, a scenario that would supply the party with the right tools to, in some cases, force Democrats to concede ground on the healthcare law.
Whether or not the U.S. ends up with a Republican-controlled legislative branch after the midterms, however, is a little more complicated. While eight in 10 Americans think Congress is out of touch with the average American, slightly less than half believe their own congressional member is one of those members who is out of touch. This propensity for faith in one's own elected officials leads to the well-known phenomenon of the incumbent rule: Staying seated, no matter your track record, is much easier than getting elected in the first place.