American Government and Politics Today, Brief Edition, 2014-2015

302 PART FouR • PolicymAking

“Obamacare,” as it was nicknamed, was the law of the land. Neither the Senate’s bill nor

the House’s reconciliation measure received the vote of even a single Republican.

Details of the legislation. Most of the major provisions of the new legislation did not

go into effect until 2014. The long delay was established in part to allow systems such

as state insurance pools to be set up more effectively, but the Democrats also wanted to

keep costs down during the initial ten-year period. The lengthy implementation, however,

presented political problems for the Democrats, who faced two national elections before

most of the programs would be in effect. Voters in those elections would receive few of

the promised benefits of the programs.

Some provisions took effect quickly, however. Young adults were allowed to stay on

their parents’ health plans until they turned twenty-six, and insurance companies could

not drop people when they became sick.

In 2014, most of the program kicked in, including the following:

n    A ban on excluding people with preexisting conditions from insurance plans.

n    A requirement that most people obtain insurance or pay an income tax penalty.

n    State health-insurance exchanges where individuals and small businesses can buy

insurance.

n    Subsidies to help persons with incomes up to four times the federal poverty level

purchase coverage on the exchanges.

n    Medicaid coverage for individuals with incomes up to 133 percent of the poverty

level.

Significant taxes to pay for the new benefits were to be phased in from 2011 to 2018.

health care: Policy implementation

The fourth step in the policymaking process involves the implementation of the policy

alternative chosen by Congress. Government action must be implemented by bureaucrats,

the courts, police, and individual citizens.

congressional opposition. Implementation would not occur, of course, if Obamacare

could be abolished before it was fully effective. Republicans sought to accomplish exactly

that. Complete repeal of the legislation, however, was difficult. Repeal would have to pass

both chambers of Congress and survive a presidential veto. Republicans, in other words,

needed a complete sweep in the 2012 elections, which they did not get.

Also, much of the reform package takes the form of an entitlement program, such

as Medicare or Social Security. Funding for entitlement programs continues on a year-to-

year basis unless it is explicitly altered or abolished. In other words, entitlements do not

depend on annual budget votes in Congress for their continued survival. Therefore, even

if Republicans in Congress were able to “defund” certain aspects of the reforms, most of

the new policies would survive.

opposition in the courts. As you have learned in earlier chapters, many conservative

state officials challenged the constitutionality of the Affordable Care Act in court. In 2012,

however, the Supreme Court ruled that most of the act was constitutional. The one excep-

tion: the Court threw out the mechanism by which the federal government could force

states to expand their Medicaid programs.

opposition in the states. Medicaid expansion is fully funded by the federal govern-

ment for the first six years and funded at 90 percent thereafter. Still, a large number of

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