The Supreme Court bolstered the Affordable Care Act on June 17, upholding the law for the third time since Congress passed it 11 years ago.
The latest challenge to Obamacare, as it is known, came from a 2018 lawsuit filed by Republicans in Texas and backed by several other red states. The year before, the Republican-controlled Congress passed a new law slashing the penalty fee for people who don’t carry insurance to $0. The 2018 suit argued that changing that one portion of the ACA invalidated every other part of the law, rendering the entire ACA moot. Lower courts upheld that contention, but the Supreme Court overruled them in a decisive 7-2 ruling. The court ruled that Texas lacked standing to bring the suit in the first place, without even weighing in on the suit’s basic argument.
There could be other legal challenges to the ACA, but the issue has turned into a political loser for Republicans on a crusade to kill a law they say amounts to government overreach. Public approval of the ACA was sharply negative when its major provisions went into effect in 2014, following a glitchy rollout and the surprise cancellation of some people’s insurance plans. But unfavorable views of the law have now dipped to just 35% of Americans, according to the Kaiser Family Foundation—the lowest level on record. Approval is 53%, close to a high point. Republicans trying to kill the law may still find support among their rank and file, but the broader public has lost interest.
Broad support for universal coverage
There has also been a notable shift in public support for more government efforts to provide health insurance to all Americans. Terminology is important. “Universal health care” means every American would have access to affordable insurance. But there would be many sources, including the employer-provided plans that now cover more than 150 million Americans. Those would not go away. “Medicare for all” or a single-payer plan would be different, because a single government program would cover everybody and replace all other options. The important distinction is that the United States could achieve universal coverage without imposing a giant new government bureaucracy on everybody.
A March Morning Consult survey found that 68% of voters support a new government effort to achieve universal coverage. That included 56% of Republicans. But only 55% of voters support Medicare for all, with 62% of Republicans opposed. Gallup surveys show that the portion saying it’s the government’s responsibility to make sure all Americans have health care has risen from a low of 42% in 2014 to 56% in 2020.
The lesson for policymakers is that voters generally favor incremental improvements that don’t disrupt the status quo. And that’s the very approach President Biden has taken toward health care. The American Rescue Plan he signed in March included an important expansion of the ACA: the elimination of an income cap that made some people without insurance ineligible for subsidized coverage. Higher-income people now qualify for subsidies that limit insurance premiums to 8.5% of their income. That provision lasts through 2022 and could help 3.7 million people lower their insurance costs. Biden wants to make the expansion permanent.
Biden also established a special enrollment period, starting in February, for people to get coverage through the ACA if needed because of disruptions caused by the coronavirus pandemic. The White House says 1.2 million Americans have signed up. There are still around 30 million Americans without health insurance, however, and an estimated 40 million more who are “underinsured,” with coverage that still leaves them with hefty medical bills.
Avoiding a big political fight
Biden wants to narrow the uninsured gap further. While campaigning for president in 2020, Biden opposed the Medicare for all plan Sen. Bernie Sanders and some other Democratic candidates favored. Instead, he touted a “public option,” similar to Medicare, that would be last-resort coverage for people who can’t get affordable care any other way. Enrollees would pay for coverage, but rates would probably be lower than what a private-sector plan would cost.
Biden has not included his public option in any of the big bills he has teed up for 2021. That indicates a couple things. One, Biden is satisfied, for now, with the incremental ways he’s been able to expand coverage. Two, creating a public option would be a huge political fight that could derail other Biden priorities, such as his green-energy agenda. Democrats in Congress, however, have crafted legislation to create a public option similar to Biden’s idea.
The odds of this passing any time soon are low—but not zero. Democrats have been trying to craft bipartisan bills on infrastructure and other things, to indicate Biden’s agenda enjoys support beyond his own party. But that seems likely to end as an exercise in futility, with Democrats exploiting their narrow majorities in both houses of Congress to pass partisan legislation with little or no GOP support by later this year.
One possibility is a giant Democratic bill larded with infrastructure and social-welfare spending, with a public option stuffed in as Dems go for broke. If not, the public options will percolate in Congress indefinitely, perhaps with better prospects if Democrats are able to enlarge their majorities in the 2022 midterms. With Obamacare looking more stable than ever, health reformers can shift from defense to offense.
Rick Newman is the author of four books, including "Rebounders: How Winners Pivot from Setback to Success.” Follow him on Twitter: @rickjnewman. You can also send confidential tips, and click here to get Rick’s stories by email.