Race, Policy Feedbacks, and Political Resilience

What Health Reform Tells

Us about American Politics

Lawrence R. Jacobs

University of Minnesota

Suzanne Mettler

Cornell University

Abstract The passage and initial implementation of the Affordable Care Act (ACA)

were imperiled by partisan divisions, court challenges, and the quagmire of federalism.

In the aftermath of Republican efforts to repeal the ACA, however, the law not only

carries on but also is changing the nature of political debate as its benefits are facilitating

increased support for it, creating new constituents who rely on its benefits and share

intense attachments to them, and lifting the confidence of Americans in both their

individual competence to participate effectively in politics and that government will

respond. Critics from the Left and the Right differ on their favored remedy, but both

have failed to appreciate the qualitative shifts brought on by the ACA; this myopia

results from viewing reform as a fixed endpoint instead of a process of evolution over

time. The result is that conservatives have been blind to the widening network of support

for the ACA, while those on the left have underestimated health reform’s impact in

broadening recognition of medical care as a right of citizenship instead of a privilege

earned in the workplace. The forces that constrained the ACA’s development still rage in

American politics, but they no longer dictate its survival as they did during its passage

in 2010.

Keywords health reform, politics, partisanship

The implementation and operation of the Affordable Care Act (ACA), though tumultuous, fraught, and obstacle ridden at every stage, have

nonetheless transformed the politics of health reform in the United States. Since the New Deal, American reformers had struggled uphill to guarantee

health coverage to all Americans. They eventually succeeded in attain- ing government coverage for seniors, disabled, and certain categories of

Journal of Health Politics, Policy and Law, Vol. 45, No. 4, August 2020 DOI 10.1215/03616878-8255505 � 2020 by Duke University Press

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low-income people. They failed, however, to establish national health

insurance for theworking-age population—until the enactment of the ACA. It was remarkable enough for the law to be enacted, but all the more so

for it to survive over the next decade. Political division and dysfunction bombarded the ACA at every turn: throughout its arduous journey through

Congress to President Obama’s desk, during the repeated court challenges that followed, and as much of its implementation took place amid the quagmire of federalism. The rigid partisan divide in Congress produced a

party-line vote on passing the Affordable Care Act in 2009–10 and, after its passage, foreclosed possibilities for national lawmakers to create practical,

technical adjustments. Partisanship in state governments slowed or stymied their efforts to shepherd the rollout of the law’s programs for low- and

middle-income Americans. The partisan divide also split ordinary Amer- icans in their views about the law. The election of Donald Trump and a

Republican Congress in 2016 initiated an unprecedented attack on this landmark legislation: bills to repeal the ACA passed in the US House of

Representatives and came within one vote of clearing the US Senate, surviving only when Senator John McCain joined his Republican col- leagues Susan Collins and Lisa Murkowski in opposing it.

The persistence of the ACA over its first decade of such formidable odds represents an immense achievement. It did not occur readily or automati-

cally; in fact, it nearly failed at multiple junctures. Yet today, the law not only carries on but has gained greater support and generated political

involvement among ordinary Americans. The ACA is increasingly chang- ing the nature of political debate. The forces that constrained its develop-

ment still rage in American politics, but they no longer dictate the ACA’s survival as they did during its passage in 2010.

New policies often remain fragile during their early years; ideally, policy

makers can nurture them, enacting helpful adjustments along the way and providing administrators with ample resources and other assistance to

ensure success (Berry, Burden, and Howell 2012; Patashnik 2008). The ACA, however, emerged amid a firestorm in American politics, as inten-

sifying partisan polarization and congressional gridlock fostered an envi- ronment that is inhospitable to reform. The resilience and growing strength

of the ACA, even in the midst of this environment, present a puzzle that requires explanation.

Together and separately we have been tracking the topsy-turvy history of the ACA. In studies represented by a string of publications and papers, we conducted elite interviews, examined primary and secondary sources,

collected multiple waves of panel data, and conducted multivariate

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regression analysis. While some of our findings, particularly regarding

early implementation, confirm aspects of the familiar patterns associated with partisanship, lobbying by powerful interests, and legislative gridlock,

we also found that these patterns did not dictate the ACA’s first decade. As time went on, we found, the ACA itself generated policy feedback

dynamics that have enabled it to survive and even, in some respects, to thrive. In these regards, it presents striking—if contingent—exceptions to the dynamics of contemporary American politics.

