Paul Starr has an excellent article up on the American Prospect website running down how the Democrats are now winning on health care. Starr notes:
"It took a long time, but the Affordable Care Act finally paid off politically for Democrats in the 2018 election. According to exit polls, voters rated health care the top issue, and they trusted Democrats on it more than Republicans....
In 2018, unlike the other elections since the ACA’s passage in 2010, voters had seen what Republicans were actually proposing to do about health insurance....[T]he legislation passed by Republicans in the House and endorsed by Trump would have resulted in millions of people losing coverage and sharply increased costs for others, especially for older people buying insurance in the individual market. Unable to pass that bill in the Senate, Republicans saw the whole repeal-and-replace effort collapse.
Seizing on the Republicans’ failed rollback, Democratic congressional candidates and the groups supporting them highlighted health care more than any other issue. According to an analysis by Wesleyan Media Project, 54.5 percent of all Democratic ads from September 18 to October 15 discussed health care; those ads focused overwhelmingly on protecting people with preexisting conditions and on Republican efforts to undo the progress under the ACA....
Not only do the election results put an end, at least for the next two years, to Republican congressional efforts to undo the ACA; the voters also chose to extend coverage. Five states are now likely to expand Medicaid—three (Idaho, Nebraska, and Utah) where voters passed referenda in favor of expansion, and two (Kansas and Maine) where a shift from a Republican to a Democratic governor removes the last obstacle to expansion."
Starr advocates that Democrats now move to extending and improving the ACA, particularly in the context of the 2020 election campaign. I agree completely. Starr in particular advocates what he calls "Midlife Medicare", making Medicare available to those 50-64. I am fine with that though there is a lot to be said for "Medicare for All", especially in a campaign context. Even if such an approach is difficult to implement all at once, it can serve as both a rallying cry and an identifying principle for various, more specific reforms.
I would broaden Starr's argument about the ACA and left strategy as follows. Over time, the left has accomplished many things, from building out the social safety net to cleaning up the environment to protecting public health to securing equal rights for women, black people, and gay people. These and many other gains of the left have a very important thing in common: They are “sticky.” That’s a term borrowed from economics that means, simply, they will be hard to reverse. They provide benefits that people do not want to lose — and, what’s more, they shift norms of what is right and wrong.
Social Security and Medicare are great examples of policies that once seemed radical and now are simply a part of life. The Affordable Care Act’s core innovations may turn out that way, as well, despite the controversy that has dogged the program from its inception — and the declared intent of the current administration to eliminate it.
The ACA has provided benefits to millions who don’t want them taken away, and helped to establish the principle that every American has a right to health care, guaranteed by the government. That’s why the Republican attempt to radically downsize the program hit a buzzsaw. To be sure, Republicans will keep trying. But, in the end, they will not be able to “repeal and replace” with a fundamentally less generous program.
Instead, it’s more likely that the ACA, either under that name or another, will get more generous over time. As the late conservative columnist Charles Krauthammer noted during the initial ACA repeal fight: “A broad national consensus is developing that health care is indeed a right. This is historically new. And it carries immense implications for the future. It suggests that we may be heading inexorably to a government-run, single-payer system.”
Krauthammer was despairing, but the left should be heartened by the observation. Indeed, at this point, Trump and the GOP have been reduced to hoping that if they neglect the ACA, it will collapse on its own — yet that doesn’t seem to be happening The very desperation of this “strategy” is a sign that Krauthammer may have been prescient about where American health care policy is headed.
So it has turned out. Repealing the ACA turned out to be way, way, way harder than Trump and the GOP anticipated and ultimately it failed. This emphasizes a basic characteristic of American public opinion that Trump and the GOP failed to understand and the left would do well to remember.
The dominant ideology in America combines what political scientists Christopher Ellis and James Stimson refer to as “symbolic conservatism” (honoring tradition, distrusting novelty, embracing the conservative label) with “operational liberalism” (wanting government to do more and spend more in a wide variety of areas). In their definitive book, Ideology in America, they characterize symbolic conservatism as:
"…fundamentally different from culturally conservative politics as defined by the religious right. It is respect for basic values: hard work, striving, caution, prudence, family, tradition, God, citizenship and the American flag….[I]t is the mainstream culture….It is woven into the fabric of how ordinary Americans live their lives."
And on operational liberalism they note:
"Social Security is…no exception. Most Americans like most government programs. Most of the time, on average, we want government to do more and spend more. It is no accident we have created the programs of the welfare state. They were created—and are sustained—by massive public support."
Thus, there was no insuperable ideological obstacle to the ACA and, indeed, there is no insuperable ideological obstacle to a substantially expanded role for government in health and other areas in the future. Indeed, such an expansion would be fully in accord with Americans’ durable commitment to operational liberalism.
Of course these expanded government programs will not happen all at once. Far from it. Like the programs of the past, they will be phased in gradually over time, in fits and starts, frequently in inefficient and suboptimal forms (like the ACA!). That’s the messy business of politics in a democracy. But happen they will and once enacted they will be hard to get rid of; instead, just as in the past, the programs will be modified, improved and even expanded. The reason is simple: people like programs that make their lives better and are far more likely to respond to program defects by demanding they be fixed than by demanding programs be eliminated.
Just like with the ACA.
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