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Friday marked the second anniversary of President Barack Obama signing the Patient Protection and Affordable Care Act, more commonly known as health care reform or "Obamacare." After the jump I enclose lots of news related to the milestone, including comments from Iowa elected officials and statistics on how certain provisions affect Iowans.
I consider the Affordable Care Act deeply flawed. Obama and the Democratic-controlled Congress failed to deliver on too many promises related to health insurance coverage. Many of the law's provisions haven't gone into effect yet. Most states still have minimal competition in the health insurance market. Insurance premiums continue to rise much faster than the rate of inflation. The high-risk pools that were supposed to be a bridge for uninsurable adults are covering only a tiny proportion of the eligible population.
* Amy Ward of West Des Moines, Iowa came down with a rare infection that nearly cost her life. Without the Affordable Care Act, Amy and her husband may not have been able to afford all the care she needed to recover. Before the new health care law, Amy's health insurance policy had a lifetime dollar limit.
I know Ward and her husband, Ross Daniels. During her health crisis last summer, the question of lifetime insurance caps never crossed my mind. Daniels told me last week that medical bills related to his wife's illness exceed $1.4 million, and she is still being treated for some complications. He spoke to Joseph Morton of the Omaha World-Herald:
The lifting of lifetime caps made a big difference for West Des Moines' Amy Ward, 40, who contracted a rare lung infection after getting a mouthful of water during last year's summer vacation to the Boundary Waters in northern Minnesota.
Ward's expenses after three months in the hospital, including two months in intensive care, were well above her insurance plan's $1 million lifetime cap. Under the new health care law, the cap no longer applied.
Her husband, Ross Daniels, said the hundreds of thousands of dollars in expenses above the million-dollar cap would have cost them their house and retirement savings and possibly forced them into bankruptcy.
"No partner sitting in a critical care unit watching their partner fighting for their life should have to worry about whether or not these expenses will be covered fully by their insurance," Daniels said.
Few people can say that health care reform saved them from financial ruin. Most Americans probably haven't noticed any difference in their medical care or insurance coverage since the law went into effect. But the Obama administration and Congressional Democrats tried last week to spread the word about people in every state who are already benefiting.
The Democratic staff of the U.S. House Energy and Commerce Committee released reports last week on the impact of health care reform in each Congressional district. Click the following links for pdf files on the districts represented by Bruce Braley, Dave Loebsack, Leonard Boswell, Tom Latham, and Steve King. The reports focus on the impact of seven provisions in the Affordable Care Act:
1. More young adults able to stay on their parents' health insurance plans until age 26. The estimated number of beneficiaries ranged from 2,800 people in King's current district (IA-05) to 4,200 in Loebsack's current district (IA-02).
2. Senior citizens receiving prescription drug discounts averaging about $600 per person. The estimated number of beneficiaries ranged from 6,500 people in Braley's current district (IA-01) to 9,300 people in IA-05.
3. Senior citizens receiving "Medicare preventive services without paying any co-pays, coinsurance, or deductibles." The estimated number of beneficiaries ranged from 72,000 in Boswell's current district (IA-03) to 84,000 in IA-05.
4. Preventive health care services for children and adults without co-pays, coinsurance, or deductibles. The estimated number of beneficiaries ranged from 29,000 children and 110,000 adults in IA-05 to 35,000 children and 130,000 adults in IA-03.
5. Tax credits for small businesses to maintain or expand health insurance coverage for employees. The estimated number of beneficiaries ranged from 460 small businesses in IA-02 to 520 businesses in IA-05.
6. Public health grants to "community health centers, hospitals, doctors, and other healthcare providers in the district." Nothing was listed in this category for the reports on IA-02 or IA-04. Grants awarded in IA-05 total $4.9 million. The total for IA-01 is $9.7 million, and the total for IA-03 is $23.8 million.
7. The number of children who are no longer uninsurable because of their pre-existing health conditions was estimated at 7,000 to 32,000 in IA-01, IA-04, and IA-05, 7,000 to 33,000 in IA-02, and 8,000 to 37,000 in IA-03.
