The Republican legislative charge against Obamacare appears to be dead for the time being. But the GOP’s bedeviling ordeal to roll back the healthcare law may have already backfired. Progressives might come away from this fight seeing virtue in reaching for bigger government solutions for America’s social safety net.
Obamacare’s staying power is Exhibit A of how social insurance programs are inherently sticky. Political scientist Paul Pierson has observed that conservatives perpetually fall well short of reversing the biggest expansions of the welfare state. Ronald Reagan largely acquiesced to Medicare and Social Security—even though he had long opposed both programs as menaces to American freedom. In the United Kingdom, Margaret Thatcher was stymied from unwinding Britain’s national healthcare system.
Pierson theorized that welfare state expansions last because they fundamentally reshape politics by creating strong interest groups of beneficiaries to defend these programs. “[T]he emergence of powerful groups surrounding social programs may make the welfare state less dependent on the political parties, social movements, and labor organizations that expanded social programs in the first place,” Pierson argued.
That’s why the defense of Obamacare this year proved so potent. The law’s Medicaid expansion created a new class of beneficiaries to advocate for the program, and who stood to become human carnage under any rollback. And the law created a constituency of people who counted on government help to get affordable decent coverage, and others who depended on the law’s regulations to protect them from pre-existing conditions exclusions or lifetime caps on benefits. Quite simply, Obamacare helped a lot of people—many of whom became passionate and highly credible advocates for the law in 2017.
So if Democrats can just heave a new social program over the finish line in Congress, that program can then generate its own defenders even if the political climate in Washington swings to the right. In 2010, Democrats squeaked Obamacare into law, and then proceeded to lose both houses of Congress and the White House over the ensuing six years. But by cultivating a new class of Obamacare beneficiaries, the law became remarkably resilient even as Democrats’ hold on power collapsed.
So what type of program should Democrats be trying to muster into law? One that can withstand permanent conservative opposition. One thing is clear from the Obamacare experience: Democrats will get no credit or Republican buy-in for adopting a moderate, market-centered approach for social insurance programs. Obamacare’s health insurance marketplaces were designed as public-private partnerships, where the government relies on private insurers to help expand healthcare access. Democrats famously poached this idea from former Republican presidential nominee Mitt Romney’s tenure as governor of Massachusetts. Still, Republicans vehemently turned on their own idea simply because a Democratic president had embraced it.
But a moderate policy design without bipartisan support has turned out to be extremely vulnerable. While Obamacare stands mostly intact in spite of fervent conservative opposition, the prospect of full or partial repeal of the law perpetually spooks insurance companies. Insurers hike premiums or leave markets altogether, jeopardizing the ability of whole swaths of the country to meaningfully benefit from national health reform. And of course, when a hostile administration is charged with running the program, there are countless levers it can pull to deliberately trigger an insurer stampede and to cause the program to fail. Obamacare’s design leaves it at enormous risk under a saboteur-in-chief.
The solution is to bolster social programs with more robust government-run options. Skittish Democrats built Obamacare around private insurers in order to avoid being tagged as executing a big government takeover of healthcare—but conservatives called it one anyway. If Democrats are going to be branded as overreaching socialists either way, then they may as well come away with something stronger to show for it, rather than settling for a rickety structure dependent on the voluntary participation of bottom-line-driven private companies.
To be effective in the long run, most social insurance programs need public options. For Obamacare, this might mean opening up Medicare, Medicaid, or other public insurance programs to scoop up those who are being underserved by the law’s private insurance expansion. Or maybe it means transcending Obamacare altogether with a single-payer system. Either way, buttressing Obamacare requires tilting the law’s center of gravity away from private insurance options and toward public ones.
After all, while the GOP may be licking its wounds for now, don’t count on its anti-Obamacare fever to ever truly break. A few congressional Republicans may be ready to finally pursue pragmatic tweaks to make Obamacare work better. But opposition to universal healthcare has been the central tenet of the Republican Party for nearly a decade. It’s far more convenient for the GOP to continue launching salvo after salvo at the law than it is to rethink what it means to be a conservative.
Republicans were still coming after Social Security seventy years after its enactment, trying and failing to partially privatize the program in 2005. Paul Ryan still dreams of dismantling Medicare fifty years after LBJ signed it into law—a dream built around the same public-private health insurance partnership that he and his party discredited under Obamacare.
If this history is any guide, there’s little use in hoping for a true truce over the pillars of the welfare state. Instead, progressives must fortify them to withstand an interminable barrage.