If the Supreme Court exercises a willful disregard of legislative intent and rules against the government in the case of King v. Burwell, GOP pols will likely be celebrating before every camera they see. Behind closed doors, however, the merriment could be a bit more muted as they grapple with the consequences of the decision. A ruling in favor of the plaintiff would disallow federal health insurance subsidies to residents of the 34 states who lack state run marketplaces. The Urban Institute projects that 9.35 million people will lose health insurance subsidies, and an estimated 87 percent of those losing subsidies will lose their insurance altogether. What may be more ominous for the Republican Party is the fact that 35 percent of those projected to lose subsidies reside in states that were decided by 8 points or less in the 2012 election, and in Virginia, Florida, Ohio, and North Carolina, the percentage of the estimated voting population losing subsidies is greater than the margin of victory between Obama and Romney in 2012.
Consider the table above, which shows margins of victory in the 2012 presidential race and the estimated percentage of voting age adults who could lose subsidies in swing states that do not operate state marketplaces. A small adjustment has been made to account for the fact that roughly six percent of marketplace enrollees are under the age of 18. These numbers could definitely be refined further (i.e. to account for people who have lost voting rights), but this is a blog that averages 1.7 readers a day. Statistical accuracy will improve when I reach 5.
Optimistic Republicans may point out that people who lose insurance are not necessarily registered voters or destined to become newly-minted Democrats. They might also shrug their shoulders and say that it was the ostensibly apolitical Supreme Court, not the Republican Party, that ultimately undid Obamacare. They could also highlight the fact that, even in the most affected states, 90-something percent of the population would not be losing subsidies. Furthermore, those that do lose subsidies will be younger, lower-income voters who are, statistically speaking, less likely to vote.
All of these points have some degree of validity, and ultimately the 2016 elections may turn on issues other than a year old Supreme Court decision. However, the low margin for error in many of these states means that a relatively small number of votes could turn the tide. Recall that Florida, a state in which more than a million people would likely lose insurance, was decided by a 0.009 percent margin in 2000 and, in a comparative landslide, by 0.88 percent in 2012. Even with unregistered voters and Republicans amidst those losing coverage, there will still be many voters who are angered and mobilized by the decision. Republicans might have some success in blaming the court for ill effects of the decision, but here they run into problems as well. For starters, repealing the Affordable Care Act has been an integral part of the GOP message for the past three election cycles. Regardless of how the law was undone, they will be associated with its downfall. Also, Republican control of the House, Senate, and most state legislatures and governor’s mansions puts the party in a position to address problems with the law, although it’s obviously unlikely they will move to fix a law they’ve fought so hard to break.
The loss of insurance by millions of people may also increase internal tensions within the GOP. On a state level, enthusiasm for repeal seems to have flagged, as only 7 states filed amicus briefs on behalf of the plaintiff in King v. Burwell, compared to 26 states that supported the last major Supreme Court challenge to the ACA. A Republican Congress certainly won’t be throwing a lifeline to the ACA, although pressures will arise to address the millions of people suddenly rejoining the ranks of the uninsured. However, even if the country was graced with a functional Congress, a major health care bill in the near future is a virtual impossibility, particularly with a sub-cloture majority in the Senate, a Democrat in the White House, and a national election looming. Governors and state governments, having less enthusiasm for inaction than Congress, will feel additional pressures to act or establish an insurance marketplace in their state. Any effort to do so, will unleash fierce denunciations from the right and spark intra-party squabbling during the build-up to 2016..
Needless to say, a ruling for the government will render all these political conundrums moot for the time being. Either way, these potential issues hint at an increasingly difficult political landscape surrounding the ACA. National polls have consistently shown the law to be underwater in terms of favorability, but outside a surge in unpopularity after the bungled launch of Healthcare.gov, public attitudes about the ACA have been relatively static. Furthermore, the Congressional Budget Office recently lowered its cost estimates for the law, and the number of uninsured Americans has declined sharply. Nonetheless, the law is still a major issue for the Republican base and will likely remain so for some time. But for many moderates and independents, the ACA is no longer a primary concern, and polls have consistently shown that, even if it remains unpopular, there is limited enthusiasm for an outright repeal. If the court effectively issues a partial repeal, voters may look to the GOP for solutions it is unable or unwilling to provide. If the court upholds the law, they will soldier on as vocal opponents. However, for a party already being pushed by demographics, ongoing opposition may risk political capital the Republicans cannot spare in a national election.