Braley held a panel on March 25 in Cedar Rapids, featuring three local residents who benefited from different aspects of health care reform. Democratic State Senator Liz Mathis, who represents part of the Cedar Rapids suburbs, was among roughly 75 people at the Braley event. Braley's embrace of the law is politically risky, because some of its provisions are unpopular. On the other hand, Republicans and conservative interest groups will hammer him for voting for the bill during this year's campaign. Highlighting some of the law's good points may be smarter than keeping his mouth shut and hoping the issue goes away.
"One thing that people don't realize about this is that it actually will reduce the federal budget," Vilsack said. "The Congressional Budget Office has determined that this act will reduce the federal deficit by over $100 billion over the course of the next decade."
According to Vilsack, people also overlook the tax breaks that were included in the legislation.
"Particularly for small businesses, a 35 percent tax credit is a fairly significant tax create that makes it a little bit easier to afford the cost of health care coverage for a company that has, maybe, a half-dozen employees or so," Vilsack said.
Vilsack, who is serving as U.S. Ag Secretary, invited a registered nurse at a hospital in Spencer, Iowa, to join his conference call to laud the provision that bars insurance companies from denying coverage due to preexisting conditions.
All the Iowa Republicans in Congress voted against the Affordable Care Act in 2010. Chuck Grassley took to the Senate floor last week to criticize the president's "broken promises" on health care reform.
Floor Remarks by U.S. Senator Chuck Grassley
Broken Promises in the 2010 Affordable Care Act
Wednesday, March 21, 2012
In 1994, the health care reform bill proposed by then President Clinton failed, in large part, because it would fundamentally changed health care coverage for nearly every American. In 2009, President Obama decided he would combat the failure of the Clinton Administration by repeating over and over again to the American public "if you like what you have, you can keep it."
It is my understanding he said that on 47 separate occasions while the bill was being debated in Congress. And while it may have been political useful to make that promise to the American people, it remains a promise he can't keep. The fact is that millions of Americans are seeing changes in their existing health plan due to the health law.
The Administration's regulations governing so called "grandfathered health plans" will force most firms-and up to 80 percent of small businesses-to give up their current plan by next year. When those businesses lose their 'grandfathered' status, they immediately become subject to costly new mandates and the increased premiums that follow.
Families in 17 states no longer have access to 'child-only' plans as a result of the health law. It's not known how many of the families that lost coverage for their children because of the law have been able to find an affordable replacement. In Medicare Advantage, there is one study showing Medicare Advantage enrollment will be cut in half, choices available to seniors will be reduced by two-thirds.
Then there is the open question about Americans who receive their health care through large employers. The Congressional Budget Office recently released a report with that constructed a scenario where as many as 20 million Americans could lose their employers coverage. And while I acknowledge the Congressional Budget Office report provided the number I just mentioned as only one plausible scenario, there are many of us who believe it is very plausible given the incentives the health law creates for large businesses.
The President made a further promise that I think we should talk about. On July 29, 2009, during the consideration of the health law, the President said "Medicare is a government program. But don't worry: I'm not going to touch it."
So let's take a look at the health care law and see if that promise was kept. The health care law made significant cuts in the Medicare program. On April 22, 2010, the Chief Actuary for Medicare analyzed the law and found that it would cut Medicare by $575 billion over ten years. The President said about Medicare "I'm not going to touch it." The bill cuts $575 billion from Medicare. The Congressional Budget Office wrote that over $500 billion in Medicare reductions "would not enhance the ability of the government to pay for future Medicare benefits." The President said about Medicare "I'm not going to touch it."
The CMS actuary had this to say about the Medicare spending reductions: "Providers for whom Medicare constitutes a substantive portion of their business could find it difficult to remain profitable and, absent legislative intervention, might end their participation in the program." The President said about Medicare "I'm not going to touch it."
The CMS actuary said, in essence, these cuts could drive providers from the Medicare program. I have a hard time understanding how these massive cuts to Medicare count as not touching the program. On the other hand, the biggest problem facing Medicare in the near term is the physician payment update problem that we constantly have to address here in Congress. Of course, the health care law did nothing to address that problem. Perhaps that's what the President meant when he said about Medicare, "I'm not going to touch it."
King has been one of the GOP's leading advocates of "Obamacare" repeal for the past two years. He had this to say at a press conference last week:
"If we turned to the American people and said, 'Come tear these pages out,' they would tear every page out of there," King said during the news conference, "and there'd be people standing in line to do that."
King has called the law an "assault on the personal liberty" of Americans that "nationalizes our skin and everything inside" our bodies.
