Initial Response

It’s going to take some time to dive into the Supreme Court’s 5-4 decision on the constitutionality of provisions of the Patient Protection and Affordable Care Act. The opinion is now online for those who wish to wade through it. Here’s my initial take:

1. As noted in my first post today, the individual mandate isn’t much of a mandate, but the principle of a mandate could have brought down the entire health care reform package. It didn’t, but that doesn’t mean the individual mandate, as written, will have the impact supporters of the PPACA intend. The only thing that’s new today is that this provision of the law can now be described as a “tax.”

2. Chief Justice John Roberts makes clear that he believes an individual mandate would violate the Commerce Clause. However, because he interprets it as a tax, that observation is important, but doesn’t effect the outcome. The other four Justices in the majority (Ruth Bader Ginsburg, Stephen Breyer, Sonia Sotomayor and Elena Kagan), in a separate opinion, stated their belief an individual mandate is constitutional. However, in order to form a majority they’ve signed off on Chief Justice’s Robert’s interpretation. So while having four members of the Court interpret the Commerce Clause this way is significant to legal scholars and could impact the future, for now it’s immaterial.

3. The four Justices dissenting from the majority opinion (Antonin Scalia, Anthony Kennedy, Clarence Thomas, and Samuel Alito) would have found the entire PPACA unconstitutional. Chief Justice Roberts often sides with this group of colleagues. He made history by parting ways with his more conservative colleagues. Justices might have lifetime tenure on the Court, but it still took courage for the Chief Justice to make this decision.

4. Politically, this decision is a two-edged sword for both presidential candidates. The Administration’s key domestic accomplishment has been upheld. The Administration can now move forward to implement the health care reform package without the cloud of court decisions making their work meaningless. But the President’s key domestic accomplishment is also one of his greatest liabilities in the upcoming election. The PPACA remains unpopular. Many Americans (including four Supreme Court Justices) believes it’s an unwarranted expansion of federal power at the expense of personal liberty. This decision will only flame the passions of those who take this view, meaning they’ll be going to the polls in November with one goal in mind: elect a President and Congress that will repeal the PPACA. Will supporters of the bill be as motivated and engaged? Not likely.

5. Just because the PPACA is constitutional does not mean we’ve seen the final version of the law. Congress will amend health care reform. Agencies (both federal and state) will interpret it. The PPACA is complicated and open to significant interpretation. The upcoming election will determine how much the law will change, not that it will be changing.

6. The PPACA accomplishes a lot of good things: increases access to coverage, provides some useful and meaningful consumer protections, takes the first steps needed to begin constraining health care costs, and more. The PPACA also botches a lot of important things: it will not make coverage more affordable, it doesn’t go far enough to constrain escalating health care costs, and more. Lawmakers owe it to their constituents to revisit the law and make some substantial changes. This doesn’t mean Democrats have to follow the GOP’s demand to repeal the law nor does it mean Republicans have to cave to the administration. But both sides need to recognize that the PPACA is the law of the land. Barring a GOP super-majority in the Senate come 2013, the PPACA is not going away. So responsible leaders will try to make it the best law possible.

7. The Court majority made clear an individual mandate is not justified by the Commerce Clause or the Necessary and Proper Clauses of the Constitution. This will have an impact on other social welfare efforts Congress might consider. Needing to fund expansion of the safety net through taxes is a tough political and practical challenge.

8. However, there were four votes to uphold the PPACA under the Commerce Clause. Which underscores the importance of this November election. Presidents appoint Supreme Court Justices. All of the Justices four of the Justices upholding the law under the Commerce Clause were appointed by Democrats. All four of the Justices voting seeking to overturn the law were appointed by Republicans. The Chief Justice shows that not every appointment votes in the way one would expect based on the party of their appointing President. And two of the liberal Justices joined with conservatives and agreed that the Medicaid expansion included in the PPACA was unconstitutional. But the fact is, the appointments of Republican Presidents tend to be more conservative; those appointed by Democrats tend to be more liberal. At least one, and maybe more, vacancies will open on the Supreme Court in the next four years. Who is President matters.

9. The Supreme’s decision on the Medicaid provision of the health care reform law will be interesting. In essence, a 7-2 majority said the law went too far in threatening to withhold Medicaid funding to states who refuse to expand Medicaid eligibility to those at up to 133% of the federal poverty level. They ruled the federal government can withhold the additional funding promised in the PPACA to pay for this expansion, but they can’t take all Medicaid funding away from non-participating states. Put another way: states have the ability to opt out of the Medicaid expansion. Given the importance of this expansion to reduce the uninsured, this is an issue President Obama and his allies in Congress will need to address. As noted above, the health care reform debate is far from over.

