How the War Over Obamacare Can Erode American Democracy

by: Daniel Béland, Philip Rocco, and Alex Waddan, authors of Obamacare Wars

“I can’t answer that question.” That was House Speaker Paul Ryan’s response when asked how many people would lose insurance if his plan, the American Health Care Act, became law. Ryan’s reticence reflects the political reality Republicans presently face. After six years of promising to repeal and replace Obamacare, Republicans now control Congress, the White House, and a majority of state governments and so they need to deliver on their rhetoric.

Yet, as initially laid out, Ryan’s plan seems to invite rather than deflect political pain. The proposal for flat tax credits would likely increase premiums for many lower and middle income Americans, while providing tax relief for higher earners. The plan would make major cuts to Medicaid, which covers millions of low-income Americans while paying for roughly half of all live births and the vast majority of nursing home stays. Unsurprisingly, healthcare industry stakeholders from consumer groups to the American Medical Association oppose the plan.

So, why has Ryan led his party into supporting a plan that will only exacerbate the most unpopular aspects of health care provision? As our book Obamacare Wars suggests, the answer lies with how partisanship has trumped constructive efforts at bipartisan policy making. In March 2010, every Republican representative voted against passage of the ACA. After that, rather than helping fix problems with the law as it was rolled out, most Republicans, at both the federal and state level, aimed at undermining effective implementation of the reform.

For example, in Congress Republicans gutted the risk corridor program, designed to stabilize the individual market as insurers developed experience with covering new and costly populations of consumers. When premiums increased as a result, Republicans simply blamed Obamacare itself. As we detail in our book, in the states, many Republican Governors and state legislatures did not join with the Medicaid expansion and refused to establish their own state level insurance exchange.

Importantly, not all efforts at obstruction were successful. The Obama administration was quickly able to implement regulatory reforms, such as banning insurers from discriminating against consumers with pre-existing conditions and requiring insurers to cover dependent children up to the age of 26. The Ryan plan spares these especially popular provisions from the chopping block.

But just as partisanship largely shaped the ACA’s implementation, it now shapes the fight over repeal. In drafting their plan, House Republicans shut out policy expertise, even from conservative wonks like Avik Roy and James Capretta. Instead, they relied on party insiders, convinced that the only “problem” is the fact of the ACA’s initial passage, but there is irony in the Republican resolve. The ACA was modeled on ideas previously endorsed by conservatives and implemented in Massachusetts under Mitt Romney. This has left Republican leaders with few options they can brand as a distinctive “conservative” alternative. How do you privatize a law that already relies on private markets? How do you “devolve” a law that already relies heavily on action by state governments? The answer that Ryan proposes amounts mostly to spending cuts and upward redistribution that will hurt the Republicans’ own electoral base.

If politicians still fear electoral backlash for decisions that harm voters, the AHCA is unlikely to survive in its current form. Yet, the efforts to keep policy under wraps and to push through key decisions without extensive deliberation suggests that Ryan thinks policy effects could be decoupled from electoral punishment. Perhaps, when Republican voters experience sticker shock at the physician, Obamacare will still be blamed. This seems to be the outcome Ryan is gambling on. His willingness to throw the dice illustrates the intensely partisan context in which Obamacare developed. Republicans simply heaped all political blame for bad outcomes on Democrats. If they can continue to do so while running government at all levels, it will have ramifications beyond the ACA. Rather, it will mean that partisanship is capable of eroding the foundations of electoral democracy itself.

Daniel Béland, Philip Rocco, and Alex Waddan are the authors of Obamacare Wars: Federalism, State Politics, and the Affordable Care Act (University Press of Kansas, 2016).

2016 Elections: A Guide for the Perplexed

9780700622764By Dick Simpson and Betty O’Shaughnessy, Authors of Winning Elections in the 21st Century

Trump triumphed. Since he will become President of the United States, his victory matters. If he carries out his platform promises, he will create major changes in tax policy, immigration, foreign policy, Supreme Court appointments and, therefore, in social policies like abortion and gay rights. There will be broad resistance to those Trump policies but by executive orders and the momentum of the first hundred days of his presidency in Congress, he will get his way in changing the country’s direction in the beginning.

In Trump’s victory charisma and anger won over a less charismatic candidate following a careful game plan.

After this election, the Republicans will have a narrower margin in the Senate of probably 52-48 with Congresswoman Tammy Duckworth’s win in Illinois and a Democrat leading in New Hampshire. But to block any measures President Trump proposes, like destroying Obamacare, would require some moderate Republicans to join with the Democrats.

In the House of Representatives Democrats will probably hold 195 seats to Republican’s 240, too few to block Trump proposals. As a result, the Republicans will be firmly in control under Speaker Paul Ryan, but he may not be lock-step with Trump on all issues.

There were other lessons. Every election seems to be more expensive than the last. 2016 was one the most expensive elections in American. At least $1.3 billion was spent by Presidential candidates, $1 billion by candidates for the House of Representative, and $700 million on the U.S. Senate contests. Contested congressional election candidates spent at least from $2 million each and many spent much more. U.S. Senate races often cost $20-$40 million or more depending on outside PAC spending. In states like Illinois, a half-dozen state legislative districts spent more than $2 million on each of the opposing candidates which is a new record in Illinois. In the most expensive race for Illinois State Legislature, the candidates spent from $106 – $133 for each of the 20,000 votes they each received.   We desperately need real public funding of campaigns or “Small D Democracy” as advocates call it.

After 2014 there were 20 women in the U.S. Senate and 84 in the House of Representatives. Having Hillary Clinton as a major party Presidential nominee was a breakthrough for women this year, but women still have a hard time gaining parity with men at all levels of government. These 2016 elections only slightly improved situation as women hold only 20% of all elected offices. This needs to change, just as more Latino and Asian-Americans need to be able to run strong campaigns and get elected if our government is to look more like the U.S. population.

There were several reform experiments in the 2014 and 2016 election cycles. In many states, voters can register or change their registration online. Early voting has been extended brought to some college campuses. More people voted early than ever before. Absentee voting can now happen without giving any reasons in most states. And voters were still allowed to register in many precinct polling places even on Election Day. However, Automatic Voter Registration has not yet been widely adopted even though it would allow more people to participate and vote without artificial barriers.

Much of this year’s elections happened behind the scenes at both the national and local elections. Our book Winning Elections in the 21st Century decodes how voter analytics, social media, and old-fashioned door-to-door campaign work proceeded out of the spotlight. It also provides a handbook for those who are dissatisfied with candidates who were elected from local school board member to the President to win with popular participation in the elections of 2018 and beyond.

So what is next? Those who support President Trump will work to help him to have a successful first 100 days in office. Those who oppose President Trump and his policies will work to build resistance as many did when they opposed Reagan’s economic policies back in the 1980s. But the opposition must present a clear alternative and sell it to American voters if they are to win future elections.

In the end, this was an election in which the majority of American voted no against the elites and the status quo. There have been more than 4.4 million home foreclosures since the Great Recession began in 2008. There have been no real salary increases for the working and middle class. Unemployment, especially in ghetto areas and among young adults, remains too high. Americans were mad as hell and by their vote they signaled they aren’t going to take it anymore.