Archive | Health Care

Evaluating Forecasts of the Supreme Court’s Health Care Ruling

This is a guest post by my colleague Brandon Bartels.

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As the issue of forecasting has been on the minds of political scientists and journalists as of late (examples 1 2 3 4), I thought I would weigh in on this issue as it pertains to predictions of the Supreme Court’s ruling on the Affordable Care Act (ACA). My goal here is to provide a means of evaluating various forecasts of this landmark ruling. I focus on 11 predictions—included at the end of this post—from political scientists, law professors, and journalists made in print (or broadcast). These 11 predictions, I believe, provide a good representation of the forecasts that were proffered more generally.

Just to review, in National Federation of Independent Business v. Sebelius, the federal government had argued that the individual mandate was constitutionally permissible under three clauses of the U.S. Constitution: (1) the commerce clause, (2) the necessary and proper (N&P) clause, and (3) the tax clause. By a vote of 5 (Roberts, Scalia, Kennedy, Thomas, Alito) to 4 (Ginsburg, Breyer, Sotomayor, Kagan), the Court ruled that the mandate was unconstitutional under the commerce clause and N&P clause. But by a vote of 5 (Roberts, Ginsburg, Breyer, Sotomayor, Kagan) to 4 (Scalia, Kennedy, Thomas, Alito), the Court ruled that the penalty assessed to individuals for not purchasing health insurance amounts to a tax, which is constitutionally permissible under the tax clause, and the ACA was upheld (with exception of the narrow interpretation on the Medicaid issue). The four dissenters (Scalia, Kennedy, Thomas, Alito) wanted to strike down the entire ACA as unconstitutional.

To evaluate various forecasts, we should assess not only predictions for the overall case disposition (strike or uphold), but the predictions for the vote splits on each legal provision and the reasoning individuals gave for their predictions. Below the fold are summaries of forecasts by three political scientists, four law professors, and four journalists categorized by these important components (as well as on the severability issue). On the overall case disposition that the Court would uphold the ACA, among political scientists, Bailey and Maltzman were correct, while Segal and Evans were incorrect. Three of the four legal scholars examined here correctly predicted that the ACA, and particularly the mandate, would be upheld. Note that Kerr (in 2010) and Adler registered their predictions a full 2 years before the Court’s oral arguments on the case. Early on, many legal scholars correctly believed that the Court would not overturn the ACA. Among the journalists analyzed here, three of the four were correct, with Toobin famously reversing course—thinking it would be struck down—in an interview on CNN after oral arguments.

None of these forecasts correctly predicted that the mandate would be ruled unconstitutional under the commerce and N&P clauses yet constitutionally valid under the tax clause. Schultz was close on these particulars when he predicted—albeit with little certainty—that the Court would “more likely [vote] 5-4 to strike down the individual mandate on commerce clause grounds (maybe upheld on taxing authority)” (emphasis added). Moreover, nobody predicted that Chief Justice Roberts would be the lone conservative justice to join the liberals to uphold the mandate, let alone on tax clause grounds instead of commerce or N&P clause grounds. While Bailey and Maltzman (who registered their forecast back in November 2011) correctly predicted the overall case disposition, their predictions on the vote splits and the reasoning were less than accurate (a point to which they concede to an extent). They incorrectly implied that the Court would find the mandate constitutionally valid under the commerce clause, arguing that Wickard v. Filburn (1942) and Gonzales v. Raich (2005) were “[the] most clearly relevant [precedents].” These precedents provided a legal justification for upholding the mandate under the commerce clause, and Bailey and Maltzman predicted that Roberts and Kennedy and maybe even Alito would vote to uphold the ACA on commerce clause grounds. All three of these justices, of course, voted that the mandate was unconstitutional under the commerce clause, and Kennedy and Alito voted to invalidate the entire ACA. The rationale for Bailey and Maltzman’s prediction is deference to some of the key legal precedents declaring Congress has broad regulatory powers under the commerce clause. Bailey and Maltzman conclude by saying, “Policy motivations won’t be irrelevant, but score this one for law.” After the decision, they wrote a follow-up post titled, “The Law Matters.” However, the type of legal constraint that Bailey and Maltzman predicted would occur—deference to key commerce clause legal precedents—actually did not occur, particularly among Roberts and Kennedy (and Alito, for whom Bailey and Maltzman had some doubts about voting to uphold).