"Piece after piece, we know how bad this is," King said. "I don't have to do down through the list. It's unaffordable, unsustainable, unconstitutional. The Supreme Court will get a look at this later this month and I hope to be there to hear that argument."
King's office sent out this press release on March 23:
King: Two Years Later ObamaCare is One, Massive Empty Promise
Washington, DC- Congressman King released the following statement to mark the two year anniversary of ObamaCare becoming law:
"Today marks an event that will not be celebrated," said King. "The American people have rejected this government takeover of their healthcare. Americans know that ObamaCare infringes on our liberty and they know that the price tag is unsustainable. It seems that every day brings new revelations about its skyrocketing costs and its overstated coverage provisions. ObamaCare is one, massive empty promise. The next President must make 100% repeal his number one priority so that this second anniversary of ObamaCare's passage is the last."
I did not see any public comments on the health care reform anniversary from Loebsack, Boswell, or Latham. Latham's Congressional campaign focused on the issue in a fundraising e-mail blast that went to supporters on March 23. Iowa Citizens for Community Improvement Action Fund posted the full text of that e-mail here (pdf). Excerpt (emphasis in original):
Do you really want the same Washington who brought you the compassion of the IRS, the competence of federal bureaucrats, and the efficiency of the Hurricane Katrina response to deliver the health care your family depends on?
This month the non-partisan Congressional Budget Office (CBO) announced that the new health care law will cost hardworking taxpayers nearly double what was promised by the President.
This is just the latest in a string of broken promises about, and failures of, the President's new health care law that has meant higher costs for patients and taxpayers while raiding Medicare and putting seniors and veterans at risk.
I [am] working to repeal this bad health care law and replace it with legislation that gives American's [sic] what they really wanted from health care reform.
Iowa CCI Action slammed Latham in a press release on March 23 (excerpt):
Latham confuses facts, figures in latest email to supporters
CCI Action Fund finds use of CBO numbers on healthcare reform misleading, troubling
Des Moines, IA - In an email to supporters Friday, Congressman Tom Latham claimed that the Congressional Budget Office (CBO) announced that a new health care law will cost taxpayers nearly double what was originally estimated.
This claim runs counter to reports that the cost has only increased by 8% - a far cry from the 50% increase Latham claims in his email.
"It's concerning, but not surprising, to see politicians twisting figures around to fit the narrative they want the American public to believe, true or false," said Matthew Covington, Strengthen Social Security organizer for the CCI Action Fund. "What should be more concerning is Latham's promise to work to repeal the law and replace it with something else, which would be Paul Ryan's budget plan that guts Medicare and Medicaid."
Late last week, the U.S. House voted to repeal one portion of the health care reform law. The Independent Payment Advisory Board was established to help reduce federal spending on health care. The bill repealing that provision could have had substantial bipartisan support, if House Republicans hadn't added "tort reform" to the mix. Pete Kasperowicz reported for The Hill,
Democrats spent much of the week arguing against the GOP plan to pair up the repeal of the Independent Payment Advisory Board (IPAB), something many Democrats supported, with tort reform, which most Democrats opposed.
In Wednesday's six-hour debate on the bill, several Democrats said they support IPAB repeal along with Republicans, because they fear the board could recommend Medicare cuts without having to gauge the opinion of Congress. But they chaffed at the tort reform language that, among other things, would impose a nationwide limit of $250,000 in punitive damages in medical lawsuits.
"I'm very disappointed that the Republican leadership has robbed many Democrats of their ability to vote cleanly on IPAB repeal, and have instead, yet again, politicized this body," said Rep. Frank Pallone Jr. (D-N.J.). "When will you learn?"
Memo to Mr. Pallone: it's not in Republicans' interest to help you vote to repeal something unpopular. Adding a poison pill for Democrats is just hardball politics.
On March 22, the House approved H.R. 5, repealing the Independent Payment Advisory Board, by a mostly party-line vote of 223 to 181 (roll call). Latham voted for the bill. Braley, Loebsack, and Boswell opposed it. King was one of four Republicans to take the unusual step of voting "present." He explained why in this press release (emphasis in original):
King: Partial Repeal Only Empowers ObamaCare
Washington, DC- Congressman King released the following statement today after the House voted to repeal one of the most egregious pieces of ObamaCare, the Independent Payment Advisory Board (IPAB). King voted 'present' on H.R. 5, the IPAB repeal bill, to signify his opposition to a piecemeal strategy of ObamaCare repeal.
