Photo by Gabriela Quiros, KQED Science

On KQED Public Radio’s The California Report Magazine on Friday, Scott Shafer talked with Marian Mulkey, the director of the Health Reform and Public Programs Initiative at the California HealthCare Foundation, a health-policy think tank (and a funder of the show).

Edited transcript:

SCOTT SHAFER: First of all, the Affordable Care Act has gradually been getting phased in nationwide. Give us a sense of what’s been happening up to now, right here in California.

MARIAN MULKEY, CALIFORNIA HEALTHCARE FOUNDATION: California has implemented many of the early provisions of the Affordable Care Act, making some new extensions of coverage available, for example, to young adults, assuring that pre-existing conditions are covered for children, and implementing many of the early programs — one for people with pre-existing conditions is in place and covering people already.

California has taken steps in terms of planning and establishing a state-based exchange, which is the marketplace by which people will be able to view their choices, identify what’s available for them and access federal subsidy support for buying coverage.

SHAFER: And it’s fair to say California has been further out in front on that than pretty much any other state?

MULKEY: Yes, California was early in determining it wanted to have a state-based exchange and moved quickly, immediately after the passage of the law in 2010 to start one up and to make some initial decisions.

SHAFER: Some people thought that after the Supreme Court weighed in and basically affirmed the Affordable Care Act, that would kind of be the end of the story. But we do have this big election coming up — the President, Congress. What could change depending on the outcome of that election?

MULKEY: Well, everybody’s eyes are on the presidency right now, and certainly there is a difference. If Obama is re-elected, then we remain on the path that we understand pretty well now, in terms of implementing the Affordable Care Act. If Romney is elected, then I think it’s fair to say, at a minimum, there’s a little bit of a pause, that people are looking toward Washington, and it will likely take months before it’s really clear what the new administration intends to do and what Congress will allow or encourage them to do.

SHAFER: And last month, Governor Brown vetoed a couple of bills that basically would have required insurers to cover all Californians, regardless of pre-existing conditions, even if the Affordable Care Act is gutted by the new president or the Congress. Why do you think he did that?

MULKEY: There was certainly pushback from the insurance industry about separating that individual mandate that’s in the federal law from the guaranteed issue, or the requirement to sell to everyone regardless of their health, which was in the state law. But I think it’s fair to say that there were many details in those bills — they compromised across all the stakeholders on some of them, and apparently didn’t get all the way to a compromise that the governor could uphold when it came to his desk. I think it’s likely that those issues will be revisited very soon in 2013.

SHAFER: Looking ahead to January, we understand that the governor intends to call a special session of the Legislature, focusing on health. How might this election determine what they might focus on?

MULKEY: If President Obama is re-elected, and we appear to continue down this path toward implementing the Affordable Care Act, then California has many pieces of unfinished business around the specific way we do that.

The individual market rules that you described earlier, certainly the way that we expand and pay for a MediCal expansion — those would be high on the to-do list for the Legislature. On the other hand, if Mitt Romney is in the White House or if Governor Brown’s tax proposition doesn’t pass, then I think attention will go in many different directions. It won’t be so focused narrowly on the implementation of the Affordable Care Ac; there may be higher priorities with respect to balancing the state budget.

Rep. Dan Lungren and Dr. Ari Bera are campaigning to represent the newly drawn 7th Congressional district in northern California. (Photos: Republican Conference and Randy Bayne via Flickr)

When Republican Rep. Dan Lungren faced a crowd of Tea Party supporters and Democratic detractors at a recent town hall meeting in the town of Carmichael, outside Sacramento, the arguments showed how explosive the Medicare debate can get in the hottest races in the country.

At La Sierra Community Center, the long line of seemingly irritated constituents made clear just what is on the minds of voters here: the Republican proposal to give future beneficiaries, those currently 55 and younger, a fixed amount of money to buy Medicare coverage from the government or private insurance companies.