10. While watching the news about the decision, an ad by Concerned Women for America with a vicious (and somewhat inaccurate) attack on the PPACA aired on CNN. The upcoming election will be about the economy, but health care reform will be a major factor as well.

7. People who predict what the Supreme Court is going to do and how they are going to do it are making wild guesses. Pundits take another blow.

So, I don’t pretend to have any special insight on the meaning of the Court’s decision today. But my mother misses these posts so I thought I’d return to the keyboard again. I’ll try to write a more thoughtful piece later today or in the next few days. In the meantime, please let me know your thoughts on all this.

New Hampshire Votes: Thoughts on the Republican Primary

If Pete Townsend wrote a rock opera about the 2008 New Hampshire primary, no doubt there would be a moment when former President Bill Clinton would sing of Senator John McCain,

I thought I was
The New Hampshire comeback king.
But I just handed my comeback crown to hi – im
.”

Written off just months ago, New Hampshire voters revived and revved up the Arizona Senator’s campaign with what appears to be shaping up as a strong victory over former Governor Mitt Romney. Meanwhile, Iowa winner former Governor Mike Huckabee, bereft of a strong evangelical presence, finished a distant third. (According to a CNN exit poll, evangelicals made up about 60 percent of Iowa Republican caucus goers, but only about 21 percent of New Hamphsire voters).

My guess is that the GOP — or at least the GOP leadership — will start rallying around Senator McCain. He now stands, ironically given his personality and history, as the most undamaged “traditional” Republican in the race. Conservative, but with an independent streak, his position on social issues could appeal to the GOP’s church going constituency while his pragmatism could appeal to Wall Street going Republicans.

Governor Romney on the other hand, doesn’t seem to be appealing to enough of any constituency resulting in a campaign that has little momentum at all — at least not of the forward variety. To be fair, however, exit polls indicate the Governor got the majority of Republicans casting ballots, but Senator McCain made up more than the difference by earning the support of independent voters (in New Hampshire, independents can choose which primary to participate in on election day, and more than 40 percent of New Hampshire voters belong to neither major party). Huckabee is clearly energizing the social conservative wing of the Republican party, but he has yet to gain much support from the business side of the party. The result, he ran a distant third in New Hampshire.

The wild card is former Mayor Rudy Giuliani. It’s hard to envision Republicans nominating a pro-choice, anti-gun, New Yorker, but anything is possible. Mayor Giuliani strategy is either brilliant or fatally flawed. His plan seems to be to avoid the early nominating contests in states like Iowa, New Hampshire and the upcoming South Carolina, let the other candidates engage in an exhausting elimination battle, resulting in one, damaged candidate stumbling into the states where the Mayor is making his stand, like Florida. The danger, however, is that by missing the early events, the Mayor could make himself irrelevant, ceding time to a candidate to become the decisive frontrunner who will barrell into the next wave of primaries sails full and war chest replenished.

Michigan, which holds its primary next Tuesday, January 15th, will be critical. Governor Romney (whose father was governor of the state), Governor Huckabee and Senator McCain have all polled well there at one time or another. The state could propel any of the three front-runners to an all but unassailable position or further muddy the waters.

The next test for the GOP will come just four days later when Nevadans caucus and South Carolina Republicans head for the polls (the Democratic primary in South Carolina is a week later). Will Michigan resurrect Governor Romney? Is resurrection even possible for his campaign? Will South Carolina revive Governor Huckabee? Will he need reviving after Michigan? Can Senator McCain unite the party in less than two weeks? Or will they all stumble into Florida on January 29th where Mayor Giuliani awaits?

Wish I knew, but I can’t wait to find out.

Close Votes in Reader Presidential Survey Results

The polls are open in New Hampshire, but they’ve closed on the first Alan Katz Health Care Reform Blog Unscientific Presidential Survey (the AKHCRBUPS, for short). And while we won’t know who won in the Granite state for awhile, we can now report on the winners, and losers, among this blog’s readers.

Republicans: Respondents gave a plurality of their first place votes to former-Mayor Rudy Giuliani takes the top spot followed closely by Senator John McCain who, in turn, was just ahead of former Governor Mike Huckabee. Former front-runner and former Governor Mitt Romney finished a distant fourth.

The survey asked participants to list their second and third choice. Weighting the results (first place = 3, second place =2 and third place =1), however, doesn’t change the order of the finish, although Governor Romney does move closer to the pack as does former Senator Fred Thomas. 

The comments provided by respondents showed some Republicans displeased with their choices this election cycle. As one Republican put it, “It just might be the first time I won’t go to the polls during the primary season.”

