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).

Obamacare and the Presidential Election

9780700621910As January 31 marked the deadline for those wanting to avoid being penalized for lack of healthcare coverage, Washington Post’s Monkey Cage features an Op-Ed by “Obamacare Wars: Federalism, State Politics, and the Affordable Care Act” authors Daniel Béland, Philip Rocco, and Alex Waddan.  Discussing three ways a Republican president could dismantle the Affordable Care Act, the authors build upon the discussion in their book and offer a timely examination of federalism, politics, and the Affordable Care Act.

Publisher’s Pick: New Books from UPK

9780700620890As lawsuits against Obamacare again await a decision by the Supreme Court, many might wonder about the prominent role of state attorneys-general in bringing suits attacking the health care law. Recently we published the first study of litigation pursued by many state attorneys-general on policy issues, focusing on cases involving the liability of tobacco companies for the health consequences of smoking and litigation involving climate change and Obamacare. Paul Nolette’s “Federalism on Trial: State Attorneys General and National Policymaking in Contemporary America” shows how states, working together, have sought to use the courts to influence the policies of the federal government from both the left and the right. Liberal state attorneys-general have used law suits to push the government to adopt aggressive policies against climate change while cases have been litigated by conservative state attorneys-general to stop Obamacare. Nolette explores the legal strategies employed in these cases, the involvement of private interest groups in supporting the litigation, and the role of state politics, especially the ambitions of the attorneys-general and their relationship to other state leaders, in determining who will sue. Charles Epp says that “Nolette’s rich, carefully researched analysis shows that AG’s litigation campaigns are coordinated, politically polarized, and enhance federal regulation as much as challenge it.”

One of the exciting aspects of publishing now is that the internet and blogs like this offer the opportunity to build new connections between our authors and new audiences for their ideas and work. As a publisher of books on current affairs as well as history, I am eager to see these books join the conversations about important issues. From time to time in this blog, we will highlight new Kansas books that can change the way we think about critical issues now or important events of the past. Paul Nolette’s book is a great example of the public affairs books we publish and that we will bring to your attention in this blog and through our other marketing efforts.

–Written by Chuck Myers, Director of University Press of Kansas