Standing at a podium in the auditorium, Margie Metzler, a 67-year-old woman with the group Seniors Against Lungren, told Lungren that she had been laid off at age 61 and went four years without health insurance until she qualified for Medicare. “I don’t want to kick the people under 55 under the bus,” Metzler said of Rep. Paul Ryan’s Medicare plan.

A few moments later, another woman took to the microphone with this reprimand: “All you protesters can think about is where your next government entitlement is going to come from. Rome is burning and you’re all acting like children.”

And those were the polite exchanges.

Eastern Sacramento is where the two Californias come together — where the liberal, urban coast meets the conservative exurbs and rural farmland. Lungren has had a safe seat in Congress in large part due to the district’s Republican majority.

But following the 2010 census, an independent state commission redrew the district’s boundaries, resulting in an even split. Each party has 39 percent of registered voters. And with Lungren facing a challenge from Dr. Ami Bera, a local physician running against him for the second time, this patch of California has emerged as a test case as to how potent the fight over Medicare — and health care in general – will be in the 2012 election cycle.

“Lungren and Bera are very effective stand-ins for the two sides of the national debate,” said Dan Schnur, director of the Jesse M. Unruh Institute of Politics at the University of Southern California.

For his part, Lungren spent much of the town hall explaining the Republican position, saying that Medicare would be modeled after the health program for federal employees, relying on private insurance companies to negotiate lower costs with medical providers. “No one will be denied Medicare,” Lungren told the standing-room-only crowd.

Democrats, from President Barack Obama to incumbent members of Congress, cast themselves as a buffer against a Republican-sponsored, post-Medicare apocalypse. In recent weeks, many Democrats have seemingly shed their trepidations about supporting Obama’s signature domestic policy achievement, the Affordable Care Act.

But Bera has been championing that message for the last two years.

In local television advertisements and “senior-to-senior” phone banks, Bera has been eager to tout the law’s benefits and remind voters here, where unemployment hovers near 11 percent, what they would lose if the law was repealed. Parents could no longer keep their children on their health insurance policies until age 26, he tells them; insurance companies could once again charge women higher premiums than men; and preventive care would cost more.

“We’ve started to move forward and build off what’s good,” said Bera. “For me, the next step is to address the cost of care.”

Bera was a newcomer to politics in 2010 when he ran a surprisingly strong campaign against Lungren, losing by 7 percentage points in a year in which Republicans made record gains in the House. But in this year’s rematch, Bera is placing greater emphasis on his medical background. He served as chief medical officer for a large California hospital chain and later in the Sacramento County public health department, tasked with providing medical care for some 225,000 uninsured people.

“As a doctor, I’ve sat with patients who have had to choose which prescriptions they could afford to fill,” said Bera during an interview at his Elk Grove, Calif., campaign headquarters. “I understand how important closing the doughnut hole is,” he said, referring to a provision in the federal health law that reduces out-of-pocket prescription drug costs for some Medicare beneficiaries.

Some health policy analysts have wondered why many Democrats have waited so long to start explaining the law to voters.

“If supporters of the Affordable Care Act would take this issue head on then I think they could change public opinion,” said Henry Aaron, a senior fellow of economic studies at the Brookings Institution. “There’s a lot of misunderstanding of what the act does and how it would affect the lives of most Americans.”

That strategy could prove successful in a statewide campaign in California — a recent Field Poll found that 54 percent of registered voters support the Affordable Care Act while 37 percent oppose it. But here in eastern Sacramento County, it is a riskier tactic, where roughly one in five voters in the newly drawn 7th congressional district identify as independent voters.

Schnur, a veteran of Sen. John McCain’s presidential bid, says it’s unlikely the fulminating over Medicare and the federal health law will appeal to many of California’s independents. “Congressional candidates use the issue to motivate their own party’s base,” he said. “They’re not using it as an issue to attract swing voters.”