Contrast this reasoning with that of both Segal and Evans, who predicted that the Court would strike down the mandate under the commerce clause along ideological lines (5-4, just as the vote actually occurred on the commerce clause issue). So while Segal and Evans both incorrectly predicted the ACA would be struck down, their predictions on the constitutionality of the mandate under the commerce clause were exactly right, while Bailey and Maltzman’s prediction on this specific issue was incorrect. Moreover, Evans’ prediction underscores the importance of oral arguments, a topic political scientists have analyzed. Some who thought the Court would uphold the ACA before oral arguments changed their tune after oral arguments (see Toobin), given the tough questioning of the Solicitor General by some of the conservative justices (including Kennedy) who some people thought would vote to uphold.

The broader point is that there can still be value in incorrect forecasts and flaws in correct forecasts, particularly in a case as complicated as this one. While Segal and Evans were wrong on the overall case outcome, their predictions on the reasoning contained considerable accuracy and therefore contain great value. The ultimate value of Segal’s forecast is his prediction that the case would be decided largely along ideological lines and that several of the justices would not be constrained by certain commerce clause precedents or judicial restraint and concerns over deference to the political branches. The only vote Segal missed, albeit the pivotal one, was Roberts’ vote on the tax clause. On that one vote on that one issue, Segal overemphasized the role of ideology, but for every other vote on the other issues, he was correct. Bailey and Maltzman overemphasized the influence of legal precedent and underestimated the role ideological preferences would play, particularly among Kennedy on all aspects of the ruling and Roberts on the commerce clause issue.

Many of the journalists and legal scholars, including Adler, Tribe, Sacks, and Kerr (2010), emphasized judicial restraint and predicted that, above and beyond issues related to commerce clause precedents, the Court would not strike down a law of this political magnitude, especially the president’s signature domestic achievement. That part of the reasoning underlying the upholding of the ACA arguably characterized Roberts’ vote (I return to this issue below). Furthermore, Sacks appears to be correct, to an extent, when he argues that the “battle this time is likely to be an intra-conservative conflict between the economic libertarianism underlying the mandate’s challenge and the traditional principles of judicial restraint that have defined right-wing jurisprudence for more than a half-century…. [I]nvalidating a sitting president’s signature legislative victory on commerce clause grounds is freighted with deeply unpleasant institutional memories both for the court and the conservative legal movement.”

While the commerce clause part was not quite right, Sacks anticipated the tension between Roberts and his four conservative colleagues. It is worth noting that Roberts had already demonstrated his deference to federal power, particularly in U.S. v. Comstock, which recognized broad congressional power under the N&P clause (see Kerr’s analysis of this topic). Kerr (in 2010) and Adler, while correct that the Court would uphold the ACA, seem to have overemphasized the extent to which several of the justices would be constrained by issues of judicial restraint and deference to Congress and the president on significant domestic laws. While Greenhouse correctly predicted the outcome, she overemphasized the impact of commerce clause precedent (even more than Bailey and Maltzman), having predicted that the Court would uphold on commerce clause grounds “by a wide margin.” Kerr’s revised prediction in 2011 also overemphasized the impact of commerce clause precedent to about the same extent as Bailey and Maltzman.

Despite some of these errors, most of these forecasts combined prediction with explanation about the rationale underlying the prediction, particularly tying the prediction to theory and the mechanisms underlying the behavior. Even those who incorrectly predicted the outcome still added value. As this exercise has hopefully shown, there is great value in assessing and comparing political forecasts—ones that were both correct and incorrect—after the fact.

Evaluating these forecasts also helps us think about what were the true motivations underlying the justices’ votes—particularly Roberts’. My own opinion is that Roberts got what he wanted: a decision that exhibits judicial restraint (he does appear to favor robust federal power, as evinced in the Comstock decision as well), interprets the commerce clause as not permitting the individual mandate (throwing a bone to the conservative legal movement), and holds that the penalty for not complying with the mandate amounts to a “tax,” which could lay the groundwork for later repeal of the ACA.

Another take on Roberts’ motivation comes from Steven Teles at SCOTUSreport. In the Court’s most high profile cases involving potential clashes with Congress and the president, Teles argues the following:

[A]s an institutional matter justices have some sense of how far they can legitimately push on the political branches, and they make that judgment and then figure out a legal rationale to back themselves up….. Roberts, no doubt influenced by his position as Chief Justice, made the call that he could pull at the seam of the law pretty hard but couldn’t unravel it completely….There is an element in Supreme Court decision-making that can be explained by statesmanship rather than jurisprudence…. On no really important aspect of jurisprudence did Roberts actually break from his conservative brethren, but he did make a different political judgment than they did—not on what the Court could get away with, but what was really appropriate for it to do on a matter of such great policy significance.

