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Pulling It Together: The Repeal Trap?

Almost a year into an often acrimonious health reform debate, we stand poised for near certain passage of historic health reform legislation. Yet, somewhat perplexingly, there’s now talk about whether a law that has not even been enacted might actually be repealed and reporters have been calling asking what the chances of repeal may be.

I have a very hard time imagining any scenario for repeal unfolding. Calls for repeal have much to do with maneuvering for advantage in the upcoming midterm election and little to do with how the American people will ultimately feel about the law. And the role of health reform in the midterms should not itself be over played. While the issue may be used to get the attention of voters in some districts who tend to turn out to vote in mid-term elections, health has not generally been a powerful voting issue in elections, and other issues such as jobs and the economy (as well as now potentially terrorism) are likely to be much bigger factors.

To be sure, once health reform passes there may be an “expectations gap,” with the public expecting help with their health insurance to arrive much faster than it actually will. One of our recent tracking polls found that about half of Americans believe that people will begin getting help buying coverage and insurance companies will be required to accept all comers this year or next. The actual timeline in the bills is slated to be quite a bit slower, and in the meantime it’s likely that costs will rise and the number of uninsured will increase as they would have if no health reform bill had passed.

But by 2013-2014, the only available remedy to people’s continuing struggles with health insurance will be the law itself—passed by the Congress, signed into law by the President and ready to provide tangible assistance to the public. Rather than support calls for repeal, the public’s reaction is much more likely to cut the other way—people will put pressure on their elected representatives to accelerate implementation of the insurance reforms and subsidies they can get under the law. Critics may be able to rally their base with attacks on health reform legislation, but it will deliver too much to too many to win general public support for repeal.

Implementation is not self-executing. It will take sustained and well-planned effort to make sure the public understands what the legislation does and how it will benefit them. Many groups have a role to play in making this happen as does the government. But once the legislation is out there, elected officials will have every incentive to make it work and keep it popular and perhaps even to improve on the help it provides to people struggling with their health care bills.

It’s an old maxim in political science that benefits once conferred are difficult, if not impossible to take away, and there are a variety of groups that will benefit under health reform: about 15 million additional people will be covered by Medicaid; 18-20 million people will receive new government subsidies for health insurance each year; many will benefit over time from guaranteed access to insurance regardless of pre-existing conditions; older people buying insurance on their own will see their premiums fall; and 3 million Medicare beneficiaries who fall into the donut hole each year could get better drug coverage. Virtually everybody gets added peace of mind from the insurance reforms that will protect them or a family member from being barred from insurance if they have a pre-existing condition or from being dropped or charged more if they get sick.

Experience with the Medicare prescription drug law may be instructive. In July of 2004, seven months after the law was passed, we asked people on Medicare what lawmakers should do about the law. 10 percent said it should be repealed. Four months later 12 percent of seniors said the same thing. Two years later in November of 2006, about a year after enrollment in drug plans began, we asked the public as a whole what message they would send to policymakers about the law. Still just 8 percent favored repeal while most favored improvements of different kinds.

Some have argued that the fact that the process of paying for the law begins before the benefits kick in will add to frustration with the law. But the financing structure of the law, a complex array of savings and revenue measures that affect many different groups, could actually become a strength that protects it from broad-based public resentment after passage. That’s because there is no single broad-based tax to rally the American people against. Health providers and industries take hits, but for the most part (with the exception of insurers), they have largely acquiesced to the savings and fees. Very high-income people will probably face higher taxes, though relatively few people would be affected. Young and healthy people may pay higher premiums as insurance market reforms are implemented, though many of them will be buying coverage for the first time so may not notice the difference. And, the so-called “Cadillac plan” tax (if it is included in a final deal) could end up affecting a large number of employers and workers over time since the thresholds for the tax grow much more slowly than the expected increase in premiums, but the effects will be indirect and not necessarily obvious to people. According to the Joint Committee on Taxation estimates, in most cases the tax wouldn’t be paid because insurers and employers would instead trim coverage or introduce efficiencies to avoid it. The fact that the burden of paying for health reform is spread across so many different interests and groups has made the law vulnerable to traditional behind the scenes lobbying on Capitol Hill, but its combination of widespread benefits and targeted pain will provide political insulation with the public at-large after passage.

Still, health reform legislation will undoubtedly be controversial up until the (expected) passage and beyond, and debate about repeal may play a role in the mid-term elections later this year.  It will be especially important for the news media to keep any discussion of repeal in the context of the mid-term elections in which it will be raised so as not to add momentum to an idea that is mostly a reflection of the rough and tumble of election campaigns. Once the law is passed, there is little chance that the public will do anything but seek its more rapid implementation, and policymakers will work to build on and improve it over time.