This is Bal­lot Watch. Today is the fourth in the series of arti­cles on the upcom­ing bal­lot ini­tia­tives and some key local elec­tions. Some of these will cover top­ics in com­mon with mul­ti­ple states, while oth­ers will look at a state level.

Pun­dits used to say that Pres­i­dent Obama would not (or, some­times they claimed, “could not”) run for reëlec­tion on his record as Pres­i­dent. They specif­i­cally claimed he could not (or would not) run on his great­est sin­gu­lar leg­isla­tive accom­plish­ment, the Afford­able Care Act (ACA), also known as Oba­macare. Of course, most of these pun­dits also claimed this elec­tion would be a “ref­er­en­dum” on the President’s first term, not so much a “choice elec­tion” where the pub­lic was pre­sented with an option between visions for the future.

Con­found­ing these par­tic­u­lar pun­dits, Pres­i­dent Obama is, in fact, run­ning on his record, and is press­ing the case for Oba­macare. Even Repub­li­can Vice Pres­i­den­tial nom­i­nee Paul Ryan has pre­sented the upcom­ing elec­tion as a “choice” (“You are enti­tled to the clear­est pos­si­ble choice, because the time for choos­ing is draw­ing near…”). The Demo­c­ra­tic defense on these issues is hav­ing an effect. Just this last Sun­day, Mitt Rom­ney had to admit there were many things he “liked” in health care reform, after hav­ing repeat­edly promised to “repeal” it, on “day one.”

A num­ber of states, appar­ently in an effort to affect the vote this Novem­ber, have bal­lot ini­tia­tives deal­ing with Oba­macare. What will be the effect of these mea­sures on the upcom­ing elec­tion? What prac­ti­cal effect might they have on the future of health care reform in America?

Mon­tana, Wyoming, Alabama, and Florida will all have votes on amend­ments to their state Con­sti­tu­tions claim­ing in var­i­ous ways to nul­lify or mod­ify the ACA’s indi­vid­ual choice between car­ry­ing insur­ance or pay­ing a token fine on their fed­eral income taxes. These pro­posed amend­ments would have no law­ful effect if enacted. A state can­not con­sti­tu­tion­ally block a fed­eral law. In other words, these states can­not pre­vent the fed­eral gov­ern­ment from assess­ing the tax penalty on indi­vid­u­als in their state do not pur­chase insurance.

Of course, there are rel­a­tively few peo­ple who would be affected by the poten­tial penalty, since most Amer­i­cans already have insur­ance through an employer. The main effect of this pro­vi­sion is to increase the size of the insur­ance pool, mostly by bring­ing in healthy peo­ple who might oth­er­wise think they don’t need insur­ance. Adding healthy peo­ple to the insur­ance pool increases the like­li­hood of lower prices for every­one. Thus, only few peo­ple are affected, the impact of bring­ing them in would be ben­e­fi­cial, and these amend­ments would almost cer­tainly be inval­i­dated in fed­eral court. That being the case, it’s not clear why the state leg­is­la­tures are wast­ing time and money by putting these ques­tions on the bal­lot, except for rather cyn­i­cal par­ti­san politicking.

Mis­souri is going in a slightly dif­fer­ent direc­tion. There will be a con­sti­tu­tional amend­ment on the bal­lot which would pro­hibit any state agency from set­ting up an insur­ance exchange such as required by the ACA, with­out being specif­i­cally autho­rized to do so by state law. This is an appar­ent attempt to pre­vent Demo­c­ra­tic Gov­er­nor Jere­miah Wil­son “Jay” Nixon from com­ply­ing with the Afford­able Care Act. The amend­ment would fur­ther specif­i­cally autho­rize any “tax­payer of this state or any mem­ber of the gen­eral assem­bly with legal stand­ing” to sue any gov­ern­ment offi­cial for allegedly vio­lat­ing the pro­vi­sions of the amendment.

The ACA encour­ages states to set up “insur­ance exchanges” where cit­i­zens can com­pare poli­cies from var­i­ous insur­ance com­pa­nies and choose one so as to com­ply with the require­ment to pur­chase insur­ance. If a state doesn’t set up such an exchange, the ACA allows the fed­eral gov­ern­ment to set one up for use by cit­i­zens of that state. The Mis­souri amend­ment would pro­hibit any state agency (again, read: “Gov­er­nor Nixon”) from coop­er­at­ing with this process in any way, unless specif­i­cally autho­rized to do so by the state legislature.

None of this would pre­vent Oba­macare from going into effect in Mis­souri. It would, per­versely, ensure that the “fed­eral takeover of health care” that Repub­li­cans claim to oppose would progress one giant step for­ward in Mis­souri, thanks to the ded­i­cated work of Repub­li­can law­mak­ers. That is, this action would force the fed­eral gov­ern­ment to set up the exchange in Mis­souri with­out any input from any Mis­souri official.

Despite hav­ing lost the bat­tle in Con­gress to enact health care reform, and despite hav­ing lost the ques­tion in the Courts all the way up to and includ­ing the Supreme Court of the United States, Repub­li­cans in var­i­ous states are still try­ing use health care reform as a wedge issue. Will it work?

It might. Mil­lions of Amer­i­cans are see­ing ben­e­fits from Oba­macare. The ACA adds eight years to the sol­vency of Medicare, thus ensur­ing Medicare’s exis­tence until at least 2024. Oba­macare closes the Part D pre­scrip­tion drug “dough­nut hole”, result­ing already in hun­dreds of dol­lars in sav­ings each year for America’s seniors. Oba­macare elim­i­nates life­time lim­its on insur­ance ben­e­fits, sav­ing thou­sands of lives and tens of thou­sands of bank­rupt­cies. The ACA now requires insur­ance com­pa­nies to rebate cus­tomers who are over­charged for their insur­ance, and many thou­sands of Amer­i­cans have received rebate checks. Women will no longer be charged more for insur­ance sim­ply because they are women. Chil­dren can no longer be denied cov­er­age for pre-​​existing med­ical con­di­tions. Young adults up to age 26 can now remain on their par­ents’ insur­ance.

This is just a small sam­ple of the improve­ments in health care and health insur­ance that Amer­i­cans are already see­ing. More are com­ing. Repub­li­can efforts to repeal or oppose or inhibit Oba­macare may well act as a wedge issue in this year’s elec­tion. The ques­tion is — Which way will the scalpel cut?

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