Teles’s argument suggests a sort of post-hoc rationalization process of decision making akin to the attitudinal model (Segal and Spaeth) but tweaked to fit broader separation of powers issues. That is, stake your position on what is the best judgment given the situation, then cloak that judgment around a legal rationale that makes enough sense to make it look as if one was guided in a bottom-up, law-driven decision process. From this point of view, maybe Roberts, who felt it was most appropriate to uphold the ACA, really did feel that the mandate was constitutional under the commerce and N&P clauses, but he felt he had to go with a less sweeping legal justification to uphold it—in this case, the tax clause—than either of those clauses in order to appease conservative audiences. One thing we do know for sure: just as the “switch in time” still evokes a great sense of scholarly intrigue about the true motivations of another Justice Roberts—Owen Roberts—some 75 years later, scholars and Court observers will be analyzing Chief Justice John Roberts’ vote on the ACA case for years to come.

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Shifting Views of Health Care Reform?

I predicted that the Supreme Court’s decision on the Affordable Care Act—no matter the ruling—was more likely to polarize opinion than to change many minds.  Some early evidence supported that contention.  See my post and also Mark Blumenthal.

However, a new Washington Post/ABC News poll finds support for health care reform has increased since an early April poll.  In the recent poll, 47% support “the federal law making changes to the health care system” and 47% oppose it.  In the earlier poll, the split was 39% support and 53% oppose.

The major shift seems to be among independents (from 35% to 48% support).  (NB: At those links, you need to use the Post’s handy widget to generate the results by party identification.)   Support among Democrats (up 5 points from the earlier poll) and Republicans (+3) is much more stable.

However, I assume those results lump together independents who lean towards a party and “pure” independents.  If the results are being driven mainly by independents who lean Democratic, then the Post trend might reflect partisan polarization as well.  Hopefully we’ll have some more new polls soon, and we can see whether a consistent trend is developing.

 

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Supreme Court’s ACA Decision Polarizes, Doesn’t Persuade

Before the Court’s decision came down, I predicted:

How will the public react?  I have written on this previously here and here.  Do not expect public opinion about the ACA to change very much in reaction to the decision.  Public opinion about the ACA has been quite stable and polarized along party lines since forever.  See Dan Hopkins’s graphs, Scott Clement’s graphs, and this paper by Douglas Kriner and Andrew Reeves.  Supreme Court decisions, rather than providing an authoritative and persuasive statement on the issue, often simply polarize people further.  In this case, I expect the Court’s decision to be the subject of continued partisan debate, making continued polarization in public opinion likely.

A new Kaiser Family Foundation poll is out.  Here is a summary (pdf).  Here is the pertinent finding:

Many observers have wondered in recent days whether the Supreme Court’s ruling would change overall views on the longcontested law itself, or alternately if the decision would galvanize the intensity of one political party more than the other. This early snapshot of opinion suggests that, at least in the first days after the court ruling, the overall shape of public opinion on the ACA hasn’t changed, with the public still split at 41 percent favorable, 41 percent unfavorable, and 18 percent undecided. The partisan divide that lies beneath is also unchanged. What did change, however, is the intensity of Democratic support for the measure. While still outstripped by Republicans’ overwhelmingly strong opposition to the law, the proportion of Democrats that say they have “very favorable” views of the law jumped from 31 percent in May to 47 percent this month, an all‐time high in Kaiser polling stretching back two years.

In other words: polarization.

Among independents who do not lean toward a political party, support for the law increased 6 points, which is likely not statistically significant (although it bears watching the ongoing trend among this group).  See the seventh slide here (pdf).

Given that the majority of independents say that “opponents of the law should stop their efforts to block the law and move on to other national problems,” the implication for Romney may simply be: talk about something else.  Which is what he seems to want to do anyway.  More reason, as Brendan Nyhan discussed, that the Court’s decision, however important for policy, is not a political turning point in terms of the campaign.

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Health Reform’s Next Judgment Day

This is a guest post by Jonathan Oberlander, Professor of Social Medicine and Health Policy and Management at UNC-CH. He is is author of The Political Life of Medicare and is currently working on a book entitled Against All Odds: The American Struggle for Health Care Reform.

