Health Reform Without Apology
The Affordable Care Act is under relentless attack from conservatives. Yet progressives are too ambivalent about defending it.
The states are a central arena for health reform, and the stakes are high for our own time as well as for future battles. But Starr focuses on the national stage and neglects the critical importance of what is happening in the states. Although the most progressive reforms were defeated in Washington, D.C., Vermont is moving toward creating a single-payer system, and Oregon and perhaps other states are heading in the direction of a public option. State flexibility has also ushered in a nearly unnoticed and highly significant engagement of state Republican officeholders. While the media portrays a ferocious unified conservative opposition to the ACA, key components of health reform (especially the new insurance “exchanges”) are being planned and implemented in GOP-controlled swing states (including the conservative Republican administrations of John Kasich in Ohio and Scott Walker in Wisconsin) as well as generally red states like Mitch Daniels’s Indiana and conservative bastions like Haley Barbour’s Mississippi. What’s going on in the states deserves concentrated attention and creative coalition building.
How the 2012 elections play out will be decisive not only, of course, for control of the President’s veto pen but also for control of Congress. The Senate’s arcane rules will pose stark challenges to outright repeal (as they did to enactment) even if the ACA’s implementation suffers delays or selective eviscerations. Shifting alliances and new interests may dampen efforts to repeal health reform: Well-organized Medicare beneficiaries who vote at high rates can be organized to fight hard against cuts to their new benefits; the scaling back of new protections against insurance marauders should elicit vociferous protests from consumer groups and congressional constituents (including those in Republican districts); insurers themselves may well push for the individual mandate (or a similar mechanism) if they continue to be required by law to accept all comers. The stickiness of administrative law may make a quick dismantling of new insurance regulations more daunting than currently imagined. (Republican leaders have begun to shift from “repeal” to “repeal and replace” and, more recently, to “waivers,” which appears to concede implicitly that the ACA’s basic framework survives.)
Meanwhile, the constitutional challenges that will be heard by the Supreme Court have been resisted and reframed by most lower courts of appeal. Although perhaps not likely, some of the Supreme Court justices—including some of the Republican appointees—may see institutional wisdom (as the 4th Circuit Court of Appeals recommended) in ducking the highly political case for the time being. The justice likely to cast the decisive vote on the Supreme Court, Anthony Kennedy, has a history of pragmatism that may leave him unwilling to approve the full repeal or gutting that conservatives seek. Even if the Court does strike down the individual mandate, there are other mechanisms to discourage free riding that lawmakers or the Administration could adopt. As the Government Accounting Office reported earlier this year, enrollment could be encouraged by imposing fees for signing up late, making it easier to join by extending assistance to individuals, and conducting effective public outreach—a strategy used by Lyndon Johnson in the mid-1960s to swell enrollment in the voluntary part of Medicare above initial estimates.
Implementation of the ACA opens a new chapter in the politics of health policy, much as the passage of the Social Security Act in 1935 started a struggle over income security for seniors that continued for generations. As with the ACA, Social Security began as a limited program that fell far short of reformers’ preferred remedies, leaving out, for example, agricultural and domestic service workers. To win votes in Congress (especially southern Democrats), the legislation excluded about two-thirds of all African-American workers (upwards of 80 percent in parts of the South) and over half of all working women.
The story of limited beginnings followed by expansion is common. It also describes the trajectory of Medicare, whose benefits have widened considerably since its passage in 1965 and is now a potential platform for a single-payer system. The ACA fits within America’s history of pragmatic realism. If the ACA withstands today’s savage onslaught in the face of tepid support from many of its natural adherents, it will likely generate a range of options for the next round of reformers intent on further widening access and controlling costs. Tomorrow’s pragmatic problem-solvers are likely to build on the ACA’s areas of effectiveness and the new precedents it sets and to seek new solutions to its shortfalls.
Opponents of reform well understand the significance of the ACA for future health policy, which accounts for their speed and ferocity in building well-financed and potent national and state operations. This level of awareness and engagement is less evident among supporters of reform—including advocates for single-payer financing and the public option. The future of health reform—and the remedies most favored by progressives—depends on sustaining the ACA by conveying its importance in clear and compelling terms, by building inclusive coalitions, and by exploiting the new developmental trajectories that the ACA initiates.
Post a Comment