GWEN IFILL: Little more than a week after the Supreme Court upheld the Affordable Care Act, the Republican-led House of Representatives once again signaled its displeasure.
WOMAN: One this vote, the yeas are 244, the nays are 185. The bill is passed.
GWEN IFILL: With that, House Republicans voted, yet again, to repeal the Affordable Care Act.
House Speaker John Boehner:
REP. JOHN BOEHNER (R-OH), Speaker of the House: When this bill passed, we were promised that the health care law would lower costs and help create jobs. One congressional leader even suggested it would create 400,000 new jobs. Well, guess what? It didn't happen.
GWEN IFILL: The House has voted to repeal or gut health care reform more than 30 times since it was enacted. But with Democrats controlling the majority in the Senate, the repeal won't become law.
The Supreme Court upheld most of the president's health care law, including the individual mandate that requires people to obtain insurance or pay a penalty. The court ruled Congress was within its right to approve a penalty under its taxing power.
House Majority Leader Eric Cantor hit the law on that front.
REP. ERIC CANTOR (R-VA), House Majority Leader: The president said throughout the health care debate, as did former Speaker Pelosi and my colleagues on other side of aisle, that this health care law was not a tax.
Well, we now know that Supreme Court has spoken. It is a tax. Madam Speaker, it's time to stop all the broken promises, and get back to the kind of health care people in this country want.
GWEN IFILL: Democrats accused the Republicans of wasting time on what they said is now settled law.
Peter DeFazio is from Oregon.
REP. PETER DEFAZIO (D), OREGON: How about doing something productive for the American people in terms of lowering health insurance and health care costs, instead of your political theater here? The Supreme Court has ruled. Let's roll up our sleeves and improve what is the law of the land.
GWEN IFILL: Minority Leader Nancy Pelosi tried to highlight some of the law's benefits, including guaranteeing coverage to children with preexisting conditions.
REP. NANCY PELOSI (D-CA), House Minority Leader: What is the takeaway from this debate? The takeaway is that -- the protections House Republicans are voting to take away from America's families. Today, up to 17 million children have the right to health care coverage even if they have diabetes, asthma, leukemia, or any other preexisting medical condition.
GWEN IFILL: While most polls show the American public remains split on the law, a recent Kaiser Family Foundation survey found a slight majority of independents believe Republicans should end efforts at repeal.
REP. STENY HOYER (D-MD), House Minority Whip: Polls show a clear majority of Americans want Congress to move on from the health care issue and spend time focusing on creating jobs.
GWEN IFILL: The battle also played out on the campaign trail today.
Speaking before a crowd at a NAACP meeting in Houston today, Mitt Romney drew boos when he said his policies, including repealing the health care law, would do more to help African-Americans.
MITT ROMNEY (R), Presidential Candidate: If our goal is jobs, we have to stop spending over a trillion dollars more than we take in every year.
MITT ROMNEY: And so -- and so to do that, I'm going to eliminate every nonessential expensive program I can find. That includes Obamacare. And I'm going to work to reform and save...
GWEN IFILL: At the White House, presidential spokesman Jay Carney criticized the Republican-led House.
JAY CARNEY, White House Press Secretary: Casting these votes again and again and again, it's probably on average once every few weeks, does nothing to improve the bottom line for middle-class families.
GWEN IFILL: Outside Washington, a number of Republican governors are choosing not to enforce some parts of the law.
The Supreme Court gave states the right to opt out of the Medicaid expansion, which would cover about half of the 32 million uninsured who would get new coverage. Medicaid is a joint federal-state program that supplies health coverage to the poor.
Nebraska today became the latest state to indicate they will climb aboard that bandwagon, joining the Republican governors of five other states, including Texas and Florida. That could mean four million fewer people would qualify for Medicaid.
Governors in eight other states have also said they are leaning toward opting out.
Health and Human Services Secretary Kathleen Sebelius said today she has received letters from a dozen governors who support another part of the law, the creation of the insurance exchanges that allow consumers to compare health plans.
But the Medicaid expansion remains an expensive sore spot for others. In Nevada, we turn to Jon Ralston, political columnist for The Las Vegas (sic) Sun, in Texas, to Emily Ramshaw, editor of The Texas Tribune, and with an overview in Washington, to Margot Sanger-Katz, health care correspondent for National Journal.
Margot, I want to start with you.
Give us a sense in general about what this resistance is about, who is resisting and why.
