Theda Skocpol Review in “Dissent”: ACA is Progressive
In her review of Paul Starr’s book, she explains:
And why are budgets so tight? Because, over
recent decades, Democrats and moderate Republicans
have retreated on taxing people, especially
the wealthy, to pay for federal
programs. The chickens are coming home to
roost, with an aging population, a financial crisis,
and ever more fanatic right-wing resistance
to taxes. Health reform suffers particularly from
tax resistance, because health coverage costs
money. Starr claims that financing Affordable
Care was not a big problem, but he could not be
more mistaken. There were tough battles to the
very end about where to get money to pay for
lower income subsidies and the huge expansion
of Medicaid. In the last days, the Democrats in
the House forced higher charges on business
and wealthy Medicare beneficiaries, making
Affordable Care more redistributive—but also
arousing new determination by the privileged
to avoid those charges.
Starr’s scattered explanations of the success
and failure of different legislative efforts attribute
too much political sway to public opinion.
Public opinion actually favors most specific aspects
of health reform, including, by bipartisan
majorities, the new rules and subsidies of Affordable
Care. In the abstract, the public is always
ambivalent about large government
reform efforts. But it hardly matters, because
the general public does not decide the content of
policy battles. Politicians, interest groups, and
some experts are the key actors. Starr fails to explain
why certain interest groups, such as many
health providers, have, over time, switched
their positions to become more open to federally
subsidized expanded coverage as a way to
ensure that patients can pay for services. And
he never tells us why Republicans have moved
in such an extreme opposite direction—to the
point that market-oriented plans such as Romney’s
that were considered conservative orthodoxy
only a few years ago are now denounced
as “unconstitutional” and “socialist.” The GOP
has moved into an alliance with business sectors
and privileged citizens who do not want to
pay for universal coverage.
Starr portrays
recent decades of U.S. politics
as a series of yo-yo sways alternating between
left and right. He suggests that partisan
polarization is relatively even. But this is an unhelpful
portrayal. Republicans have gained
dominance and galloped much further to the
right since 1980. The center in national policy
debates has moved steadily toward tax cuts,
deregulation of business, and cuts in vital social
programs—and, in tandem, inequality has
grown to ancien régime proportions. Starr lists
all the relevant facts. But his model of long-term
political change is not informed by the changing
ideological, organizational, and socioeconomic
context. Consequently, Starr does not
explain why taxes and public budgets are now
such flashpoints. Yet super-rich resistance to
paying any higher tax rates is exactly what lies
behind the GOP turn against Medicare and
Medicaid. And opposition to Affordable Care is
fueled by the unwillingness of certain business
interests to accept lower profits along with reductions
in public subsidies for wasteful insurance
programs and restrictions on fraudulent
marketing practices.
Tea Party populism hardly makes an appearance
in Starr’s book, either. Yet thousands
of grassroots Tea Partiers stoked a lot of fervor
against Obama. The Tea Party brings together
elite, ultra-free-market actors who press the
GOP never to accept taxes or regulations on the
wealthy, with older white middle-class Americans
who are deeply anxious about public programs
such as Affordable Care or education
that might use taxes to pay for benefits to lower
income people, younger adults, and immigrants.
At the grassroots, the Tea Party is a generational
populist movement of resentment;
and Tea Partiers will accept privatization of Social
Security and Medicare for future generations
as long as these programs remain for them
in their old age. That is why the Ryan plan is
structured as it is—to protect Medicare now
while imposing new costs through privatization
on younger age cohorts.
Starr stresses the individual mandate as
the popular Achilles’ heel of Affordable Care,
but that is surely wrong. The “death panel”
lie—the false claim that Affordable Care would
empower bureaucrats to deny life-saving care
to the elderly and disabled—was far more ef-
fective in 2010 because it has a metaphorical resonance.
Many older whites are worried that
their public programs will be cut to pay for Affordable
Care. Their worries are not entirely irrational,
given that both Clinton and Obama
endorsed “Medicare cuts” to help pay for more
universal health coverage, to include the mainly
younger workers who are the ones left out.
True, the Medicare cuts were aimed at costly
private insurance plans and did not cut benefits
to regular subscribers, but that is not the public
perception. In an era when Democrats are unwilling
to speak frankly to the public about
taxes, they turn to all kinds of regulatory gimmicks
and cuts in existing programs to pay for
major new social spending. That is what
Clinton did—and Obama did it again in 2009
with Affordable Care. The downside of this approach
is public misunderstanding about how
new benefits will be financed, allowing the right
wing to fuel popular fears. Tea Partiers are just
the conservative cutting edge of Obama hatred
and fear of the generational and class redistribution
promised in Affordable Care.
In sum, Starr underestimates the political
will and interests of opponents to health-care
reform. He mistakenly thinks that Affordable
Care is a very moderate reform effort—because
he focuses on Obama’s willingness to compromise
a bit with private insurance companies
and other health care businesses. Many on the
left share this preoccupation. But that misses the
fiscal and economic redistribution central to Affordable
Care. The guts of the new law are the
huge expansions of Medicaid and expensive
subsidies to make insurance available to people
earning incomes up to 400 percent of the poverty
line. Affordable Care’s new insurance market
regulations and fees on health providers
also threaten to trim profits in the health industry.
These are not minor matters in the view of
affected business interests or wealthy
right-wingers determined to block taxes.
Stark political interests are also at stake for
Democrats and Republicans. Affordable Care,
on top of Social Security, Medicare, and
Medicaid, could strengthen the bond between
middle-class Americans and a national government
that supports security for all. If all these
program survive and flourish, as most Democrats
would prefer, right-wing Republicans
have little future, especially in a society where
young people, Latinos, and minorities are gaining
ground demographically and find the Democratic
Party of the Obama era relatively
attractive. What seems like a timid reform to
some on the left is well understood as a threat to
future Republican prospects by those on the
right. They see 2012 as a last chance to cut off
Democratic reforms and preserve an everyone-
for-himself economy in which conservatives
continue to call the shots.
Republicans and right-wingers are right.
In health care, as well as in other areas with economic
and fiscal impact, the stakes in 2012 are
as high as in any pivotal election in U.S. history
(except 1860). Not because Obama is perfect,
but because he has, however partially, set out a
better path that is scary enough to the Right to
arouse fierce counter-mobilizations.
It will not do for liberals to engage in backward-
looking self-congratulation or hold out
for pie-in-the-sky perfection or underestimate
the rational fierceness of the opposition they
face. Progressives need to stop focusing on
what was left out of Affordable Care and understand
that the law is a redistributive and
regulatory breakthrough worth fighting for.
Going forward from 2012, Americans are either
going to have more broadly shared health care
paid for in part through taxes that hit the
wealthy along with others or we are going to
endure increasingly bitter battles over dwindling
health-care spending, while the super
rich use ballooning tax cuts to build bigger
mansions and rig elections. Small turns can
prove irreversible, and 2012 has all the markings
of such a critical juncture.
Theda Skocpol is the Victor S. Thomas Professor
of Government and Sociology at Harvard
University and director of the Scholars Strategy
Network, an alliance of university-based scholars
with progressive values. Her recent books
include Health Reform and American Politics
(with Lawrence R. Jacobs, 2010) and
The Tea Party and the Remaking of Republican Conservatism
(with Vanessa Williamson, 2012).