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The Supreme Court’s decision to uphold the Affordable Care Act (ACA) is a major legal and political victory for the Obama administration.  The individual mandate, with its punitive connotations, was always one of the law’s political Achilles Heels.   The mandate’s primary backers—since Republicans abandoned the idea—have been health economists and insurance companies, not exactly an overwhelming coalition.  Republicans’ success in defining the ACA with the unpopular mandate has hurt the Obama administration’s  efforts to highlight the provisions of the law that are popular.

The question was whether the mandate was also a legal Achilles Heel that could undo the entire ACA.  Now that the Court has ruled in favor of the Obama administration, those legal questions are settled.

The ruling’s political impact, though, is highly uncertain; the many inaccurate predictions regarding the Court’s decision should give us all a dose of humility about forecasting its political implications.  The Court’s decision adds to the ACA’s legitimacy, and could thereby strengthen public support for the law and Democrats’ ability to sell it.  But public opinion regarding the ACA has been extraordinarily stable since 2010, with more Americans opposing than supporting the ACA, and widespread, persistent public confusion about what the law does and does not do.  It is unclear how much the Court’s decision will impact public sentiment regarding the ACA and whether any effect will last.

After this legal defeat, Republicans will surely have no trouble motivating their base to turn out for the November elections.  Republicans’ best (and perhaps last) hope for overturning the ACA is to win the White House and majorities in both houses of Congress, and then use budget reconciliation to gut the law.

But the presidency was not lost or won today.  This election will still be influenced greatly by economic circumstances.  What happens in Greece, Spain, and the European Union  could end up having a greater impact on the U.S. election than the Supreme Court’s health care decision.

Today is indeed a historic victory for health reform, but November 6th looms ahead as reform’s next judgment day.  The election will be about much more than health care, but the fate of health reform now rests largely on what happens in the 2012 elections.

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The Law Matters

This is a guest post by Michael Bailey and Forrest Maltzman, authors of The Constrained Court.  In November 2011, they predicted that the Court would uphold the Affordable Care Act, based on modeling of the justices’ ideological preferences and attitudes toward precedent.

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After months of excruciating waiting, guessing, and waiting some more we now have heard from the Supreme Court on possibly the biggest case of a generation. We are definitely happy to claim that its decision is consistent with our prediction and our book.

There are many fascinating aspects of the case. First, it is simply not true that the Court is simply and exclusively a policy-oriented institution.  The Court is often political.  Some justices can be very political.  (Indeed, it is hard to read Scalia’s scathing attack on President Obama’s immigration policies as anything other than political.)  But the Supreme Court is not completely political.  Other factors – a complex combination of legal considerations and external constraints – can push the Court to do things differently than nine legislators would do.  Policy preferences alone do not dictate Court outcomes.

Second, this case reinforces our book’s argument about the idiosyncrasy of the Court.  We find again and again that justices differ in the degree to which any given legal or political factor matters.  We can partially predict this variation—justices with previous bench experience are more likely to respect precedent; justices appointed around the New Deal era were more likely to defer to Congress—but the variation is vast.  At some level this is consistent with the attitudinal model’s claim of broad discretion for justices, but while the attitudinal model claims justices use that discretion to pursue policy goals, we believe justices use their discretion to pursue a broad range of goals that includes their values about law and views about the appropriate role of the Supreme Court.

The most idiosyncratic choice was Kennedy’s.  Few thought the mandate would survive without his vote.  Our prediction (which was based on some judgment calls about the case) was that he would vote to strike with about 50 percent probability.  Coming off a week in which he voted against mandatory life sentences for juvenile offenders it cannot be said that he is reliably liberal or conservative.  He’s just hard to predict.

As for predictions in general, I’m glad that ours worked out, but I wouldn’t want to claim that this was the goal of what we were doing.  The goal of our models was to test theories about Supreme Court decision-making.  The prediction was a good exercise and, as it happened, adding legal elements in this case made us more confident about the Court upholding the law than we would have been from a purely policy perspective.  There is, however, always noise and I definitely wouldn’t want to make a living off of betting on Kennedy’s choices.

The political constraints might be where much of the action was.  As we predicted, Roberts wrote an opinion that “cabins Commerce Clause more than it is now.”  This is a big deal.  If Roberts limited the Commerce Clause as he did and struck the law, the Court’s legitimacy would come under a fierce assault.  The right comparison may not be Dickerson (where the Court upheld precedent that the justices likely did not agree with on policy grounds), but rather Marbury v. Madison, where the Court conceded on a particular policy in the interest of establishing a more general constitutional principle.