"IPAB is just one abhorrent aspect of ObamaCare- but it is one of the most intrusive," said King. "It is the heart of Obamacare, because without IPAB, the rationing of access to care is not possible. This unelected board of bureaucrats responsible for shaping the future of our health care must be repealed, but not as an independent piece of the law."
"We must pull ObamaCare out by the roots because it is an unconstitutional takings of our Liberty. IPAB is not distinct from ObamaCare, it is the essence of ObamaCare and for that reason the law must be repealed as a whole. The American people continue to speak out against ObamaCare's individual mandate, its attack on essential first amendment conscience protections, and its multitrillion-dollar price tag. Partial repeal only empowers this government takeover of one-sixth of the economy, and until full repeal is realized we will continue to muddle our message."
I don't share King's ideology regarding health care policy, but I do agree with him that repealing one particularly bad piece of a law weakens the case for repealing the entire law.
"Congress finds that the health care and insurance industries are industries affecting interstate commerce and the health care liability litigation systems existing throughout the United States are activities that affect interstate commerce by contributing to the high costs of health care and premiums for health care liability insurance purchased by health care system providers."
Various lawsuits seeking to overturn the Affordable Care Act question the federal government's power to force individuals to purchase health insurance. Defenders of the law generally point to the "Commerce clause" of the U.S. Constitution, which empowers Congress to regulate anything that affects interstate commerce. With the Supreme Court about to consider the legal challenges to health care reform, it would have been stupid for House Republicans to advertise the obvious: the health care and insurance industries affect interstate commerce.
The amendment seeking to strike the findings language from H.R. 5 passed on a mostly party-line vote of 234 to 173. Braley joined Iowa Republicans King and Latham in voting for that amendment. Boswell and Loebsack voted against it.
Repealing the Affordable Care Act will become irrelevant if the U.S. Supreme Court strikes down the law later this year. I expect a 5-4 ruling invalidating the individual mandate to purchase health insurance. The conservative five (Chief Justice John Roberts and Justices Antonin Scalia, Clarence Thomas, Samuel Alito, and Anthony Kennedy) may or may not invalidate the entire law for that reason. Even if they leave the rest of the law standing, the reform will fall apart. The Obama administration will not enforce "guaranteed issue" provisions (banning insurance companies from denying coverage to adults with pre-existing conditions) unless the insurance companies are guaranteed a money stream from young, healthy adults who have to purchase coverage.
Many legal experts disagree with me. Linda Greenhouse of the New York Times argues here,
The constitutional challenge to the law's requirement for people to buy health insurance - specifically, the argument that the mandate exceeds Congress's power under the Commerce Clause - is rhetorically powerful but analytically so weak that it dissolves on close inspection. There's just no there there. [...]
The government brief repeatedly cites a 2005 Supreme Court decision, Gonzales v. Raich, which upheld Congress's authority to criminalize the private, non-commercial cultivation of marijuana for medicinal purposes. Justice Antonin Scalia wrote a concurring opinion in that case.
Neither Chief Justice John G. Roberts Jr. nor Justice Samuel A. Alito Jr. was on the court then. But two years ago, they both voted with the majority in another case the government cites repeatedly, United States v. Comstock. That decision, a robust interpretation of Congress's authority to pass legislation it deems "necessary and proper," upheld a federal law imposing extended confinement on dangerous sexual predators who have completed their criminal sentences. [...]
From reading the government's brief, one might conclude that Raich and Comstock were the only two relevant cases in the constitutional firmament. But unlike the "unprecedented" mantra, these recent decisions really do shed light on the contemporary understanding of the scope of congressional authority. If the commerce power extends to backyard marijuana growing (as it did to backyard wheat growing in the famous New Deal case of Wickard v. Filburn), the notion that Congress somehow lacks the power to regulate, restructure or basically do whatever it wants in the health care sector, which accounts for 17 percent of the gross domestic product, is far-fetched on its face.
Greenhouse's piece is worth reading. I'm not convinced the justices will follow her logic, because the conservatives on the Roberts court have repeatedly shown themselves to be results-oriented rather than consistent on legal principles.
