The ACA

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).

 

 

 

 

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