Five years after it was signed into law by Democratic President Barack Obama, the Affordable Care Act — better known as “Obamacare” — still stirs plenty of political passion, both in Congress and in the campaign to succeed Obama.

If anything, the partisan strife over the health care law has been re-energized by a conservative legal attack on Obamacare that was argued in March before the U.S. Supreme Court. And Louisiana — with four Republican physicians in Congress and a Republican governor eyeing a White House run in 2016 — counts several players enmeshed in the disputes over the law, though they don’t all sing from the same songbook.

In the Republican-versus-Democrat arguments over the health care law, both sides reel off an array of facts and figures — about health insurance premiums and deductibles, medical spending, job losses, percentages of people covered, even death rates.

But there’s another set of numbers that could shape the political debate: survey results reflecting growing public support for the law. The public’s verdict has been unfavorable for years, but the numbers are changing, with recent polls showing increasing rates of approval. In one case, the yeas outweigh the nays for the first time since 2012.

The Supreme Court is expected to rule in June on the request to strike down the subsidies that help low- and middle-income Americans pay for health insurance they buy through a federally operated Obamacare exchange. In the three dozen states (including Louisiana) that did not set up a state-run exchange, about 7.5 million people receive the subsidies.

Republicans are confident the challenge will succeed, although that is not certain. If they are right, those millions will lose their subsidies, leaving them with insurance-premium charges they can’t afford.

The health care law’s mandate to buy insurance will remain intact, but it doesn’t apply if no affordable coverage is available. The upshot, health economists predict, is that younger, healthier people will stop buying insurance. Insurance companies will raise their rates to cover the higher-risk people who need insurance, forcing more out of the market and triggering what’s called a death spiral of ever-increasing premiums charged to an ever-smaller, ever-sicker pool of customers.

That effect will spread beyond the health care law’s exchanges to infect the broader insurance marketplace, economists say.

For Republican supporters of the legal challenge, the prospect of a political blowback from such a scenario can be daunting.

“Some wish to let the chips fall where they may,” U.S. Sen. Bill Cassidy, R-La., wrote in March in a column on the Supreme Court case for The Hill newspaper. “This school of thought holds that if the subsidies, mandates and penalties vanish, the private health insurance market will return to the status quo before Obamacare. As a doctor who practiced for 32 years, I can tell you this is wrong. Obamacare scorched the earth of the health insurance market as it once was.”

Competing claims

Cassidy was the lead speaker last month at a news conference with five other first-term Republican senators timed to coincide with the fifth anniversary of the health care law.

The anniversary also prompted the Democrats to trumpet their claims for the success of the law: a decline in the rate of uninsured Americans from 17 percent to 12 percent (updated as of April 1), representing 16 million newly insured people; a reduction in the growth of health care spending nationwide; and a contribution to the saving of 50,000 lives because of quality improvements in hospitals.

Cassidy is not convinced. There are still 30 million Americans who are uninsured, he says. Health care quality has suffered, he says, while insurance premiums have skyrocketed and deductibles have increased.

“In some cases, premiums have gone up $10,000 a year for a family with health care, which is of a lower quality,” he said at the news conference. He has distributed a chart showing a huge spike in average premiums in the year after the law took effect; the chart does not factor in the subsidies, which Cassidy notes are provided at taxpayer expense.

Such anecdotes are standard fare in Republican attacks on the health care law, and there’s no doubt that some people — especially those who don’t get their insurance through an employer — faced steep increases in their premiums as a result of the law, which specifies what must be covered by all policies (for example, maternity care, a benefit many people wouldn’t elect). Those coverage requirements triggered the policy cancellations that made a mockery of Obama’s promise that “If you like your health care plan, you can keep it.”

But the requirements make it difficult to draw parallels between the premium structure before and after the health care law. Representatives of eHealth — the source cited for the information in Cassidy’s chart — acknowledge that a true apples-to-apples comparison is impossible.

“You can’t just take the negative anecdotes in isolation,” said Christine Eibner, an economist with the nonpartisan, nonprofit RAND Corp. “You have to look at the people who gained subsidies and gained coverage to really get a balanced view of the law’s impact.”

A question of values?

Cassidy argues that the rising curve of health care spending started to bend downward before the law was passed. The Fact Checker column in the Washington Post says the evidence to support Obama’s claim of a dampening effect on costs “is still rather fuzzy” — and that the trend could well be reversed as more people gain insurance. But a number of economists say the law has had some effect in bending the curve, even if it is difficult to quantify how much.

But beyond all that, Cassidy said, Republicans “regard Obamacare as almost antithetical to our values.”

The law “attempts to coerce the American people,” he said. “It is full of penalties, mandates and the occasional bribe trying to force the American people to submit to the will of a federal bureaucrat. ... The whole premise of this is that government knows best.”

Not only that, Cassidy said, but the health care law has failed to meet its own goals, as 30 million Americans remain without health insurance.

Cassidy favors universal health insurance coverage. Currently, most families and individuals get health insurance through employers or government programs, such as Medicare or Medicaid. But instead of imposing a mandate on the uninsured to buy a policy, as the health care law does, Cassidy suggests signing them onto a default insurance plan automatically, while giving them the choice to opt out of it and forgo coverage if they wish.