Republicans were asked whether they “would be willing to support a Democratic candidate in the general election” and, if so, which one. A majority said no. But of those who said yes, Senator Barack Obama was their top choice, followed by former Senator John Edwards.

Democrats: Senator Hillary Clinton would be the Comeback Kid of 2008 if New Hampshire follows the AKHCRBUPS results. She tied Senator Obama for the top spot as the first choice among Democrats. Yep, tied. (They were right, every vote does count!) Senator Edwards was a distant third.

When second and third choice votes are taken into account, Senator Obama squeaks out a win over Senator Clinton. Senator Edwards and Governor Bill Richardson makes strong moves, however, with Senator Edwards coming in just ahead of the Governor. Governor Richardson seems to impress more people than are voting for him. One supporter of Senator Clinton said, “I think Richardson is being overlooked. His … national experience would be a BIG help should he be elected.” Is this the start of a Clinton/Richardson boomlet? (Probably not, but I though it was interesting.)

Good news for the GOP: When asked if, and who, Democrats would support among the Republicans, the majority said yes. Of these, Senator McCain edges out Mayor Giuliani followed, at a distance, by Representative Ron Paul.

Independents: Those who identified with neither major party got to select their preferences among all the GOP and Democratic candidates. Senator Obama was the clear winner here.

The Issues: When asked what “the two most important issues you will consider in determining which candidate to support for president,” survey participants cited the Economy as their most important issue, followed by Health Care Reform and Terrorism/National Security and then Tax Policy. Iraq was on the list, but not as high as in national polls, not suurprising given the subject matter of this blog. When second choices taken into account, the standings don’t change, but the Economy moves even further ahead while Iraq gets closer to the pack. Yet, the comments would indicate that all of these issues matter. As one respondent put it, “So which one do you pick? Holy cow!! Most all of them are crucial.”

My thanks to all of you who participated n this survey. We’ll do at least one more as the vote in California approaches.  These polls may not be scientific, but they’re fun!

Iowa Speaks!

The voters of Iowa have spoken. What they have to say may not mean much to you, but they certainly mattered to the candidates who spent months and millions trying to persuade voters not only to support them, but to brave the cold and stand around for hours in dozens of town hall like caucus meetings.

For Senator Barack Obama and former Governor Mike Huckabee it was a good day. Coming in first, by definition, is a good thing.

The key message for Democrats is that their constituency wants change. For Senator John Edwards it had to be frustrating to position yourself as the fighter for change and then to watch Senator Obama claim the change crown. But that’s what happened according to the CNN entrance survey of participants in the Democratic caucuses, 51 percent of those who stated the quality they were most looking for in a candidate was the ability to bring about change voted for Senator Obama. My guess is that Senator Edward’s extreme rhetoric worked against him and for Senator Obama.

Many voters are tired of the attack politics that is business as usual in Washington. It’s one of the reasons Congress is held in even lower esteem than President George W. Bush. House Speaker Nancy Pelosi and Senate Majority Leader Harry Reid promised to change the tenor of the debate in Washington. They failed.

I believe most Americans want leaders who will build solutions, not tear down opponents. Seeking the mantle of Change Agent in Chief while promising to make Washington even more partisan and vicious, as Senator Edwards did, is counterproductive — at best. All he did was emphasize how much of a change the more open and inclusive style of Senator Obama would be. No wonder Senator Edwards earned only 20 percent of the vote from those whose top concern was bringing about change.

Senator Hillary Clinton had a rough night, too. Now she has to pivot from a campaign based on the inevitability of her nomination to demonstrating that she has the experience to implement the change that Senator Obama promises. Not an easy sell, but her campaign is very capable. It’s far too early to count her out.

By the way, expect both Senators Clinton and Edwards to claim second place. According to CNN, when the dust settles, Senator Edwards will have gotten a few more votes, but Senator Clinton will get 15 delegates to his 14 — compared to Senator Obama’s 16.

When asked by CNN for their top issue, health care was cited by 27 percent of those attending the Democratic caucuses, behind the war in Iraq and the economy (each mentioned by 35 percent of the voters).  Of those citing health care as their top issue, 34 percent said they were voting for Senator Obama, 30 percent for Senator Clinton and 27 percent for Senator Edwards. These numbers are so close it’s unlikely to have made much difference in the outcome. These results also reflect the narrow differences in the health care reform plans offered by the three front runners.

The CNN survey of Republican caucus goers indicate a different dynamic was at work there. First, the candidate leading in national polls, former New York mayor Rudy Giuliani didn’t campaign in Iowa. This left the field to former Governors Mitt Romney and Mike Huckabee with former Senator Fred Thompson and Senator John McCain fighting it out for a relatively distant third place finish (and it looks like Senator Thompson won the consolation prize by a hair).