Roberts began his opinion by asserting, “We do not consider whether the Act embodies sound policies. That judgment is entrusted to the Nation’s elected leaders. We ask only whether Congress has the power under the Constitution to enact the challenged provisions.”  We concur.  Justices are constrained.

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The Battle Over Health Care Will Continue

Eric Patashnik sends the following:

The Supreme Court’s decision that the individual mandate is Constitutional under the federal government’s taxing power is a huge legal and political victory for the Obama Administration.  Chief Justice Roberts found a middle path, granting the main conservative argument against the law (the federal government’s regulatory powers are not unlimited) but also allowing implementation of the law to go forward.  As I wrote with my colleague Jeffery Jenkins, this does not mean that the battle over health reform is over. The partisan and ideological struggle over Social Security continued even after the Court upheld its constitutionality in Helvering v. Davis in 1937.  Social Security’s political support was not consolidated until the 1950s.

Now the debate over Obamacare shifts to the presidential campaign trail—and back to Congress.  Look for GOP efforts to defund the law’s new benefits and bureaucracies through the filibuster-proof budget reconciliation process, especially if Romney defeats Obama and the Republicans hold the Congress.

So:  a major victory today—but the battle over health reform will continue.


Patashnik is the author of Reforms at Risk: What Happens After Major Policy Changes Are Enactedwhich is a useful book to be reading about now.

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Limits on Medicaid Expansion: What Will States Do?

The Court has held that Congress can (of course) expand Medicaid to enroll additional people at higher income thresholds, but it cannot take away states’ existing Medicaid funding if they refuse to participate in the expansion.  Of course, states right now are cash-strapped and will be reluctant to turn down federal dollars.  But some may.  Which ones?  Here’s some research that may help answer that question:

“How Do States Formulate Medicaid and SCHIP Policy? Economic and Political Determinants of State Eligibility Levels” (pdf)
Reagan Baughman and Jeffrey Milyo

We exploit the existence of substantial variation in state policies toward public health
insurance for children between 1990 and 2002 to estimate the economic and political
determinants of state eligibility levels. Controlling for state and year effects, eligibility
levels are not significantly associated with either the percentage of uninsured children in
the state or the eligibility policy of neighboring states; further, variation in eligibility
levels within state is negatively associated with both the federal matching rate and state
fiscal capacity. We also observe that state political preferences, measured by the
Democrats’ share of seats in the lower chamber of the state legislature, are a relatively
important a determinant of state eligibility levels. However, other political factors, such
as party control of state government, voter turnout, legislative term limits and campaign
finance regulations do not influence state eligibility levels.

“The Policy Consequences of Class Bias in State Electorates.” (pdf)
Kim Quaile Hill and Jan Leighley

This paper tests the proposition that an electorate disproportionately representative of higher-class citizens will be rewarded with public policies in favor of its economic interests and at the expense of lower-class citizens.  We find a consistent negative relationship between the degree of class bias favoring the upper class and the generosity of indigenous state social welfare spending.  We also find that it is the underrepresentation of the poor, rather than the overrepresentation of the wealthy, that principally explains this relationship.

“The Political Economy of State Medicaid Policy” (gated)
Charles Barrilleaux and Mark Miller

We develop and test a market-based model to explain variations in states’ welfare medicine policy decisions. The empirical results support the model of state policy outputs, indicating that states’ spending efforts for welfare medicine are most sensitive to the supply of services within their borders. We learn in addition that spending effort declines with demand for services, indicating that the states spending the highest proportions of total personal income for the program are those who need it most and can afford it least. Measures of political system development affect spending effort positively and significantly, suggesting that ideology, diversity of interests, and administrative professionalism increases states’ welfare efforts.

 

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ACA Upheld

ACA has (basically) been upheld, including the individual mandate. We don’t live blog here, so just wanted to recommend the Scotusblog for what looks like a new comment every minute or so.

On the individual mandate, this post from Scotusblog at 10:25 seems to be the crux of the matter:

Amy Howe: The Court holds that the mandate violates the Commerce Clause, but that doesn’t matter b/c there are five votes for the mandate to be constitutional under the taxing power.

And the bottom line, again from Scotusblog:

The bottom line: the entire ACA is upheld, with the exception that the federal government’s power to terminate states’ Medicaid funds is narrowly read.

With the inevitable rush of “Obama wins” headlines, I do think it is worth repeating John’s point from his previous post:

My broader point is: the governments at all levels are going to do more regarding health care reform—under Democrats, under Republicans, perhaps under both. The Court’s decision today is important, but it is only one event in this ongoing process.

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Update: Here’s the link to the opinion.