Dahlia Lithwick wrote a fascinating piece for Slate arguing that "Next week's health care argument before the Supreme Court is all about optics, politics, and public opinion."
Despite the fact that reading the entrails of those opinions suggest that [Scalia, Roberts and Kennedy would] contribute to an easy fifth, sixth, and seventh vote to uphold the individual mandate as a legitimate exercise of Congressional power, the real question isn't whether those Justices will be bound by 70 years of precedent or their own prior writings on federal power. The only question is whether they will ignore it all to deprive the Obama of one of his signature accomplishments.
[...] as it happens, the current court is almost fanatically worried about its legitimacy and declining public confidence in the institution. For over a decade now, the justices have been united in signaling that they are moderate, temperate, and minimalist in their duties. From Chief Justice Robert's description of himself as just an "umpire" and his speeches about humility and the need for unanimity, to Stephen Breyer's latest book Making Our Democracy Work-a meditation on all the ways the courts depend on public confidence. Roberts even nodded at that court-wide anxiety by devoting most of his 2011 State of the Judiciary report to issues of recusal and judicial integrity, and by reversing his own policy on same-day audio release, in order to allow the American public to listen in on the health care cases next week (albeit on a two-hour delay). That means that the court goes into this case knowing that the public is desperately interested in the case, desperately divided about the odds, and deeply worried about the neutrality of the court. (Greenhouse points to a Bloomberg News national poll showing that 75 percent of Americans expect the decision to be influenced by the justices' personal politics.) To hand down a 5-4, ideologically divided opinion just before the Republican and Democratic Party conventions, would-simply put-prove that 75 percent correct, and erode further the public esteem for the court. Justice Clarence Thomas doesn't worry much about things like that. I suspect Chief Justice Roberts and Justice Kennedy worry quite a lot.
If I am right about this, some justices may believe that this isn't a fight worth having. Not now and not over this issue. Recall, even absent the health care case, the 2011 and 2012 terms will represent two of the most divisive and incendiary terms in recent memory. The court isn't just hearing the health care case this year. It also heard a Texas redistricting case, and the Arizona immigration case. Next year it will hear the Texas affirmative action case, and very likely a case that will question the entire existence of Section 5 of the Voting Rights Act. Oh, and next term, the court may well have to contend with a gay marriage case, and at the rate state legislators are passing patently unconstitutional abortion regulations, it's not unlikely the court will be revisiting Roe soon thereafter.
Given that line up of future cases, the five conservatives may want to keep their powder dry for now. I think they will.
If you believe Lithwick, the conservative five Supremes are only willing to expose their political hackery for fights that emerged in the "conservative legal academy." I doubt they will resist the temptation to undercut the re-election prospects of Obama and all the Democrats who voted for health care reform.
The question on the first day boils down to one basic issue - can the Supreme Court even rule on the constitutionality of the tax penalty associated with the individual mandate at this time?
Starting in 2014 under the Obama health law, a tax penalty is levied against people who do not purchase health insurance. That payment would be due in 2015.
At issue is a law from 1867 known as the Anti-Injunction Act. The basic thrust of that law is it prohibits lawsuits against a tax until that tax has been levied and collected.
Fast forward to 2012, and the tax penalty linked to the invidiual mandate has not been applied as yet - so the legal theory is very clear - no one has standing at this point to challenge the individual mandate penalty in court. [...]
What's really interesting about this first day is that no one brought this issue before the Court on appeal - instead, the Justices decided that they wanted to hear arguments on this matter.
So, while I'm not even close to being a legal expert, that tells me there was some support among the Justices for seriously looking at this option. [...]
A big part of the debate in Congress on the failure to buy health insurance - the individual mandate - centered on the penalty for not doing so. Is it a "tax" or just a "penalty" that is involved here?
"Tax" was not a word used often in the debate, so many argue that it should not come under the jurisdiction of the Anti-Injunction Act.
I was not aware of this legal angle before reading Dupree's post. Since Democrats tried to avoid framing anything in the health care reform bill as a new tax, the justices might conclude that Congress did not intend to levy a "tax" on individuals who refused to purchase health insurance. On the other hand, it might be convenient for the Supreme Court not to rule on this case until 2015.
"Judges in the lower courts, in the circuit courts, have made it very clear, that arguments against the act lacked merit, they have no basis in law and to overturn this health reform bill would overturn 70 years of precedents."