National Gridlock and State Implementation

In an unprecedented departure from the pattern followed previously by

partisans of both parties when landmark legislation passed over their dis- approval in Washington, DC, Republican opposition to the ACA’s passage

has yet to subside. Following the 2010 elections, party leaders took note of the influx of Tea Party Republicans that successfully flipped the House to

Republican control and identified ACA repeal as a winning issue that mobilized their voters. This in turn produced widespread agreement among political commentators and the news media that health reform was doomed

to paralysis or collapse (e.g. Boyer 2010; Edsall 2013). This narrative of doom made sense early on, but over time it has obscured immense shifts in

the law’s development. Public opinion toward health reform initially followed a pattern that has

become familiar in an age of polarization: Americans split into rigid par- tisan groupings who shared similar conservative or liberal mindsets gen-

erally, and they adopted positions of support or opposition to the ACA accordingly (Abramowitz 2010; Levendusky 2009). Such partisan sorting, according to social psychologists, results from “hot cognition,” in which

individuals are triggered by elite or media cues and respond with near automatic reflex (Taber and Lodge 2006).

The combination of the partisan standoff over the ACA among elected officials in Washington and polarized views about it among the public

reinforced each other, producing gridlock over it in Congress. This pre- vented the passage of incremental adjustments and even technical legis-

lation to fix glitches (Holahan and Blumberg 2017). Such technical fixes were familiar in the past, even after heated congressional disputes. For

instance, the enactment of the Medicare Modernization Act of 2003 was fiercely contested, and yet, after it was signed by President George W. Bush, lawmakers worked together in a bipartisan manner to revise and

improve the law.

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The patterns of partisan polarization and gridlock that hindered the ACA

in its early years broke down in the states, however, as implementation proceeded. For sure, there was a close association between early state

adoption of the Medicaid expansion and Democratic control of state leg- islatures and especially governorships. Yet, sweeping conclusions about

the ACA’s prospects generated by journalists and others were typically based on the loud and vociferous conflict in Washington and among national politicians and crucially missed the cracks in partisan stalemate

that were starting to appear at the state level. While partisanship remained (Republicans controlled all the states that blocked Medicaid expansion), a

steady pattern commenced of GOP lawmakers adopting the new benefits. One of the factors that contributed to the implementation of health

reform by states was their strategic maneuvering to engage in intergov- ernmental bargaining. In an analysis of 50 states, Callaghan and Jacobs

(2014) found that states with prior experience seeking federal waivers for social welfare programs made more progress toward Medicaid expansion

than those lacking that track record, after controlling for party control in government. In particular, this points to the mechanism of “upward fed- eralism” in which states that requested 1115 waivers from Medicaid before

2010 treated the ACA’s original design of Medicaid expansion as an opening bid for negotiations to press for greater leeway. For federal

agencies, the process of back-and-forth consultations and negotiations with interested states was welcomed as a means to identify areas of potential

compromise in order to induce state adoption of the Medicaid expansion (as was the case with Arkansas’s “private option”). However, states that

either lacked the experience of requesting waivers or were unrelentingly opposed to implementing the ACA viewed the 2010 law as a “take-it-or- leave-it” order and refused to engage in negotiations.

Empirical research added additional explanations for the loosening grip of partisanship on state implementation of the ACA, as GOP governors in

Arizona, Nevada, Michigan, and other states moved forward with the Medicaid expansion. The analysis pointed to several factors that would

later prove to be significant drivers: states appeared predisposed toward expanding Medicaid if they had previously established programs to assist

low-income people (what we more fully describe below as “policy feed- back”) or possessed the administrative capacity to manage health care

programs (Jacobs and Callaghan 2013). By 2015, the partisan control of government continued to influence Medicaid expansion and, in particular, variations in new enrollment across all 50 states. But empirical evidence

also continued to reveal the impact of state health policy and administrative

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capacity on the enrollment of individuals in Medicaid after taking into

account the influence of partisanship (Callaghan and Jacobs 2017). An important pattern became evident: political parties still mattered, but they

did not impose rigid control outside of Washington.

Cracks in America’s Oligarchy

Rising economic inequality, along with the political organization of cor-

porations and the affluent, has produced a reinforcing cycle of increasingly concentrated power and resources in contemporary American politics that

some describe as “oligarchic” (Gilens and Page 2014; Jacobs and Page 2005; Skocpol and Hertel-Fernandez 2016). The results of lopsided

organized combat are evident in tax and labor policies that advantage corporations and the wealthiest individuals.

