Will the health care reform law last after 2010 election?

Can the new healthcare reform law survive?

President Obama and Democratic leaders in Congress rightly chalk it up as an epic legislative achievement. But their fight to sustain the new law through the 2010 and 2012 elections – before key features such as subsidies and the health insurance "exchanges" take effect – could be as daunting as passing it.

One reason: House and Senate Republicans, who uniformly rejected the healthcare package, may well remain opposed.

"We don't know a lot about what the long-term implications are of sustaining laws if they are passed on such partisan votes," says Eric Patashnik, professor of politics and public policy at the University of Virginia.

How the deed was done

Democrats upended conventional wisdom when they moved a major new social entitlement without a single Republican vote. The Social Security Act in 1935 and Medicare in 1965 passed with broad, bipartisan majorities. Call it a Senate mantra: No big bill moves unless it's bipartisan.

Moreover, Sen. Scott Brown (R) of Massachusetts campaigned and won the seat once held by Sen. Edward Kennedy (D) on a pledge to be the 41st vote against healthcare reform. That alone should have sunk chances for a final bill, but he never had the opportunity to cast that vote.

Instead of producing compromise legislation, House Democrats opted to pass the Senate's version of the bill – disliked by most of their caucus – and then moved a package of "fixes" using rules that require only a majority vote by both chambers. It was a novel use of House and Senate rules. Defying the odds, it worked.

During the next two election cycles, voters won't have much to go on when judging whether they like healthcare reform. Many of the law's key features won't take effect until 2014. For Democrats, maintaining support for the law through those elections won't be easy.

What sustained Social Security and Medicare through the years was that they came to be viewed as broad entitlements that helped the middle class as well as the poor.

"Even conservatives who had ideological concerns about these bills couldn't oppose them because they developed such strong middle-class constituencies," says Professor Patashnik. "It's not clear this law will develop a similar level of support."

The parties' dueling messages

During the congressional recess, Democratic lawmakers are making a case to voters back home that the new law will offer broad security to all American families. Mr. Obama hit that theme hard in a signing ceremony for the package of fixes for the healthcare bill on March 30.

"When I took office, one of the questions we needed to answer was whether it was still possible to make government responsive to the needs of everyday people, middle-class Americans, the backbone of this country, or whether the special interests and their lobbyists would continue to hold sway," he said at Northern Virginia Community College in Alexandria. "And that's a test we met one week ago, when health insurance reform became the law of the land in the United States of America."

Opinion polls signal that many Americans see the bill as directed mainly to helping the poor and uninsured at the expense of those happy with their own insurance plans.

Congressional Democrats hope to change that view by pointing out what's in the law for the middle class.Many are telling their constituents that it will create jobs, help the economy recover, reduce the US deficit, and protect all American families from insurance company bias.

"This is a bill about the middle class. This is a bill about small businesses. This is about affordability," said House Speaker Nancy Pelosi at the San Francisco Senior Center on March 29.

"Starting right away, healthcare reform will help seniors afford prescription drugs," said Rep. Paul Hodes (D) of New Hampshire, who is running for the Senate, at a March 31 campaign rally in Manchester. "Seniors, small businesses, and middle-class families in New Hampshire can't afford to let insurance companies win."

Republicans, meanwhile, are already campaigning to repeal the law.

"The tax hikes, the Medicare cuts, the job-killing mandate, the accounting gimmicks, the backroom deals – we're going to fight to repeal them at every single turn," said House GOP leader John Boehner at a briefing on March 25.

"The American people aren't going to take this lying down. The ink isn't even dry and there's a grass-roots revolt over this bill," he added, referring to two states that have voted to reject mandates in the law and 37 others considering such measures or court challenges.

Public's objections heeded

Even a big, bipartisan vote is no guarantee that healthcare reforms can be sustained.

Case in point: the Medicare Catastrophic Coverage Act of 1988, which promised prescription-drug coverage and extended hospitalization benefits to seniors. Congress repealed the law a year after it was passed, after seniors objected to new out-of-pocket costs that kicked in before the law's biggest benefits.

In 2003, House Republicans ground out a victory for President Bush's prescription-drug reform. Sixteen Democrats in the House and 11 in the Senate gave Republicans at least a claim to be moving bipartisan legislation. Still, Democrats objected to GOP tactics to jam the bill through the House, including adding nearly three hours to a 15-minute vote. They also opposed GOP provisions to extend prescription-drug coverage to those who receive Medicare benefits through private plans (Medicare Advantage).

Now, in another twist, Democrats are using their majority to reverse that policy. The "fixes" that passed along with the healthcare reform bill cut $135.6 billion from the Medicare Advantage program from 2010 through 2019.

"It's reasonable to speculate that [a partisan vote] is another factor that increases the risk of a law being appealed or eroded over time," says Patashnik.