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Some Predictions on the Supreme Court’s Decision

Before the Court issues its ruling, I’ll put these down:

  • How will the Court rule?  Back in November, Michael Bailey did some modeling based on the justices’ ideologies and deference precedent and predicted a 6-3 or even 7-2 decision in favor of the ACA.  Scott Lemieux was dubious about this modeling.  Based on the oral arguments, Michael Evans thought that the individual mandate was in trouble.  Joe Ura thinks the Court will strike down the law, 5-4.  Sean Trende feels similarly.  Ezra Klein lists some other predictions, and ways the Court could split the difference.  Nate Silver has a judicious take.  I have nothing to add here.
  • How will the public react?  I have written on this previously here and here.  Do not expect public opinion about the ACA to change very much in reaction to the decision.  Public opinion about the ACA has been quite stable and polarized along party lines since forever.  See Dan Hopkins’s graphs, Scott Clement’s graphs, and this paper by Douglas Kriner and Andrew Reeves.  Supreme Court decisions, rather than providing an authoritative and persuasive statement on the issue, often simply polarize people further.  In this case, I expect the Court’s decision to be the subject of continued partisan debate, making continued polarization in public opinion likely.
  • Is the spending to blame?  If the Court strikes down the ACA, should we blame the fact that opponents have outspent supporters by 3.5-1 since the ACA passed?  I don’t think so.  Despite this spending advantage, note that public opinion on the ACA essentially has not moved.  And, as Dan has noted here and here, the ideas that the public has about the ACA —which might reflect the framing of the issue in the ads and broader debate—haven’t changed much either.  It is true that people’s knowledge of the ACA’s provisions is sketchy, but I doubt that a broad-based campaign of public education by its supporters would have been sufficient to change many minds.  I think the partisan polarization is too entrenched here.  More important than the spending, or even public opinion itself, might be the broader campaign by opponents within the legal community.
  • What happens next?  Although there is a tendency for media coverage of public policy debates to treat them like games—with winners and losers—that won’t be true here.  To be sure, whatever the Court rules, it will constitute a victory or defeat for some people.  But it won’t be “game over.”  It’s not clear that health care reform is dead if the individual mandate is struck down; see Lawrence Jacobs and Theda Skocpol, or the head of Aetna for that matter.  Watch the states, where you are likely to see continued innovation and experimentation.   If the ACA is upheld, it’s not game over either, as Jeff Jenkins and Eric Patashnik wrote on this blog.  The ACA is quite vulnerable to future changes.

My broader point is: the governments at all levels are going to do more regarding health care reform—under Democrats, under Republicans, perhaps under both.  The Court’s decision today is important, but it is only one event in this ongoing process.

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Framing and Health Care Reform

“The administration lost the communications war with disastrous consequences that played out on Election Day 2010.”  That is former Pennsylvania Governor Ed Rendell, but it could have been any number of pundits or political figures who argue that  the Obama administration didn’t effectively sell health care reform in 2009 and 2010.  John Sides has already used this space to show that some of the major scholarly works on Presidential messaging or framing are skeptical about the power of bully pulpit, a point Ezra Klein has made in The New Yorker as well.  Looking specifically at health care, I’ve argued that the stability in the words that Americans use to describe their views on health care reform means that it is unlikely different messages would have demonstrably changed public opinion. On Monday, I also tracked public opinion on health care reform across a variety of demographic sub-groups and found a level of sub-group stability that makes it harder still to contend that politicians’ changing messages were a central driver of public opinion.  Here, I want to use Americans’ words about health care reform to reinforce that point.  If anything, health care reform might be a good example of the limits of elected officials’ capacity to reshape public opinion through framing.

In surveys conducted by the Pew Research Center and by the Kaiser Family Foundation, respondents were asked to explain in their own words why they supported or opposed health care reform four times between the debate’s beginning in the summer of 2009 and the 2010 mid-term elections.  I took a set of commonly occurring words in those responses and then considered which words were most likely to be used by supporters or opponents of health care reform.  Below, I plot these differences (on the y-axis) by a measure tapping how commonly and consistently the words are used overall (the words’ frequencies divided by their standard deviations, on the x-axis). The words in red that are closer to the top are those used disproportionately by supporters, while those in blue indicate the language of opponents.  In all four surveys, the single word most associated with opposing health care reform is “don’t,” typically followed by “cost” (in 3 of the 4 surveys).  Terms like “pay,” “run,” “money,” and “control” were some of the other words most consistently associated with voicing opposition.

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