Healthcare Realities Trump Rhetoric

Maybe There Are Other Opportunities

By Mike Koetting December 2, 2020

The bitter fight over the ACA was never a fight about healthcare policy. The healthcare plan that Obama proposed was based on the plan developed by the American Heritage Foundation for Bob Dole to offer as the Republican alternative to the Clinton plan. It was actually implemented by Mitt Romney in Massachusetts and universally considered a success. The issue was always whether the Republicans were going to let the Democrats implement it.

An excerpt from Barack Obama’s new book that describes trying to get one Republican vote for the ACA is instructive. Senator Grassley of Iowa came to the Oval Office with a list of five reasons that he had problem with the bill.

“If we took every one of your latest suggestions would you support the bill?”


“Are there any changes–any at all–that would get us your vote?”

There was an awkward silence before Grassley looked up and met my gaze. “I guess not, Mr. President.”

Republican opposition to the bill was purely political. The uninsured rate was more than 16%, one out of every six people in the nation, but not a single Republican senator voted for a bill that was an explicitly Republican designed bill. And they whipped up cultural hysteria against the bill to justify their opposition. Does anyone think it was an accident that opposition to the ACA was concentrated in the Confederate states? There is plenty of evidence—anecdotal and empirical—that racism was a material factor in refusing to expand Medicaid and undermining support of the Marketplace exchanges.

But a funny thing happened. The ACA won anyway.

The ACA had three components:

  • Expanding Medicaid
  • Creating a subsidized private insurance market
  • Regulations governing all private insurance

All three are now firmly established as part of the American healthcare system. And uninsurance has been cut in half with none of the threatened adverse consequences.

At this point, only 12 states have not expanded Medicaid—eight having expanded in the last four years, six of them by ballot initiatives. Moreover, there is good evidence that Texas, Georgia and Florida are all in various degrees of discussion about expanding as well.

The subsidized private insurance market, despite a rocky start, has stabilized, even in the face of a barrage of sabotage attempts by Republicans.  More insurance companies are offering plans, premiums are stable or down, and enrollment has remained consistent. While important improvements are clearly possible, there is no evidence of these plans withering way;

The regulations of the private insurance market are likewise now largely taken as settled. No politician of any political party is suggesting taking away the ban on discrimination by pre-existing condition or the idea that children can stay on the family plan until age 26. The idea of “essential coverage”—that insurance plans must be relatively comprehensive—continues to be attacked rhetorically, but when Republican created alternative plans in the last several years, take-up was minimal, presumably because people recognize that non-comprehensive coverage is no bargain.

I don’t believe this signals any great change in people’s overall attitudes. Likewise, I don’t believe there is a realistic strategy for reshaping partisan divides based on the pursuit of any set of policy choices—tweaks or revolutionary. The problem is people don’t see their politics as a collection of policies. Their politics are, rather, something more fundamental–a complicated, interlocking collections of ideas, fears and concerns that create much more stable psychic frameworks than mere policies. These world-views control how they how vote much more strongly than any policy. Indeed, the causal influence runs in the opposite direction: the policies they support are a function of their overall worldview. And when one policy breaks through because it obviously “works”, it is dismissed as an aberration. Thus, despite the objective acceptance of the provisions of the ACA, Trump carried five of the six states that expanded Medicaid with ballot initiatives. This exhibit of mental gymnastics illustrates the disconnect between policies and partisan framework.

But I still believe the overall story of the ACA suggests some grounds for hope—slim to be sure—but better than anything else I can think of. When policies can be put in place that do work and people accept them, it creates a tiny bit of psychic space for other ideas that, over time, could reshape the larger political views. An article in The American Prospect quotes John Paul Lederach talking about cultural reconciliation:

Polarization is the first killer of curiosity. When people live in closed systems, they are secure in the knowledge of who their enemy is.

It’s not unreasonable to believe that if we could get more policy agreements, it would make people’s political systems less closed. Not that it is quick. It’s more like a slow leak in your attic. Each few drops create another force and over time the ceiling starts to sag and rearrange. Small policy changes are like that. Slowly, very slowly at first, they start to rearrange the underlying policy framework. Then, with luck, in a big rush of conversion as it becomes too difficult to integrate the “exceptions” into the existing political framework. In the article referenced above, Robert Kuttner says: “To say that this is a long-term project is the mother of understatements.”

What are some other areas where there might be agreements around specific policies while conceding the low probability of ending open partisan warfare? I can think of two that might be ripe—COVID relief and infrastructure spending. College debt might be another.

How these, or any other specifics, actually play out in the short term will depend significantly on how Senate Republicans behave. Regardless of how Georgia turns out, Democratic options for dramatic change will be limited. Republicans will have many opportunities to block many things Biden would want to do, and some incentive to do so given the current dynamics of their own party.

On the other hand, in recent times, the Republican constituency has been remarkably undemanding of its Congressional representatives—apparently settling for little beyond conservative judges and blocking anything Democrats want to do. Will this constituency continue to be this undemanding, or will it occur to them that there are things government can and should be doing for them? The actual promises of the Trump candidacy, not to say what he delivered, suggest such an appetite among many would-be Republican voters. The successes of the Medicaid expansion ballot initiatives suggest the same thing.  I am not ready to make a big bet on this, but the three issues above are issues on which by any measure there is a deep consensus that we must do something. At some point the demands for help may well force some action.

More generally, I think that engaging current Trump voters with curiosity and respect and changing the framework for discussion by doing a better of job of meeting real economic needs can change the country over time. After all, at least for me, the point is not necessarily to create a Democratic future, but to do a better a job of creating a society in which every citizen can fulfill her or his potential and can see her or his place in the broader world. At the moment, a huge obstacle to that project is the loss of faith that any institution, certainly not government, can meaningfully contribute in a world where the overwhelming sentiment is that we are very much on our own.

Individual policy changes, like the shift in healthcare provision, are nowhere close to sufficient to change society. But I don’t think big structural changes are in the cards right now. So we need to focus on changes we can make that push us in a sustainable direction. Each one of those becomes another dollop of water in the attic of people’s minds–gradually rearranging the building.

Author: mkbhhw

Mike Koetting’s career has been in health care policy and administration. But it has always been on the fringes of politics. His first job out of graduate school was conducting an evaluation of the Illinois Medicaid program for the Illinois Legislative Budget Office. In the following 40 years, he has been a health care provider, a researcher, a teacher, a regulator, a consultant and a payor. The biggest part of his career was 24 years as Vice President of Planning for the University of Chicago Medical Center. He retired from there in 2008, but in 2010 was asked to implement the ACA Medicaid expansion in Illinois, which kept him busy for another 5 years.

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