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Americans Evenly Split on Supreme Court Decision on ACA

A new Gallup poll taken after the Supreme Court decision to uphold the ACA shows that 46% of Americans agree with the decision and 46% disagree. Democrats strongly support it 5 to 1, Republicans oppose it 6 to 1, and independents slightly favor it, 45% to 42%. What this poll does not ask, and many polls don't ask is why people oppose it. The few polls that have done that have consistently found about 15% of the people oppose it because they want Medicare for All, that is, they want a much bigger government role in health care, not a smaller one. When that question is not asked, it makes it hard to interpret the poll.

On the other hand, maybe it doesn't matter at all. What Gallup also found is that only 6% of the respondents rate health care as the #1 problem facing the country. As a consequence of its low importance and even split, this seemingly intractable issue may actually not affect the election very much, unless either President Obama or Mitt Romney really focus on it. But they might, and then the question of whether Romney can simultaneous attack Obamacare and run away from Romneycare comes up. It could be hard if Obama keeps pointing out they are the same thing, in essence.

As an aside, Gallup has taken the cell-phone-only household problem seriously and kept polling until it had 600 responses from landlines and 400 responses from cell phones. Then the results were weighted for demographic characteristics, as usual.

A Rarely Mentioned Objection to the ACA

With all the ink and pixels devoted to the Supreme Court's decision on the ACA this week, there is one criticism that is actually legitimate and Republicans almost never make: who's going to take care of those 30 million insured people? Injecting so many new people into the health care system is going to require more doctors, more nurses, more lab techs, more MRI machines, and more of everything connected with the health-care delivery system. Lots of new doctors are not going to magically appear on Jan. 1, 2014 to take care of these people. In the short term, there will be longer waits to get services. The argument "Why should I have to wait longer to get an appointment with a doctor so some poor person can get medical care?" is callous, but at least it is legitimate, unlike "death panels." (If Democrats were clever, they might respond to remarks about "death panels" by saying: "Who do you want to determine your level of medical care, some pointy-headed Washington bureaucrat who doesn't care whether you live or die or some insurance company executive who actually has a strong preference for you dying as fast as possible?).

In the short run, more doctors from India and nurses from the Philippines could be given visas to come to the United States to take up some of the load. In the longer run, the government could offer financial incentives (such as interest-free loans) to get more students to go to medical school. But that would require expanding the capacity of the nation's medical schools. All of this is doable, but takes time and money. Getting the federal government to do this seems unlikely in the current climate, but states could do some of this to alleviate possible local shortages.

Red States May Try to Bargain on Medicaid

The one part of the ACA the Supreme Court did overturn relates to the expansion of Medicaid. In the law, states could choose to cover everyone up to 133% of the official poverty level ($14,000 for an individual, $29,000 for a family of four), for which they would get a very large amount of federal money (the carrot) or they could opt out and lose all their Medicaid funding (the stick). The Court said no. The federal government can't cancel funds owed on the existing Medicaid program. At most it could offer take-it-or-leave-it for the new one.

Some states see this decision as an invitation to haggle with the federal government. What the states would like is federal money with no strings attached. Obama doesn't want this and it is not clear how it will play out. If a governor ultimately rejects the new federal money and doesn't expand health care that could have electoral consequences. In the next campaign, the governor is going to have to explain why he turned down billions of federal dollars. Of course the explanation is likely to be: "But then we would have had to provide health care to poor people and that would have cost more than the feds were willing to pay."

Difference Between ACA and Raich Explained

In their dissent, the four justices who voted to declare the entire ACA unconstitutional did grapple briefly with Gonzales v. Raich and why its broad interpretation of the commerce clause ("growing marijuana for personal use is interstate commerce") did not apply in the ACA case. The explanation in essence is that since there would be no way to distinguish interstate marijuana from intrastate marijuana, the only practical solution was to ban people from growing it altogether. But using that reasoning, any time any state permitted a product or service not allowed in all states it would have to be banned because some of it might leak into the states where it was forbidden or people from those states might come get it where it was allowed. Think about 19-year-olds in states where the drinking age is 21 but who live close to the border of a state where it is 18. We could also think about love-stricken 16-year-olds living in New York City and looking longingly across the Hudson River to New Jersey, where the age of consent is 16 rather than New York's 17, but we are not going there.

Today's Presidential Polls

State Obama Romney   Start End Pollster
Alabama 36% 51%   Jun 29 Jun 29 Capital Survey