The Obama White House launched its campaign to pass the ACA in 2009 by making concessions to the medical professions and the powerful

interests associated with commercial insurers, hospital, pharmaceutical producers, and more (Jacobs and Skocpol 2015). These types of accom- modations are a familiar pattern in American politics, typically present

particularly when reform is attempted in a domain already populated by stakeholders. Previous efforts at health care reform failed, in part, because

such groups opposed it; for example, the American Medical Association stymied the reform efforts of Presidents Franklin D. Roosevelt and Harry

Truman, and the health insurance industry thwarted efforts by President Bill Clinton (Blumenthal and Morone 2010).

Nonetheless, the ACA departs, in crucial respects, from the pattern of bias toward the organized and affluent. Even though health reform con- tained concessions, they were granted for the purpose of its central

achievement: the extension of the right to health care as a basic component of citizenship (Jacobs 2014). The ACA succeeded in bringing health

insurance coverage to more than 20 million people and preventing more than 19,000 deaths due to the lack of medical care, according to one esti-

mate (Miller et al. 2019). The law was financed predominantly through new taxes on the wealthiest Americans, including a higher Medicare tax on

earnings and a new 3.8% tax on investment income (Tax Policy Center 2018). These historic gains occurred, in part, because of another departure:

the dynamics of organized politics changed in several respects. Organized interests often unify against expanding social welfare bene-

fits for the less advantaged, fearing tax increases and new regulations that

might accompany such policies. In the case of the ACA, however, such

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groups split, as some voiced their typical opposition but others came out as

supporters. In particular, health care providers, suppliers, and segments of the insurance industry valued the law’s distribution of subsidies and other

benefits that increased demand for health insurance, medical care, pre- scription medications, and medical equipment (Hertel-Fernandez, Skoc-

pol, and Lynch 2016; Jacobs and Ario 2012; Jacobs and Skocpol 2015). Business associations, especially the US Chamber of Commerce and the Koch network (including its conservative American Legislative Exchange

Council), contested the passage and implementation of the ACA but found their resources and influence offset, in part, by medical groups and other

health care stakeholders that favored the law’s success. As well-resourced business and professional organizations splintered,

the public interest advocates for ACA implementation weighed in. Over 9,200 lobbyists registered in state capitols to push for their clients’ pre-

ferred health policy. Callaghan and Jacobs (2016) found that states that included a greater number of lobbyists for the uninsured and vulnerable,

such as those associated with unions and consumer and charitable orga- nizations, made greater progress in implementing the ACA’s Medicaid expansion by 2015 than did states that had fewer such advocates in their

capitols. The positive and significant impact of public interest advocates held up even after controlling for the partisan control of state government,

the well-funded pressure from businesses and professionals, and other potentially confounding factors.

The Politics That Health Reform Created

The old saw about generals is that they fight the last war with less regard for intervening changes. Political commentators following health reform have

tended to fall into the same trap, assuming that the battle lines of 2009–10 would continue to define the politics surrounding the ACA going forward.

Of course, they are correct with respect to the partisan split in Washington, DC, which has certainly persisted. Nonetheless, this first decade of the

ACA’s implementation has changed the politics of health reform, specifi- cally with respect to Americans’ attitudes and political behavior.

The Changing Public

We have been carefully tracking the reactions of everyday Americans to the ACA. As reform was moving through Congress in 2009, we set up a panel

of 1,000 randomly selected American adults as well as 200 people from

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groups who are often underrepresented in surveys—lower income and

younger people. We have interviewed this panel every other fall from 2010 through 2018, creating five waves of interviews with the same group of

people. Our panel is weighted to represent US demographic characteristics and has retained many of our original interviewees.1

By 2014, the ACA’s programs were already tarnished by administrative mishaps even though most were not yet implemented; Americans’attitudes toward health reform at this stage reflected this (Jacobs and Mettler 2018).

Our analysis of the first three waves in 2010, 2012, and 2014 found that Americans were generally supportive of the ACA’s specific benefits, such

as subsidies to purchase private insurance or help for seniors to purchase prescription medication. As the years unfolded, there were also signs that

resistance to the ACA might be receding a bit: support for outright repeal remained robust but was declining, and fewer members of our panel

reported that the ACA had little or no impact on access to health care than had done so at the outset. Still, the partisan divide created a toxic envi-

ronment that undermined support for health reform overall. No regular observer of American politics would be surprised to learn that Democrats favored the law and Republicans retained unfavorable views of it.

Our sustained analysis has detected an important development as the years proceeded, however: the implementation of the ACA was changing

the politics of health reform, modestly at first and then more robustly by October 2018. This pattern is consistent with research on policy feedback:

individuals’ personal experiences with established programs and those with designs that make government’s role visible can change public atti-

tudes and political engagement, including voting behavior (Campbell 2003; Mettler 2005, 2011).