Any relevant thoughts are welcome in this thread.
UPDATE: I should have mentioned that during House debate on H.R. 5, Loebsack offered an amendment designed to "protect Medicare". Here's a video of Loebsack speaking about his amendment, which was offered as a motion to recommit the bill with instructions. That motion failed by a vote of 180 to 229. Braley, Boswell, and Loebsack supported the motion to recommit, while Latham and King joined all but one of their Republican colleagues in rejecting it. Loebsack's office highlighted the amendment in a March 22 press release:
Washington, D.C. - Congressman Dave Loebsack today offered an amendment to protect our nation's seniors. The amendment is very simple, it says: don't eliminate Medicare and don't increase costs or reduce benefits for seniors. Loebsack's amendment, offered as a motion to recommit, would help preserve and strengthen Medicare.
"I have met with seniors from across Iowa, and far too often I hear that many of them are struggling to make ends meet and how much they rely on Medicare in order to stay healthy and stay afloat financially. Our seniors did not get us into the fiscal mess we are in today and it is unfair to punish them for Washington's irresponsible behavior. We've got to balance the budget, but we've got to do it the right way. We've got to protect Medicare for seniors who've worked a lifetime to pay into it.
"The Republican plan for Medicare would force seniors to do just that. It would end the Medicare guarantee, replacing it with a voucher system. This voucher would not keep up with health care inflation, forcing seniors to pay more and more of their health care costs out of pocket. In these tough economic times, we need to find ways to be more efficient while maintaining quality of care.
"I know that seniors don't want a voucher that forces them to buy insurance in the private market. They don't want higher costs or reduced benefits. And they don't want some new-fangled program. They want to keep Medicare the way it is: a guaranteed benefit they can count on when they need it."
Recent polling by the Kaiser Family Foundation shows 70 percent of Americans, including 53 percent of Republicans, want Medicare "as it is today, with the government guaranteeing seniors health insurance and making sure that everyone gets the same defined set of benefits. According to AARP: "By creating a "premium support" system for future Medicare beneficiaries, the proposal is likely to simply increase costs for beneficiaries while removing Medicare's promise of secure health coverage -- a guarantee that future seniors have contributed to through a lifetime of hard work."
Steve King discussed the Supreme Court case on Fox News Monday. He's optimistic the justices will strike down the mandate and the entire law, which doesn't contain a "severability clause" (declaring that if one part is found unconstitutional, the rest of the law is still valid).
King's office released this statement on March 26:
King Releases ObamaCare Informational Timeline
Washington, DC- Congressman Steve King (R-IA) an ardent opponent of ObamaCare, released an informational timeline today on his website to help educate the American people on what's been discovered about ObamaCare. King said the following to highlight the first day of Supreme Court hearings:
"To mandate that everyone must buy a health insurance policy is a huge reach, and this is exactly the kind of government the Founding Father's wanted to limit," said King. "I don't know how the Supreme Court could rationalize that this law is constitutional. We need to rip ObamaCare out by the roots, making it "as if such act had not been enacted." That's the repeal language I authored that passed the House last year. Since then, however, we've learned even more about ObamaCare's unsustainable costs and its empty promises."
"I've posted a timeline on my website of all that we've discovered about ObamaCare since that House passed my repeal language last year. I hope all interested Americans will visit my website and review this timeline. When they do, they'll gain a deeper understanding of the magnitude of the decision that's before the Supreme Court this week. Today marks the first day in a historical case, and the decision could determine the direction of our nation."
To view the timeline on Congressman King's website click here.
That timeline provides a slanted view of the Affordable Care Act but contains some interesting links. I hadn't seen this report from a few weeks ago.
Voting for President Obama's healthcare reform law cost Democratic incumbents 5.8 percentage points of support at the polls in 2010, according to a new study in the journal American Politics Research.
The study helps explain why Democrats lost 66 House seats, significantly more than the median academic forecast of 44 to 45 seats, study co-author Brendan Nyhan of Dartmouth College writes on his blog. [...]
"We show that the roll-call effect on vote share was driven by healthcare reform. Democratic incumbents who voted yes performed significantly worse than those who did not," Nyhan writes. "We then provide simulation evidence suggesting that Democrats would win approximately 25 more seats if those in competitive districts had voted no, which accounts for the gap between the academic forecasts and the observed outcomes."