While a proposal to restructure Medicaid as a block grant to states is an easy sell to the Republican base, Romney will dance carefully with Congressman Paul Ryan’s proposal to replace the current individual right to Medicare coverage with modified versions of his premium support proposal — vouchers to his polite opposition, “coupons for coverage” to his more vocal detractors. Competing theories aside, Romney can’t afford a major erosion of support among older voters, all Medicare beneficiaries.

Detouring momentarily, perhaps the most lasting controversy of the 2012 primary season were the competing narratives of either a War on Religion or The War on Women, and each was linked to the continuing health care debate. Both narratives represent a political formulation of deep policy divisions (indeed, cultural divisions) and the efforts of the Republican and Obama campaigns to appeal to both base and swing voters.

Early in the year, the Department of Health and Human Services issued a regulatory interpretation that employers offering insurance coverage under the ACA would be required to cover contraception among its benefits. The rule maintained a traditional exemption for church or other religious employees where the rule would offend church teaching. The rule, however, did not extend the exemption to non-church religious affiliated organizations — colleges, hospitals and social service providers, for example.

Immediately the Roman Catholic Conference of Bishops cried foul. Their argument was that by being required to pay for insurance that would cover contraception benefits, they were being forced to violate their core beliefs. The argument was not new. In numerous state insurance mandate laws, there is a “workaround” for this potential controversy. Churches, per se, are always exempted, but the non-church organizations still include contraception as a benefit to employees, often as a separate rider, with the costs not included in the premium paid by the religious group. In essence, a professor working at Notre Dame (a Catholic University) can still get the cost of her contraception covered, but the religious institution doesn’t have to pay. Insurance companies often eat those costs, which are negligible in practice and far outweighed by the benefit of avoiding complicated pregnancies. In theory, it’s a win-win-win.

Yet, whether motivated by fidelity to doctrine alone, or by the myriad and complex relationships which have allied the Conference of Bishops with opposition to ObamaCare and broader cooperation with the political Right, Church leaders attacked the President. Commentators, liberals among them, joined the charge. Joe Biden was reported to have warned that this was a step too far.

The White House acted quickly. HHS would find a way to diffuse the controversy, aware of the compromise arrangements in many states. Church leaders were polite, but then reemphasized their opposition. Whatever the details, the Administration had taken a hard political hit.

Yet, as we have observed before, one of the cardinal rules in politics is that when you are in real trouble, count on your opponents to overplay their hand.

As the controversy raged, Sandra Fluke found unanticipated fame. Fluke, a Georgetown University law student who would be denied contraception coverage were the Church’s position to stand, spoke not of herself but of a fellow student who lost an ovary through a condition treatable with birth control medication.

Out of the Right came the bombastic thunder of radio host Rush Limbaugh. If Fluke wants a birth control benefit,  he argued, she wants us to pay for her to have sex. Therefore, she’s a slut, or worse. The comments simply do not deserve repeating.

An asterisk on the controversy, however, was Limbaugh’s second day remark. Not satisfied with the “slut” attack on a student expressing a widely held view, Limbaugh suggested on the air that if he had to “pay” for Ms. Fluke’s sexual relations, he ought to watch them via video. The comment reflected neither the law nor any link to reality. But no American media figure other than Rush could have gotten away with so extraordinarily offensive a comment. Money, money, and capital P power keep him on the commercial airwaves and pulling Republican strings.

But what just happened? The Bishops were attacking Obama with considerable success, framing the action on health benefits as an overreach by government. Then, almost overnight the Administration was on offense, protecting access to contraception, defending a young woman from the assaults and insults of right wing radio, and converting the War on Religion to a War on Women. An exclamation point for the Administration was provided by a Congressional hearing chaired by Congressman Darrell Issa in which a panel of male witnesses were invited to discuss “religious freedom” and women, Ms. Fluke specifically, were barred from discussing contraception.

Such competing views are part of a larger process. As the general election takes form, Mitt Romney has secured the Republican nomination, but the presence of dyed-in-the-wool social conservative Rick Santorum throughout the primary season has pulled the presumptive nominee off his economic message and away from centrist voters. He will attempt to hit the re-set button (or shake the Etch-a-Sketch, as it were) but his positions are much farther away from independents than when he started the campaign.

Much will happen in the months ahead. The Court’s decision and the elections make December’s Belmont Stakes of budget battles seem very far off. But the end of 2012 will bring a mighty confluence of events. Most pressingly, there will be the expiration of the Bush tax cuts, for all of us, not just the rich. The failed Super Committee of Thanksgiving 2011 locked the Congress into huge “automatic” cuts to Federal spending at the start of 2013 if a miraculous agreement is not reached by the New Year. Once again the deficit reduction drumbeat will sound its call to battle. Likely the best-case scenario for the economy will be a projection of weak growth against a backdrop of global risk. The hope, and perhaps the fear, is that a combination of reelected officials and a flock of lame ducks ready to fly out of Washington will gather to govern America. And key decisions will be required before anyone takes their next oath of office.

The mere thought of it raises the stakes in this Triple Crown beyond imagination — and for better or worse, the starting bell has rung, the gates sprung open . . . and they’re off!


Jim Tallon is the president of the United Hospital Fund, a think tank in New York City. He served previously as Majority Leader of the New York State Assembly. To read the entire series in this commentary, click here. All political cartoons by DonkeyHotey.

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