The candidates views on God seemed to be the big issue for those showing up at the GOP caucuses. According to the CNN’s entrance poll,  77 percent of those attending the Republican caucus stated that the religious belief of the candidates mattered a great deal (36 percent) or somewhat (31 percent) in their decision. Only 15 percent of Republican caucus participants said the candidate’s religion didn’t matter at all. Of those who said it mattered a great deal, 56 percent said they’d be supporting Governor Huckabee. Only 11 percent said they’d be supporting Governor Romney — the same percentage that professed support for Senators McCain and Thompson.

When it came to specific issues, the top issue for 33 percent of the Republicans was illegal immigration, followed by the economy (26 percent), terrorism (21 percent) and the war in Iraq (17 percent). Health care reform didn’t make the list. A plurality of the voters citing each of these four issues as the most important to them said they’d be supporting Governor Huckabee.

What to make of the Iowa results?

  1. The expectation for Governor Huckabee and Senator Obama going into New Hampshire’s January 8th primary have gone up considerably. And it’s always a bad thing when a candidate fails to meet expectations.
  2. Coming in first in Iowa will give their war chests a nearly immediate infusion of cash (actually, credit card and Paypal donations). The Internet enables candidates to harvest contributions at speeds unfathomable in prior elections. More money will make it a bit easier for them to meet expectations. But as Governor Huckabee demonstrated to Govenor Romney, money doesn’t always translate into votes.
  3. Iowa will become yesterday’s news as soon as the New Hampshire polls close. Whatever happens there will serve as the context for the next news cycle.
  4. Perhaps most meaningful to regular readers of this blog, and as predicted here earlier, health care reform is unlikely to be a decisive factor in the primaries.

Roughly 340,000 residents of Iowa have now shaped the 2008 presidential election (that’s roughly the size of the city of Santa Ana). Now you can, too, by participating in the Alan Katz Health Care Reform Blog Unscientific Presidential Survey #1. I hope you’ll take a couple of minutes and participate. 

Health Care Reform and Iowa

With Iowans going to caucus today it’s tempting to write about how this marks the beginning of journey toward national health care reform. Unfortunately, that’s not the case. The impact of Iowa on the health care reform debate will be minimal. To be sure, there will be exit polls parsing the issues that matter to voters (health care will be high on the list). In reality, however, the positions of the candidates within each party are too similar to be sway many voters one way or the other.

On the Democratic side, the health care reform plans outlined by Senators Barack Obama and Hillary Clinton, former-Senator John Edwards, and Governor Bill Richardson are fairly similar. They all seek to reduce the uninsured through expansion of public programs. They all have cost containment provisions. The only differences are that Senator Clinton and Senator Edwards would require all consumers to obtain coverage. Senator Obama focuses more on affordability issues and Governor Richardson’s proposal avoids the creation of new bureaucracies.

On the Republican side Senator John McCain, former-Governors Mitt Romney and Mike Huckabee, and former-Mayor Rudolph Giuliani all seek to increase the number of Americans with medical coverage through tax incentives and fewer restraints on the private sector. Even Governor Romney has backed away from the heavy government role he championed in Massachusetts.

Once the general election is engaged the differences between Democrats and Republicans on health care will move front and center. That’s then. For now, even though voters are concerned about the issue, it won’t greatly impact the results coming out of Iowa.

There will be one interesting dynamic to watch, however. In Iowa, independents can choose to attend the caucus of either party. If exit polls show unaffiliated voters made their choice of caucus because of a candidate’s stand on health care reform it would provide important insight on which party’s approach is resonating with swing voters. 

That today’s caucuses in Iowa are unlikely to provide much insight into voters thinking about health care reform doesn’t make them any less interesting. They kick off the most unusual presidential election in generations. For the first time since 1928 no sitting president or vice president is on the ballot. Then there’s the sheer number of possible “firsts” we may witness. Senator Clinton could be the first woman president? Senator Obama could be the first African American to hold the office? Governor Romney is seeking to be the first Morman elected president and Mayor Giuliani wants to be the first Italian chief executive. The list goes on, but you get the idea.

And think of the possible match-ups in November. The nominees could both be New Yorkers (Senator Clinton and Mayor Giuliani). Far more interesting would be having the Republican most willing to work with Democrats (Senator McCain) facing off against the Democratic most willing to work with Republicans (Senator Obama). Then there would be the most ironic match-up: Governor Romney versus Senator Edwards — two wealthy, out-of-office white guys with perfect haircuts.

Iowa matters — just not so much concerning health care reform. Regardless of the match-up the next 11 months will be exciting. OK, not if we get stuck with Romney versus Edwards, but let’s hope it doesn’t come to that.