While all eyes focused on the presidential race, the ultimate fate of the Affordable Care Act (ACA) could depend on the Senate contests in the states.

Even if Mitt Romney were elected, he alone could not overturn major provisions of healthcare reform. Only Congress can pass the legislation needed to change the ACA.

Republicans are expected to maintain control of the House, but if Democrats hold the Senate, they will be able to block House bills aimed at eviscerating “Obamacare.”

What is at stake

If Republicans take the Senate, the two chambers could pass legislation that would:

· eliminate the premium subsidies designed to make health insurance affordable for middle-income and low-income families
· bring an end to Medicaid expansion, and
· rescind the individual mandate that everyone buy insurance or pay a tax.

Under “budget reconciliation,” Republicans would need only a simple majority to pass such legislation. In the Senate, 51 votes would do it. Today, Republicans hold 47 seats.

Razor-sharp margins in many states make it impossible to predict outcomes. Polls only give us a blurry snapshot of one moment in time – and in states like Arizona, candidates have been trading leads from week to week.

Much will depend on the demographics of who turns out to vote.

What could happen: Three scenarios

If Obama is re-elected, Republicans would have to hold onto their 47 seats, and pick up four in order to take over the Senate. Even then, the president could be expected to veto most attempts to gut health care reform.

If Romney wins the White House, Republicans would need to net just three seats; in a tie, Vice President Paul Ryan would cast the 51st vote.

There is a third possibility: Democrats have a shot at winning Senate races four states where Romney should beat Obama (Montana, Missouri, Arizona and Indiana.) Conceivably, we could wind up with a Republican White House and a Democratic Senate. For reform’s opponents, this would be extraordinarily frustrating. It’s not likely that Senate Democrats would compromise on key ACA provisions that enjoy widespread support, such as premium subsidies.

States where Republicans could lose seats

For more detailed polling data and predictions – from the American Prospect and electoral-vote.com – click on this map.

MASSACHUSETTS: In a race that could be captioned “Wall Street vs. Women,” Democrat Elizabeth Warren, a spunky consumer advocate who has taken on the big banks and spearheaded the creation of the Consumer Financial Protection Bureau, faces incumbent Republican Scott Brown. Bloomberg reports Brown has received $2.7 million from Wall Street, compared with $273,378 for Warren. Warren appeals to a different base.  As of mid-August, 43 percent of the Harvard Professor’s donations had come in amounts of $200 or less – compared with 15 percent of Brown’s .

Meanwhile, Brown’s voting record on equal pay and access to contraception has contributed to an enormous gender gap. As of Oct. 11, Warren enjoyed a 26-point lead among likely women voters while Brown held an 18-point lead among men.

But recently, Warren’s overall popularity has been slipping. The highly-respected non-partisan Rothenberg Report now lists the race as “toss-up/tilt Democratic.”  Six days before the election, a Boston Globe poll showed the candidates locked in a dead heat, with 47 percent each.

NEVADA, ARIZONA, INDIANA and MISSOURI: Rothenberg calls Nevada and Arizona “toss-up-tilt/Republican” states, Indiana “pure toss-up,” and Missouri “Democrat-Favored.”

In both Nevada and Arizona, Latinos account for 16 percent of the electorate – which could help Democrats. Nevada U.S. Rep. Shelley Berkley supported the “Dream Act,” which lets young undocumented immigrants avoid deportation under certain conditions. Republican Senator Dean Heller did not. Nevertheless, Nevada’s 11.8 percent jobless rate could hurt Berkley.

In Arizona, U.S. Rep. Jeff Flake is running against Republican-turned-Democrat Richard Carmona. A Puerto Rican raised in Harlem, Carmona fought in Vietnam, and then earned degrees in nursing, biology, medicine, and public policy. Under George W. Bush, he became Surgeon General. In 2006, Carmona left the post, accusing the administration of political interference.

Indiana and Missouri: self-inflicted wounds. First, Republican primary voters chose Tea Party-backed challenger Richard Mourdock over six-term Indiana Republican Senator Richard Lugar. Then, while debating Democratic opponent Joe Donnelly, Mourdock suggested that a “rape pregnancy” is something “God intended.”

