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Which Path for Health-Care Politics in 2015?

This was published as a Wall Street Journal Think Tank column on January 6, 2015.

Yogi Berra said that when you come to a fork in the road, take it. It will be that kind of year for health-care politics. The status quo is not an option.

The key to which path the Affordable Care Act takes is how the Supreme Court rules in King v. Burwell, the case that concerns whether subsidies in the health law can be provided to millions of low- and middle-income enrollees in states with federally run insurance marketplaces.

The effect on people as well as politics could be substantial. A decision for the plaintiffs would deny insurance subsidies for millions, threaten the viability of the marketplaces, and potentially throw the ACA back into the congressional arena (and onto front pages nationwide). Partisan debate about the health-care law could reignite nationwide.

But if the court sides with the government, the ACA could gradually be transformed from the lightning rod of partisan division it has been since enactment in 2010 to a more ordinary political issue. The upside scenario for the ACA has received much less attention than the downside. Consider:

  • After a rough start with the infamous Web site problems in 2013, the ACA is largely working as intended. There is no obvious risk of serious meltdown on the horizon to keep the law at the center of political or media debate. The law faces many implementation challenges, but none of the doomsday predictions have proved accurate: There has been no rate shock. Premium increases in the new marketplaces have been modest. Employers have not dumped coverage, and the ranks of the uninsured are shrinking.
  • Efforts by the Republican-controlled Congress to chip away at the ACA could fuel the fire if they gain traction and force presidential vetoes. But congressional debates may turn out to be largely symbolic gestures to satisfy campaign promises to the base. They may also be  relatively short-lived as the political world  pivots to the 2016 presidential campaign. The major presidential candidates who set the tone for the election will want to look forward–not back–and to appeal to the political middle. So will many of the 24 Republicans scheduled to defend Senate seats in 2016 (Democrats will be defending nine).
  • The president is likely to veto any legislation he views as striking at the core of the ACA. Vetoes would sustain the political war surrounding the law that has benefited critics by rallying anti-Obamacare partisans to their side. But vetoes would also play into the hands of a president whose poll numbers are going up as he aggressively wields executive authority to advance his policy agenda in his final two years in office.
  • The anti-ACA fervor on the right has always been a proxy for anti-Obama sentiment. That sentiment is being redirected to other issues as the president exercises executive authority on immigration and the environment (including toward the president’s use of executive authority itself). When President Barack Obama leaves office, the ACA’s role as a proxy for anti-Obama fervor will fade, as will, in all likelihood, the term Obamacare.

Ahead of oral arguments at the Supreme Court this spring, it is far from clear which path ACA politics will take. But as the Supreme Court weighs the ACA once again, it’s clear that the heat will go either way up or way down in 2015.

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California.