MARGOT SANGER-KATZ, National Journal: So, I think there are two main reasons why we're seeing resistance from governors.
One, I think it is political. They really don't like the health care reform law. They have made arguments against it all along. And this is a way of kind of rejecting it and saying, we don't want to participate in Obamacare, we don't want to help implement this law.
I think the second problem is that a lot of these governors are concerned about the long-term costs associated with expanding their Medicaid programs. The governors that have chosen not to implement tend to be in kind of poorer states. And what that means is that they don't cover a lot of people on Medicaid right now, but they would have to cover a lot if they did this.
And time over, the share that states are going to have to pay is going to increase. And I think they're worried about what effect that will have on their budgets.
GWEN IFILL: Do we know what those dollar signs are like yet?
MARGOT SANGER-KATZ: You know, it's a very slow phase-out.
So, for the first three years, it's completely free for states. And I think that's one of the reasons why Secretary Sebelius and the president have said that they're pretty confident that all the states are going to sign on, but it increases over time. And it looks like in a couple of these states like Texas, over time, it will end up being a couple percentage points over their current state budgets.
GWEN IFILL: Emily Ramshaw in Texas, you write that Governor Perry has called this a brazen federal intrusion. What's his reasoning?
EMILY RAMSHAW, The Texas Tribune: Sure.
Perry's reasoning really is that this is a massive intrusion, that states should be the ones deciding how to oversee their Medicaid programs. I'm in a state, for example, where the governor ran for president on a states-rights platform, where our attorney general really aggressively sued the federal government over federal health reform.
So this is a state that wasn't likely to try to expand Medicaid.
GWEN IFILL: And so what is the cost in Texas for opting out? As we just heard from Margot Sanger-Katz, this is, at least in the short term, supposed to be a federal responsibility.
EMILY RAMSHAW: Sure.
The estimation right here in Texas is that between 2014 and 2019, there would be about 100 billion federal dollars coming in at a cost to the state of about $6 billion. So, obviously, that's a tradeoff. Six billion isn't pocket change, but, at the end of the day, Texas' feeling really is that this is a massive intrusion and that Texas would rather sort of see a federal waiver, where Texas could operate Medicaid as it sees fit, as opposed to implementing any kind of national program.
GWEN IFILL: Jon Ralston, first, I want to apologize. I think I said you were The Los Angeles Sun. Of course, you're in Las Vegas.
So I want to ask you about what Governor Sandoval has said, which is that he's unlikely to opt in. What's the reasoning there?
I don't think you're hearing me, Jon Ralston. We will get back to you, and I will apologize again.
Back to you, Margot Sanger-Katz.
Tell me a little bit more about has this debate has played out. Has it resonated at all in the polls? Are people paying attention to the Medicaid portion of this? So much of the discussion has been about taxes.
MARGOT SANGER-KATZ: Yes, I think that's right.
I don't know that this is necessarily something that's registered at the federal level, but I do think in some of these states where the governors have said no to Medicaid, it is going to make more a difference.
It's worth noting that the Medicaid expansion was supposed to be about half of the coverage expansion under the health care law. So around the country, it's about 17 million people are estimated that they will get coverage through this expansion. And if a lot states say no, that is going to erode one of the main goals of the law, which was to get insurance for the uninsured.
GWEN IFILL: Now, we have seen some states where they have said no, Margot, and we -- where they have said no, but then they have said, well, maybe. And it sounds like people haven't quite figured it out yet.
Has it trickled down yet to state legislatures?
MARGOT SANGER-KATZ: So, state legislatures are ultimately going to have to make the decision in almost every state.
This Medicaid expansion is going to have budgetary implications, and state legislatures have control over that. I think it's going to take some time. There are a couple of these governors who have come out with very strong statements in opposition. There are a couple who have said we're definitely going forward no matter what.
There's a much larger group in the middle who have said we need to talk to state agencies, we need to do budget estimates, we need to talk to our legislature. And I think we are going to see -- probably in 2013 we are going to see more of these states kind of deciding one way or the other and doing what they need to do in order to do the expansion or not.
GWEN IFILL: Governor Ralston -- Governor Ralston -- Jon Ralston, I gather you can hear me now.
JON RALSTON, The Las Vegas Sun: I can.
GWEN IFILL: I want to come back to you on what Governor Sandoval has had to say, which is that Nevada is unlikely to opt in. That seems carefully phrased. What does that mean?
