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Health Reform: Repeal or Just Tie In Knots?

07/19/2010 09:28 am ET | Updated May 25, 2011

Theda Skocpol has an interesting analysis in the July issue of Health Affairs that makes me anxious. In it, she takes a look at Republican challenges to health reform and gives special attention to the mid-term elections and the stumbling blocks facing the implementation of reform. I wrote about this a little bit last week, and was fairly optimistic. I said, relying on history for support, that the GOP would pick up seats in both the House and the Senate. I stopped short, however, of predicting a Republican takeover of either chamber. Skocpol has me second-guessing myself.

What I thought was one of the more worrisome challenges--the courts overturning the law--she claims is little more than "political theater, cleverly scripted to provoke media coverage, rev up partisans, and convince uncertain or uninformed voters that something big and scary still remains at issue." In this case, historical precedent suggests--but does not guarantee--that the courts are going to stay out of it as much as possible. The real action is what happens if the GOP wins control of Congress.

On this count, Skocpol stresses that the state of the economy in the late summer and early fall will be the biggest determinant of electoral outcomes in November. While this is generally comforting--Congress and the Obama administration have taken some vital steps to help the economic recovery--it is not wholly reassuring, as we have experienced a fair number of "hiccups" that have served to keep panic close at hand for most of us. If we experience another dip, the Democrats could be in trouble.

So what happens in each case? Well, if the Democrats retain control of both chambers, it should be business as usual. But, if the Republicans gain control, things could get interesting, and not for the reasons you might think. It really looks more and more like a total repeal of health reform (the Patient Protection and Affordable Care Act or PPACA) doesn't have much traction. However, everyone knows that implementation of a law is where the real action is. The GOP could decide to try and pass laws that would undo specific pieces of the PPACA, they could change funding and/or subsidy levels, and they could go a long way in making implementation nearly impossible, all without actually striking down the legislation through repeal.

As Skocpol makes clear, we are an opportunistic and quite selfish people--we want the benefits of government for ourselves, but we shun the idea of large-scale government involvement in the abstract. This dichotomy explains how America's seniors were able to tell the government to keep its hands off their Medicare without their head exploding from the cognitive dissonance. So which will win the day: individual benefits or fears of big brother? In the end, it will probably depend more on how the stock market does from August to October. And on this one, history tells us that the Democrats have reason to be concerned--just Google "Dow Jones" and "October."

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