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Health Reform’s Next Judgment Day

- June 28, 2012

This is a guest post by Jonathan Oberlander, Professor of Social Medicine and Health Policy and Management at UNC-CH. He is is author of The Political Life of Medicare and is currently working on a book entitled Against All Odds: The American Struggle for Health Care Reform.


The Supreme Court’s decision to uphold the Affordable Care Act (ACA) is a major legal and political victory for the Obama administration.  The individual mandate, with its punitive connotations, was always one of the law’s political Achilles Heels.   The mandate’s primary backers—since Republicans abandoned the idea—have been health economists and insurance companies, not exactly an overwhelming coalition.  Republicans’ success in defining the ACA with the unpopular mandate has hurt the Obama administration’s  efforts to highlight the provisions of the law that are popular.

The question was whether the mandate was also a legal Achilles Heel that could undo the entire ACA.  Now that the Court has ruled in favor of the Obama administration, those legal questions are settled.

The ruling’s political impact, though, is highly uncertain; the many inaccurate predictions regarding the Court’s decision should give us all a dose of humility about forecasting its political implications.  The Court’s decision adds to the ACA’s legitimacy, and could thereby strengthen public support for the law and Democrats’ ability to sell it.  But public opinion regarding the ACA has been extraordinarily stable since 2010, with more Americans opposing than supporting the ACA, and widespread, persistent public confusion about what the law does and does not do.  It is unclear how much the Court’s decision will impact public sentiment regarding the ACA and whether any effect will last.

After this legal defeat, Republicans will surely have no trouble motivating their base to turn out for the November elections.  Republicans’ best (and perhaps last) hope for overturning the ACA is to win the White House and majorities in both houses of Congress, and then use budget reconciliation to gut the law.

But the presidency was not lost or won today.  This election will still be influenced greatly by economic circumstances.  What happens in Greece, Spain, and the European Union  could end up having a greater impact on the U.S. election than the Supreme Court’s health care decision.

Today is indeed a historic victory for health reform, but November 6th looms ahead as reform’s next judgment day.  The election will be about much more than health care, but the fate of health reform now rests largely on what happens in the 2012 elections.