To make insurance more affordable, Cassidy would provide tax credits, with the amount of the credit deposited into a health savings account that limits spending to medical purposes, including policy premiums. To finance the credits, Cassidy would tap existing Obamacare tax streams.

Individuals and families could shop for the coverage they want. “As a rule, we want the patient to have the power,” Cassidy said.

The coverage would be portable between jobs. Insurance companies could charge more to cover people with poor health histories, but the expanded size of the pool of insured should restrain premiums by spreading the risk, in Cassidy’s formulation.

Details of the plan — or whether to adopt the approach at all — would be left up to individual states.

Cassidy is part of a working group in the Senate that is preparing a potential response to a Supreme Court ruling that would kill the Obamacare subsidies. Other Republican senators are developing proposals for more complete alternatives to the health care law.

Limiting government’s role

In the U.S. House, Rep. John Fleming, of Minden, serves as co-chairman of the GOP Doctors Caucus, whose 18 Republicans include fellow Louisianians Ralph Abraham, of Alto, and Charles Boustany, of Lafayette. None of the three Louisiana doctors finds much to like in Obama’s signature health legislation.

“It’s a very top-heavy, mandate-ridden bill,” Boustany said. “It is forcing the demise of the private practice of medicine by interposing this massive bureaucracy between the doctors and the patients, and these mandates are driving up costs and reducing choice for American families and individuals.”

Abraham favors a limited governmental role in health care. At his medical clinic in Mangham, he said, he had to hire two workers just to handle administration of the law.

“I’m just seeing it from the ‘trenches’ view,” he said.

The Doctors Caucus is working on a plan for responding to the Supreme Court case, building on a 2013 proposal advanced by the Republican Study Committee, a conservative group then headed by Steve Scalise, of Jefferson, who is now House majority whip.

The revised version tracks several of the proposals outlined by Cassidy, including automatic enrollment, premium-payment aid deposited in an health savings account and tapping the existing health law’s revenue streams — at least until 2017, when, presuming a Republican is elected president, the entire law could be repealed and replaced with something less odious to Republicans.

Other ideas under consideration by the doctors would boost competition by allowing health insurance companies to sell their policies across state lines and permit small businesses to form purchasing aggregations. Those aggregations, or perhaps a federal high-risk pool, could address the issue of insurance for people with chronic illnesses or pre-existing conditions.

A driving principle, Fleming said, is “letting the marketplace work its magic.”

“You make sure to drive the cost down through competition, and you enhance the quality through competition,” he said. “And then government, using our safety-net system, helps pay the cost, but only after the prices have been properly adjusted through the marketplace.”


Gov. Bobby Jindal parts company in several ways with the Republicans in Congress, whom he accuses of preparing to “wave the white flag of surrender on repealing Obamacare” with “Democratic-lite” proposals for “Obamacare-lite.”

He wants nothing to do with preserving the health care law’s revenue streams — projected to total $1 trillion through 2022 — nor with any other parts of the law.

“We must replace every single word of Obamacare,” he said in a February speech.

Jindal cut his teeth on health policy: In 1996, at age 24, he was named head of the Louisiana Department of Health and Hospitals, and in 1998, he was appointed executive director of a federal commission studying the future of Medicare. In 2014, Jindal published his proposal for replacing Obamacare on the website of America Next, a nonprofit organization that serves as the vehicle for his policy ideas.

An all-but-announced candidate for president in 2016 — he has delayed an official declaration until after the current session of the state Legislature — Jindal says his “Prescription for Consumer-focused Health Reform” is the only complete Obamacare alternative put forth by a potential Republican contender for the White House.

The Jindal plan shares some common elements with the proposals floated by congressional Republicans: insurance sales across state lines, beefed-up health savings accounts, purchasing pools for small business and private associations, portability of coverage for people changing jobs, devolution of policy from the federal government to the states.

Instead of a tax credit, his plan would offer everyone a standard tax deduction for the purchase of health insurance.

Jindal proposes the creation of a 10-year, $100 billion federal fund that would be distributed to the states, provided they reduce premiums to make coverage more affordable and guarantee access to insurance for individuals with pre-existing conditions, through a high-risk pool or other mechanism. The states also could use the money to subsidize coverage for low-income earners who would not get much of a benefit from a tax deduction.

The $100 billion would come from reform of Medicaid and changes to medical lawsuit rules.

Jindal rejects what his plan calls “the liberal shibboleth” of universal coverage. That drew criticism from Ramesh Ponnuru, a conservative columnist and senior editor at the National Review, who wrote, “The great flaw in Jindal’s plan is that it would cause millions of people to lose their coverage.”

But to support his idea, Jindal quotes Obama himself, who in 2008 said, “The problem is not that folks are trying to avoid getting health care. The problem is they can’t afford it.”

Jindal says his plan “is designed to protect freedom and lower costs.”

Follow Gregory Roberts on Twitter, @GregRobertsDC. For more coverage of government and politics, follow The Advocate Politics Blog at politicsblog.