Will health care reform work in the end?
In light of the Supreme Court decision yesterday upholding the Affordable Care Act, I thought this brief excerpt from Health Care Reform and American Politics: What Everyone Needs to Know by Lawrence R. Jacobs and Theda Skocpol was in order. — Blog Editor Alice
Matters are far from settled for the Affordable Care framework that promises significant new benefits for the vast majority of Americans to be paid for by taxes on the wealthy and fees from businesses. The U.S. political system gives disproportionate leverage to the privileged and well-organized economic interests—the very groups that Affordable Care designates to pay for improved health care for all of their fellow citizens. The fat cats don’t like it, and they have potent weapons at their disposal to fight back—money for media campaigns, legions of lobbyists, and now, with the Citizens United decision by the Supreme Court, an unlimited ability to contribute to electoral campaigns. With every resource at their disposal, such groups will continue to weigh in as regulations are written at the federal level—and also as rules for insurance exchanges are devised in fifty different states. They will stalk the new law in the courts. And they will use the electoral process to elect Representatives and Senators and governors and state legislators who share their sympathies—people they can lobby, along with administrators, to make changes in taxes, subsidies, and rules. Much of this will happen out of public view, as it will be complicated and not easy to dramatize on cable news.
We will not know for a decade or so how far the push-back gets. The sway of the powerful may well produce a steady rollback of many of the specific ways in which Affordable Care helps middle-income and lower-income Americans. It is just too easy and tempting for public officials of either party to enact tax breaks for the rich, or adjust regulations and subsidies as demanded by well-heeled business interests. Each little change will seem small enough for an individual legislator, including a Democrat, to rationalize. But the little concessions to the status quo and to the rich and the powerful will add up.
There are also rosier scenarios—either much rosier or somewhat rosier. Perhaps the new law will withstand most of the initial attacks—and dodge many of the concerted efforts to trim back taxes, relax rules, and reduce help for everyday Americans. Vigilant citizens can help to hold the line, yet key stakeholders are also likely to prevent certain kinds of rollbacks. Affordable Care rules say that insurance companies can no longer deny applicants because of “pre-existing” adverse health conditions, or charge them huge, surprise payments when they become sick, or dump them altogether when they become costly. These new insurance rules are so popular that no political party in power is likely to be able to get away with going back to the pre-2010 status quo ante. Consequently, insurers who do not want the rules without additional paying customers will aim to protect public subsidies that enable millions to buy insurance. Another powerful force for holding the line against rollbacks is the AARP, which seeks to protect improved subsidies for prescription drugs and preserve help for nearly retired people who get laid off and need to purchase health insurance on their own. Conservative and liberal activists alike may also win victories in states or regions that they want to preserve, giving them a stake in the survival of Affordable Care. Conservatives might have a favorite market-based system, for example, while progressive reformers might succeed in setting up public options or even a single payer system in particular states or regions.
In short, if Affordable Care survives lawsuits and immediate resistance from more conservative delegations in Congress, its prospects will start to rise. Americans always turn out to value and support major social programs that help individuals and families gain basic security with dignity. Social Security and Medicare were only enacted after ferocious opposition on par with resistance to the Affordable Care Act, and both remained politically controversial for some time after initial enactment; but as they were carried through and the initial visions of reform were realized in practice, these laws became beloved and indispensable to most American families. Social Security and Medicare also encouraged older citizens, regardless of educational or income levels, to become more attentive about government; before these programs were established, seniors voted at about the same level as other Americans, but now they are the nation’s most regular voters, vigilant about politicians who might mess with their benefits and rights.28 The same may happen with Affordable Care in due course, after its meaning becomes clear to most Americans—including to the younger, minority men and women and the less affluent of all backgrounds who are, in truth, the biggest winners in the emerging health care system. New generations of voters may come to rely upon Affordable Care’s protections and subsidies, and staunchly defend them in future elections and public debates. Many conservatives have fiercely opposed comprehensive health reform precisely because they fear it will be very popular once fully in place.
Even if Affordable Care withstands just some of the counterreactions to come, the limitations of the purely negative strategies pursued by conservatives and Republicans in the health reform battles of 2009 and 2010 will become apparent. The decision by Republicans in Congress to just say no to negotiations for bipartisan bills in effect removed them from the negotiating table after the Senate Finance Committee completed its work in the early fall of 2009. This, in turn, opened the door for moderate and liberal Democrats to make reform legislation more progressive in late 2009 and early 2010—above all, to insert taxes on the rich that will be very hard to roll back, because doing so would balloon the federal deficit.29 What is more, the continuing right-wing clamor for repeal months after the White House signing ceremony belies the fact that the new Affordable Care legislation is already “on the books,” that it is, day by day, month by month, restructuring how individuals and businesses pay for and receive health care. Unless an entirely unexpected judicial ruling strikes down all the legislation, significant parts—including regulations hemming in the behavior of insurance companies—will almost certainly endure. Health care in the United States will not go back to the way it was before March 23, 2010. Ongoing struggles over the full implementation of Affordable Care have a way to go, but they will not reverse all that has been legislated. In one way or another, we have already seen an irreversible shift in U.S. politics, along with an historic expansion in the social rights of American citizens.
Lawrence Jacobs and Theda Skocpol are the authors of Health Care Reform and American Politics: What Everyone Needs to Know, which we have a sneaking suspicion may already be undergoing revision and updates. Lawrence R. Jacobs is the Walter F. and Joan Mondale Chair for Political Studies and Director of the Center for the Study of Politics and Governance in the Hubert H. Humphrey Institute and Department of Political Science at the University of Minnesota. Theda Skocpol is the Victor S. Thomas Professor of Government and Sociology at Harvard University, a member of the National Academy of Sciences, and past president of the American Political Science Association.