Theda Skocpol on the Self-Imposed ACA Quandary of Republican Governors

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February 20, 2015;The Atlantic

The NPQ Newswire has cited Theda Skocpol before on a number of variations on political advocacy, so it is a pleasure to see an article from Skocpol on the political problems facing Republican governors concerning conservatives’ longstanding crusade to destroy the Affordable Care Act.

As NPQ has written recently, the King v. Burwell case now before the Supreme Court, prompted by conservative think tanks, could bring down the Affordable Care Act if the court somehow decides that health insurance subsidies should not be provided to people who purchased their health insurance on the federal health exchange. The problem comes for some Republican governors who have figured out how to work with—and live with the benefits of—the ACA.

The prime example is Ohio governor John Kasich, who got the support of the Ohio Chamber of Commerce to convince the Ohio legislature to expand Medicaid eligibility. In the process, more than 230,000 Ohioans were able to purchase health insurance on the state exchange, many receiving subsidies that reduced their premiums to an average of $100 a month. Skocpol references the Dayton Daily News to the effect that insurance companies are flocking to the Ohio exchange—16 this past year, compared to 12 on the exchange in the first year of ACA enrollment, and offering 290 plans in 2015 compared to about 200 in 2014.

A somewhat similar situation confronts New Jersey Governor Chris Christie. In New Jersey, expanded Medicaid eligibility has given new coverage to 350,000 residents. However, because the state doesn’t sponsor a health exchange, the 200,000 or so Garden State residents who purchased insurance on the federal exchange and got subsidized to do so would potentially lose their subsidies as a result of King v. Burwell.

Kasich and Christie are both potential Republican presidential candidates. If King v. Burwell were to succeed in denying insurance subsidies to people who purchased policies on the federal exchange, they would have to explain to the public how it makes sense to provide subsidies to the very poor through Medicaid but to deny subsidies to people just above the expanded Medicaid income eligibility level. Even governors who are ardent opponents of the ACA, like Wisconsin’s Scott Walker, who has rejected both Medicaid expansion and a state exchange, would have to explain how they can justify the deprivation of subsidies from people who purchased their policies on the federal exchanges, particularly since Walker’s strategy has been to push people who would have qualified for expanded Medicaid to purchase insurance on the federal exchange instead.

Essentially, Skocpol has pointed out how the Republican governors who are potential presidential candidates have in many cases taken the route of “politically pleasing anti-Obamacare rhetoric” while knowing that many of their lower-income constituents have benefited extensively from the provisions of the Affordable Care Act. Skocpol’s expertise in nonprofit advocacy should lead to suggestions for nonprofits to mobilize their stakeholders to explain that the ACA has brought major benefits to lower income households in their states and that the strategy of the ACA. As a result of the ACA, healthcare has turned into an issue for nonprofits beyond those specifically mission-focused on health. Whether people get health coverage, what they pay as insurance premiums, whether the coverage leads to improved healthcare delivery, and other factors embedded in the implementation of the ACA take a wide swath of nonprofits into the healthcare arena—and potentially into healthcare advocacy, regardless of how the Supreme Court rules in King v. Burwell.—Rick Cohen