But “Mourdock’s comments aren’t comparable to Missouri GOP Senate candidate Todd Akin’s earlier musings on ‘legitimate rape,’” observes Jennifer Duffy, who tracks Senate races for the Cook Political Report, an independent bi-partisan newsletter.  Aikin’s remarks handed the election to Democrat Claire McCaskill.

Where Republicans hope to pick up seats

MONTANA, NEBRASKA and NORTH DAKOTA: Montana Incumbent Democrat Jon Tester won in 2006 by only 3,562 votes out of 400,000, and Tester acknowledges that Romney will take the state. Republicans also are counting on Nebraska and North Dakota, where Democratic senators are retiring – though in North Dakota, high-energy former Attorney General Heidi Heitkamp has surprised Republican Rick Berg. Rothenberg calls all three “toss-ups.”

Where Democrats may lose seats

FLORIDA and VIRGINIA: In both states, outside groups have invested heavily in defeating well-known Democrats. In Florida, Democratic Senator Bill Nelson faces U.S. Representative Connie Mack IV – another recognized name, thanks to his father’s Senate career and his great-grandfather’s baseball fame. The Virginia race pits former governor and Democratic National Committee Chairman Tim Kaine against former Republican Senator and Governor George Allen.”

WISCONSIN: With Democratic Senator Herb Kohl retiring, Wisconsin was seen as a safe race for Democratic Rep. Tammy Baldwin. But former Republican Gov. Tommy Thompson has turned it into an ugly contest – another “pure toss-up.”

The bottom line:

“Whoever wins the Senate, I would be surprised if anybody had more than a 51-seat majority, says Cook’s Jennifer Duffy.

Maggie Mahar is an author and financial journalist who has written extensively about the American health care system. Her book, Money-Driven Medicine: The Real Reason Health Care Costs So Much, was the inspiration for the documentary, Money Driven Medicine. She is a prolific blogger, and recently relaunched her HealthBeat Blog. This post originally appeared at www.healthinsurance.org.

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2 Responses for “The Future of Health Reform May Turn on Senate Races”

  1. john says:

    This is an interesting scenario ….

    “Conceivably, we could wind up with a Republican White House and a Democratic Senate. For reform’s opponents, this would be extraordinarily frustrating. It’s not likely that Senate Democrats would compromise on key ACA provisions that enjoy widespread support, such as premium subsidies..”

    What a plot line that would make for!

    My only complaint: I wish that you’d told us a little more about the democratic candidates other than the fact that they’re, well … democrats. Would like to have seen a little more analysis about how individual Democrats and Republicans can be expected to behave on healthcare …

    Tommy Thompson is obviously a big healthcare name. Do we have anything to say about what his election might mean?

    Also curious about your take on the potential Leavitt scenario described in Dr. Halamka’s post below ..

  2. Maggie Mahar says:

    John–

    Thanks for your comment. On healthinsurance.org I have a word limit. (Their readers don’t like long posts, so I just didn’t have enough space to speak to all of the issues you mention..)

    To answer your questions:

    The Democrats running for the Senate all support premium subsidies and the individual mandate. (They know that, without the mandate, health insurance premiums would skyrocket.) They may not all support expanding Medicaid, but I doubt they would vote against it. (None that I know of have come out against it.)

    Tommy Thompson has “pledged to be the ’51st vote’ to repeal “ObamaCare,”
    http://www.brookfieldnow.com/blogs/communityblogs/177181761.html
    I guess that says it all.

    On Dr. Halmaka’s post– He writes “Giving standards-making to a consortium of vendors would be a step backwards.”

    I totally agree. But I’m not entirely convinced that he (or anyone commenting on health care reform) “stands above the political fray” (as he says he does.)

    Health care reform is an intensely political issue. The ideological divide is huge.
    When it comes to healthcare IT conservatives believe that “we should let the market decide.” Progressives would prefer more top-down guidance.

    But I don’t know Dr. Halamaka, and haven’t read enough of his writings to know where he stands on these issues.

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