Bending Toward Universal Health Care

IN finding the Affordable Care Act constitutional, a narrow majority on the Supreme Court, led by Chief Justice John G. Roberts Jr., has surprised almost everyone. The decision is a victory for the century-long struggle to ensure basic health coverage for virtually all Americans, and it sets the nation on a path toward more rational, cost-effective ways of delivering care. These will be the eventual outcomes — but months and years of fierce political battles lie ahead.

Although the court upheld the act, President Obama’s signature achievement to date, there were important twists. The federal government cannot order all Americans to have or buy health insurance, though it can collect a tax from those who do not have coverage after 2014. The federal government can offer the 50 states money to expand Medicaid coverage to all of the poor and near-poor — but cannot punish states that refuse by fully withdrawing existing Medicaid funds.

The decision shifts the political terrain for both parties. Over the past four years, the Republican Party has given up its traditional commitment to use regulated markets to extend health insurance coverage to all. It was Democrats who passed a law with elements long favored by Republicans — a law that radicalized Tea Party Republicans have now sworn to obliterate.

The ruling does not make President Obama’s tough re-election bid any easier. The health care law, as enacted in 2010, required everyone to buy insurance once it was affordable, but its authors avoided talking about Congress’s power to tax. Now the Roberts opinion makes it impossible to avoid speaking about a tax penalty. Media and legal analysts will want to keep the debates over the individual mandate going, and economists will ask whether taxes will need to be raised to compel recalcitrant holdouts to buy coverage after 2014. Will Mr. Obama be trapped in an endless mandate-discussion loop and forced to expend even more political capital on the one really unpopular part of health reform?

Not necessarily. Mr. Obama can now claim the mantle of “constitutionality” for his health care law — and start talking about the parts that are popular with 60 to 80 percent of Americans. Democrats, indeed all supporters of health reform, can tag Republicans with wanting to repeal or block those popular features like the insurance rules that protect people from being denied coverage for pre-existing conditions; the new benefits for young adults and older people on Medicare; the promised extension of affordable coverage to more than 30 million more low-income and lower-middle-income families; and tax credits for small businesses.

For as long as political scientists have measured public opinion, we have known that Americans respond to abstract questions by opposing “big government” but evaluate particular government benefits and actions very differently. As long as opponents of health reform could ask “Is it constitutional?” the argument was on their terrain. Now the debate will swerve back toward the popular core of the act, if the White House and Congressional Democrats are savvy in how they talk about existing and future benefits. (Reform supporters can also truthfully point out that only 2 out of every 100 people will be affected by the mandate without enjoying subsidies to help them buy affordable coverage.)

Mitt Romney and his fellow Republican refuseniks are in a new bind. They cannot wield the club of nonconstitutionality anymore. And in the debates, how is Mr. Romney going to bash Mr. Obama for extending to all Americans the very same insurance regulations and affordable health coverage that Mr. Romney enacted as governor for the people of Massachusetts — who like the results very much? We predict that Mr. Obama will eat Mr. Romney’s lunch.

Of course, it’s possible that the European economic crisis will send the world economy into another recession; that Mr. Romney and the Republicans will sweep the presidency and both houses of Congress; and that the Republicans will gut financing for the act. Using simple-majority budget rules, they could slash Medicaid and trim or delay subsidies to help low-income families buy private insurance. But they would still not have the 60 votes they’d need in the Senate to actually repeal the act — and the Supreme Court has now left intact the new rules for insurance companies and state-level exchanges prominently included in the law.

Moreover, the Republicans would create a political mess for themselves if they tried to “defund Obamacare,” as many conservative lawmakers have vowed. Insurers would still have to issue policies to all comers, sick or healthy — but they would not get millions of new paid customers using credits and subsidies to buy their products. The states, including those with Republican governors, would be left with millions of citizens needing health care, but much reduced funding to help them. Many insurance companies and health care providers, not to mention health care reformers and Democrats, would fight to restore financing.

The same kind of dynamics would play out for states that choose to opt out of the Medicaid expansion in the act. (The Supreme Court ruled on Thursday that states may do so without losing all of their federal Medicaid financing.) The law provides for 90 percent federal subsidies for expanded Medicaid coverage, and states will find it hard to turn down this offer. As more and more states move toward universal coverage and well-functioning insurance exchanges, states that opt out will have trouble attracting businesses and health care professionals and lose out to other states in economic development.

In short, the historic court ruling ensures the law’s survival in the long run, even if partisan battles over particular regulations and expenditures continue for some time. The arc of history now bends toward health care for all — and greater efficiency in the system as a whole. Mr. Obama and the Democrats may have to talk about health care more than they had planned going into November. But in the months and years ahead, the political challenges for Mr. Romney and the Republicans are even greater.

Theda Skocpol, professor of government and sociology at Harvard, and Lawrence R. Jacobs, professor of political studies at the University of Minnesota, are the authors of “Health Care Reform and American Politics: What Everyone Needs to Know.”

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