Our research found early signs of the ACA’s effects on the politics of

health reform. By late 2014, Americans who gained insurance coverage and saw tangible benefits of subsidies and help for seniors became, com-

pared to their earlier atttitudes, more appreciative of the law’s impact in expanding access to coverage (Jacobs and Mettler 2018).

Despite these signs of increasing appreciation of the law’s specific benefits, however, our analysis of public attitudes toward it in late 2014

made evident why overall public support for the ACA generally had not yet grown (Jacobs and Mettler 2018). The ACA had created benefits, but

it also introduced burdens in the form of taxes. Although the taxes fell

1. Overall, 66% (949 of 1,473) of panelists from prior waves sampled completed the wave 5 interview. Forty-four percent of the original 2010 survey (524 individuals) responded to all five waves, and 58% (691 individuals) participated in both 2010 and 2018.

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predominantly on a small group of Americans in the top 1% of the income

distribution, they initially contributed to antireform judgments (Tax Policy Center 2018). Partisanship and distrust of government, moreover, continued

to overwhelm even Americans’ positive experiences of it when it came to their overall evaluations of health reform. Compared to their assessments in

2010, individuals who identified as Republicans and resented government and taxes increased their unfavorable assessment of reform’s impact on access, as did those who lost insurance coverage since the ACA’s enact-

ment. Nonetheless, the upward trend in the appreciation of the laws’ fea- tures would, within the next few years, harken more fundamental shifts in

public opinion and political behavior.

Four Features of the New Health Politics

When President Obama and Democrats struggled to pass health reform in 2009–10, the stakes remained vague to most Americans, as neither the

scope of the benefits nor the recipients of the burdens were apparent. As the ACA reaches its 10–year anniversary, it provides concrete services and its impact on the lives of everyday Americans has become tangible—and

expected. Anticipated burdens have failed to materialize for most people. New health policy changed the politics of health reform in four respects.

First, Americans have become increasingly accustomed to receiving the ACA’s benefits, and that has led to growing support. The partisan frame that

initially defined responses to the ACA has given way, for many Americans, to a pragmatic frame, in which more acknowledge the value of receiving

needed health coverage. Panel data shows that support for the ACA increased by the fall of 2018 to its highest level since the law’s enactment, and the most intense opposition had receded to its lowest point. More

individuals have also been reporting that the ACA affected their lives and improved their access to health care, even after Republicans and the Trump

administration attempted to undermine the law. In particular, individuals have grown more appreciative by 2018 compared with earlier years of the

ACA’s help for seniors to achieve prescription drug coverage, subsidies to purchase private health insurance, and guarantee of insurance for the

children of insured parents until 26 years of age. Second, the Washington GOP’s threat to repeal the ACA in 2017–

18—once they controlled both the White House and both chambers of Congress—jolted a broad swath of Americans to become more supportive of the law than they had been before the 2016 elections (Zhu, Mettler, and

Jacobs 2019). Democrats had long been supportive of the law, but in the

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wake of the GOP threat, support for it increased among rank-and-file

Republicans. The GOP threat also changed voting behavior: it mobilized Democrats to assign greater importance to the ACA in their candidate

selection and depressed the intent of Republicans to cast a vote based on health reform. In other words, the strategy of the Washington GOP back-

fired: repeal rallied Democrats to become more politically engaged and muted opposition among everyday Republicans.

Third, the ACA is giving rise to new constituents who rely on its benefits

and share intense attachments to them. The GOP’s repeal threat awoke several groups of beneficiaries, making them more fully appreciative of the

new health care benefits by the 2018 elections than they were previously. Americans who had realized that the ACA expanded access before the

2016 elections became more supportive afterward. More striking, the GOP threat stirred greater appreciation for the ACA’s impact among individuals

who had not registered such views previously as well as among low-income people who were especially dependent on the new coverage (Zhu, Mettler,

and Jacobs 2019). New policy that creates new constituents represents a politically potent

form of policy feedback (Campbell 2003). The ACA’s decade of operations

is now starting to coalesce new beneficiaries as a self-conscious set of constituents, although the extent to which political leaders or groups will

mobilize them as such remains to be seen. A fourth feature of the new politics of health reform is the ACA’s impact

on political efficacy (Mettler, Jacobs, and Zhu 2019). According to our panel data, between the ACA’s passage in 2010 and the 2018 elections, the

survival of health reform and distribution of its concrete benefits prodded individuals to higher levels of confidence in their individual competence to participate effectively in politics and l

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