As of mid-September, polls show a tight race, despite major spending on both sides by independent committees. The Democratic Congressional Campaign Committee has listed the district at the top of its “Red to Blue” target list, and the American Action Network, a conservative political advocacy group, has sponsored pro-Lungren mailers telling seniors that Lungren “is fighting to protect Medicare for California seniors.”

That hasn’t stopped Bera supporter Bob Ireland, a 75-year-old retiree and Medicare beneficiary, from trying to persuade some of his contemporaries to vote for the Democrat. At a recent senior-to-senior phone bank at Bera’s campaign headquarters, Ireland spoke from personal experience as he tried to sell them on his candidate, telling them the benefits of the Affordable Care Act that he’s received as a senior on Medicare.

“I just had an annual physical,” Ireland said on a recent call, “and I didn’t pay a cent.”

Flickr/U.S. Navy photo, Todd Hack

The U.S. Supreme Court’s ruling on the Affordable Care Act June 28 has consumed lots of attention. Republicans are talking about repealing the act, while Democrats defended the law as “transformative of our society.” Why is it that this has become such a polarizing issue?

Pew Research Center President Andrew Kohut, a veteran pollster, shared some insight, based on his public opinion surveys, in a wide-ranging conversation this week with PBS NewsHour’s Jim Lehrer:

“Instrumental to the dislike of this program is the mandate,” said Kohut, referring to polling last month that showed that Americans are divided on the Obama-backed health reform law but that a majority disapprove of the “individual mandate,” that requires individuals to purchase health insurance coverage or face a penalty. “What has been overwhelming is the reaction to the mandate in particular and the concern about the role of government.”

The role of government… in health care and so many other aspects of American life… has become a central point of debate this election year.

Take a look at this graph from the Gallup poll: A decade ago, roughly 6 in 10 people believed the federal government had a responsibility to make sure all Americans have health care coverage. Now just 5 in 10 think so.

Gallup health care survey 2000-2012

Yet, the government’s role in ensuring health care coverage under the Affordable Care Act is a much smaller one than in other proposals Americans have debated in recent years.

Remember the “public option”…? That was the proposal for a government-run insurance plan to compete with private insurers as part of the health care overhaul. It was widely popular, according to a New York Times poll in 2009.

The national telephone survey, which was conducted from June 12 to 16, found that 72 percent of those questioned supported a government-administered insurance plan — something like Medicare for those under 65 — that would compete for customers with private insurers. Twenty percent said they were opposed.

But it didn’t pass muster in Congress and didn’t end up in the final version of the law.

Looking back a little further, Ezra Klein, writing in the New Yorker, reminds us that the “individual mandate” that conservatives now consider a government intrusion, actually began its life as a conservative idea.

The mandate made its political début in a 1989 Heritage Foundation brief titled “Assuring Affordable Health Care for All Americans,” as a counterpoint to the single-payer system and the employer mandate, which were favored in Democratic circles.

Here’s a link to that brief, by Stuart M. Butler with the conservative Heritage Foundation, which formed the basis for a Republican alternative to President Clinton’s plan for health care reform in the early 1990s.

A lot of Americans still don’t fully understand what the Affordable Care Act would do (or what the Supreme Court did last week). In fact, the New York Times reports, some of the politicians campaigning to repeal the law are actually proposing to replace it with… elements that are already in it.

A spokesman for Representative Rick Berg, Republican of North Dakota who is seeking a Senate seat, told a reporter in his state that Mr. Berg wants to replace Mr. Obama’s health care law with one that does not deny insurance coverage to people with pre-existing conditions and closes the “doughnut hole” — a gap in pharmaceutical coverage — for people on Medicare. Those are two of the most popular provisions of the law Mr. Berg would repeal, which would be difficult to replicate without the regulatory mandates and tax increases he has vowed to reverse.

So what IS in the law? For an easy overview, check out this animated video from the Kaiser Family Foundation. It was produced before the Supreme Court’s ruling (and has been viewed more than 400,000 times) but most of it still holds true:

And then let us know what you think: What IS the role of government in terms of health care?