JON RALSTON: Yes, it's a very good question, Gwen.
I think his initial reaction, which came on the same day a TV interviewer asked him about it, and he said, as you said, he's unlikely to opt in. Then, within 24 hours, he was backing off of that a little, just saying they wouldn't automatically opt into it.
Listen, Nevada provides very penurious Medicaid benefits compared to a lot of states. We have about 300,000 people on the Medicaid rolls now, Gwen. The estimates are is there will be a 15, maybe 20 percent increase under the expansion.
But the argument that Sandoval is making is it's the administrative costs that would go up, because as one of your previous guests said, for the first three years, it's full reimbursement on all the medical costs.
So the only real issue becomes a philosophical issue and the long-term costs for a state like Nevada and some others. So I think Sandoval is going to wait to see what happens with the economy and then make a decision. More interestingly, though, Gwen, is that the liberal Democrats in this state who have agitated for years for more people on Medicaid appear to have had their vocal chords removed during this period and are not coming out with any kind of full-throated embrace of this.
Why? During a campaign season, no one wants to be seen as maybe advocating for what Sandoval said this might incur, which is a tax increase.
GWEN IFILL: Emily Ramshaw, how does that play out in Texas?
EMILY RAMSHAW: Sure.
The conversation in Texas is really a little bit different. It's an overwhelmingly conservative state. And the people who turn out to vote here are overwhelmingly conservative. So there was a lot of relief that the Supreme Court ruling, what it was, allowed Texas to opt out of Medicaid.
The people who might want to be included in this Medicaid expansion traditionally, they are not the people who vote in Texas. And so I think a lot of the opposition to opting out of a Medicaid expansion really isn't going to be heard here, because this overwhelmingly conservative state, this overwhelmingly Republican legislature really doesn't support participating in any kind of an expansion.
GWEN IFILL: So, is there anything right now that is before the state legislature, if they're even in session, that would speak to this?
EMILY RAMSHAW: Our legislature doesn't convene here until January.
While Rick Perry came out and said Texas is not going to be a part of any expansion, some lawmakers sort of quietly raised some eyebrows and said, look, this decision actually is up to us. You know, we may be able to approach CMS, approach the Obama administration for some kind of agreement on this.
And I think that's yet to be seen in this upcoming legislative session.
GWEN IFILL: So I wonder, Jon Ralston, whether people aren't waiting until after the election to see what happens, whether this -- if Romney is elected, obviously, there may be a different outcome.
JON RALSTON: Yes, I think that's exactly right, Gwen.
That's especially true, I think, of Governor Sandoval and some of the Democrats in our legislature, which also is not in session, doesn't convene until next February. They want to let this play out. They don't want to take a strong stand during an election cycle.
And Sandoval, not coincidentally, I think, is very close to Rick Perry, and I think they're in sync on this issue. Perry was one of his mentors, and I think to some extent he's following that lead. But he's also caught in between on this, because he's a guy who was really conservative when he was running, but now has somewhat moderated his stances, has even let a couple of tax increases or not let taxes expire, which has raised the ire of the right. So I think he's still finding his way.
He doesn't have to be on the ballot again until 2014. But this is going to have an impact, even a minor impact on his budget for the next legislative session.
GWEN IFILL: Margot Sanger-Katz, are there other implications nationally? We are also talking about states like Louisiana and Florida, where there are big Medicaid populations. Has there been pushback at all? Have there been political ramifications from these declarations to pull out?
MARGOT SANGER-KATZ: So, I do think that it's a little bit early, but hospitals are very much in favor of the Medicaid expansion.
The health care law cuts funds that they get now to pay for people who don't have insurance. And the way the law was designed was, that would be -- they would get more payments from people who have insurance and especially through the Medicaid program. So hospitals tend to be very powerful lobbies in state legislatures. And I think that especially safety net hospitals, but really all hospitals feel very strongly that they want to be able to have the Medicaid expansion go forward.
The other thing that is worth noting is that even though the populations that will be left out may not be the most powerful voting blocs in the state, I think it's a little bit hard politically for governors to say, we won't do this expansion, even though the federal government is paying 100 percent of the bill at the beginning, and even though the health care law is going to give financial assistance to people who of higher income to buy insurance and will give nothing to the poorest residents of those states.
GWEN IFILL: Margot Sanger-Katz of National Journal, Jon Ralston of The Las Vegas Sun, and Emily Ramshaw of The Texas Tribune, thank you all very much.