To run on Obamacare or not? That is this election's question. Over the summer, "Meet the Press" moderator David Gregory suggested congressional candidates in tough districts and even the White House may deliberately avoid running on the healthcare law. Yet, some progressives poo-poo such claims-calling, instead, for candidates to embrace a "full-throated defense" of the Affordable Care Act (ACA).
These conflicting views raise the question: in light of the available evidence, is it reasonable to believe that ACA will be a net voter winner for the president?
Results of the 2010 cycle offer insight to the answer. In that election, Democrats lost 6 seats in the Senate and 63 seats in the House-representing the largest swing in House seats in the GOP's favor since 1938 and exceeding the typical gains of 16 House seats in off-year elections. These historic gains far surpassed predictions nonpartisan analysts made in April 2010 (right after Congress passed the healthcare law). They likewise exceeded those of the 1994 wave election.
State level changes were arguably even more impressive. Republicans gained 7 governorships and 680 seats in state legislatures. All told, the GOP received control of 22 state legislative chambers in the 2010 election cycle, while their opposition gained none. This left Republicans with more state legislative seats (3,941) than in any other time since 1928, when they held 4,001.
Admittedly, the size of this electoral tsunami cannot be laid entirely at the feet of the healthcare law. Nevertheless, various analyses by political scientists demonstrate that "supporters of health care reform paid a significant price at the polls." Not only did this cost votes, but it appears to have cost seats-with at least one solid empirical analysis showing that "health care reform may have cost Democrats their House majority." Some progressives such as Rep. Barney Frank retrospectively conceded that President Obama made a mistake in not backing down on health reform after the Scott Brown victory in January 2010. Others such as Sen. John Kerry admitted that their Party paid a political price, but that this was worth it because they were on the "right side of history." Likewise, House minority leader Nancy Pelosi is proud of the health care law and that argues "politics be damned" as she is convinced that public opinion will change once people better understand what is in the law.
Public opinion, however, has been remarkably impervious to the flood of information that has come out since the law's passage in March 2010. RealClearPolitics.com tracked 128 different polls conducted since that date; and in only a single instance did those opposing repeal outnumber those in favor. The site's current average shows 50.2 percent in favor of repeal versus 41.2 percent who are opposed.
Across these disparate polls, those favoring repeal have never dropped below 40 percent and have been as high 63 percent; those opposed to repeal have never exceeded 48 percent and have been as low as 32 percent. Thus, with the exception of a single poll, the degree to which those favoring repeal have outnumbered opponents ranges from three to 31 percent.
Meanwhile, the importance of healthcare relative to other issues has also held steady among votes. Leading up to the 2010 election, roughly 4 in 10 voters said that healthcare or health care reform would be extremely important in determining their votes. In contrast, the dominant issue (cited by about 6 in 10 voters) was the economy or jobs. Nearly two years later, the most recent Washington Post/Kaiser Family Foundation poll found the cost of health care still ranks second only to the economy as the most important problem facing the country, 59 versus 44 percent respectively. (And pollsters collected this data prior to the selection of Paul Ryan as Mitt Romney's running mate.)
When asked about specific health issues, respondents in the same poll ranked Medicare as extremely or very important by a much higher percent (73 percent) than those who attach the equivalent level of importance to the 2010 health law. The cost of healthcare, Medicaid, and providing health coverage to the uninsured likewise ranked somewhat higher than ACA itself. But as the fierce controversy over $716 billion in the law's spending cuts to Medicare illustrates, most of these issues will be framed in the context of how well ACA addresses them compared to the plan(s) offered by Romney and Ryan.
It should be no surprise to learn there is a sharp partisan divide regarding the healthcare law. Rep. Pelosi's hopes notwithstanding, the trends are not encouraging. The Kaiser tracking polls show that the percentage of Republicans who favor the law peaked at 24 percent in August 2011 and has declined to only eight percent currently. More importantly, among independents (who, after all, will be determining the election's outcome), favorable views have declined by 15 percentage points since June 2008. Even among Democrats, favorable views peaked at 75 percent in September 2010 and now have declined to 64 percent. Perhaps of equal importance, as Kaiser puts it, "Republicans' intense opposition outpaces Democrats' enthusiastic support."
Advocates tout the fact that individual components of the law poll very well. Yet, the types of questions asked undercut the value of the results. More than 70 percent of respondents report liking "easy-to-understand plan summaries" of their health benefits, health insurance exchanges, and elimination of costs for preventive health services. But that's like asking whether people would like it if someone else paid for oil changes for their car. The response presumably would be very different if they were asked whether it was a good idea to force auto insurers to pay for the cost of oil changes.
The big unknown in the mind of current voters relates to Mitt Romney's plan. More than 70 percent of voters report having a "basic understanding" of what President Obama would do on healthcare if he won the election, versus only 45 percent who understand Gov. Romney's plans on the issue. In the context of that level of voter ignorance about policy details, it should not be surprising that 53 percent trust the president at least "somewhat" to make the right decisions about the future of the health law, versus 40 percent for Romney. And there is not even a consensus among the polls on the latter point. For example, the most recent Rasmussen poll of likely voters shows that on healthcare, voters trust Republicans slightly more than Democrats on the issues of health care (44 to 41 percent) and the economy (45 to 40 percent).
On the most important issue-Medicare-anywhere from 70 to 81 percent of voters oppose reducing Medicare benefits (with opposition steadily rising by age). The Kaiser poll shows that most voters prefer "Option A: Medicare should continue as it is today, with the government guaranteeing all seniors the same set of health insurance benefits" over "Option B: Medicare should be changed to a system in which the government guarantees each senior a fixed amount of money to help them purchase coverage either from traditional Medicare or from a list of private health plans." Of course, the latter is not an accurate way of describing the current Ryan plan, which allows seniors a choice between traditional Medicare and private health plans and gives them a dollar amount that is certain to allow them to purchase at least two plans at no additional cost. A very similar market-based bidding approach has resulted in the 10-year cost of Medicare Part D being 41 percent below original CBO budget projections. In contrast the $716 diverted from Medicare by ACA will within a decade, according to Medicare's own actuary, reduce physician payment levels to below those paid by Medicaid and will make 15 percent of hospitals participating in Medicare lose money.
Thus, for voters for whom health care is an important issue, how they vote ultimately depends in very large part on whether they get an accurate or distorted picture of what the ACA will do to Medicare and how candidate Romney's approach would differ from that. All indications now suggest this will be a close election. Other issues such as an "October surprise" could well affect the outcome in ways that are completely unforeseeable. Those random variables aside, attitudes towards healthcare may well tip the balance of this election. Stay tuned.
 This excludes Scott Brown's January 2010 victory in the special election to replace Senator Ted Kennedy even though candidate Brown won on an explicit platform promising to be the decisive 41st vote against the pending health reform legislation which by then had passed both the House and Senate and needed only to be reconciled in conference committee before final passage into law.
 In 2010, Republicans increased the number of state legislatures that they fully controlled by 11 (to a total of 25, the highest ever since 1952, when they controlled the entire legislature in 26 states. Viewed a different way, Democrats had a 60-36 advantage in the 98 partisan state legislative chambers prior to the 2010 elections (2 were tied) but were in a 39-57 minority when those elections ended.
 Specifically, this careful analysis showed that had Democrats in competitive House seats voted against the Affordable Care Act, the party "would have retained an average of an additional 25 seats and would have had a 62% chance of winning enough races to maintain majority control of the House."
 The lone poll was a CBS/NYT poll from January 2011 showing 40 percent favored repeal compared to 48 percent who opposed it.
 The announcement of Paul Ryan as VP candidate on August 11 occurred after the end of this poll, conducted July 25-August 5. Admittedly, summer polls need to be taken with a grain of salt since many voters simply are not yet intensely focused on the election.
 The Ryan announcement occurred at the tail end of this poll, conducted August 5-12.
 Specifically,only 42 percent of Democrats have a very favorable opinion of the law, versus 66 percent of Republicans who have a very unfavorable view.
 Most Americans would sensibly recognize that such a law likely would drive up the cost of their own auto insurance since now their policy would have to cover both the cost of the oil changes themselves as well as whatever it would cost to process "claims" for oil changes. With a third party covering this cost, consumers would be much less price sensitive, so the inevitable result would be higher costs across the board compared to a system where everyone paid for their own oil changes. The more appropriate question is how people view the law if fully informed about all of its benefits and its costs.
 That is, the Medicare subsidy would be set by competitive bidding at a level equivalent to the second lowest cost plan in their geographic area. This ensures that the dollar contribution will keep pace with medical costs. This is similar to the approach now used for Medicare Part D, under which Medicare covers 74.5 percent of the average weighted premium for a standard plan, determined through a bidding process.