How Politically Durable is the ACA?

by Reihan Salam

When you think about the most durable achievements of American social democracy, what comes to mind? I think of programs like Social Security and Medicare that managed to build incredibly inclusive constituencies. Medicaid and other means-tested programs, like Pell Grants, are in theory more vulnerable. But Medicaid also indirectly benefits large numbers of middle-income households by relieving the burden of providing aging parents with nursing home care, etc. Federal student loans flow to large numbers of young adults raised in middle-income households. Federal K-12 spending is relatively modest, yet it is spread across a wide range of school districts, including affluent districts. Having a diverse class of beneficiaries distributed across congressional districts, and across political cleavages, seems to be a really good way to ensure that a given program will have a long shelf life. 

So I was struck by Ezra Klein and Sarah Kliff’s new article on the implementation of the Affordable Care Act. Klein and Kliff describe how the Obama administration is using campaign-style tactics to encourage young people to enroll in the new state-based insurance exchanges:

This is where Obama officials say their campaign experience — and their candidate — gives them an advantage. The profile of the people they’re trying to entice into the exchanges almost perfectly matches the profile of Obama voters. And they are confident they know how to talk to those voters.

“If we were having this debate last year, the pundits would be saying that ‘it’s not clear Obama will get young people out to the polls again, it’s not clear if African Americans will turn out to vote’,” said Nancy-Ann DeParle, the former head of the White House Office of Health Reform and deputy chief of staff to Obama. “Well, guess what? As Barack Obama has repeatedly shown, he knows how to get people out. And I think they will turn out to enroll in health plans just as they did to vote last November.”

One assumes that the subsidized insurance coverage offered under the ACA will benefit a fairly large number of people, some of whom will be Republicans. But if the political scientist John Hudak is right, the ACA is remarkably well-targeted to Democratic voters:

In fact, because the president’s and Democratic governors’ electoral constituencies share demographic characteristics, their pursuit of similar voters motivates support for the law. By contrast, Republicans are successful because of the support of different demographics than Democrats. These electoral forces (not principles such as liberty or empathy) drive elected officials’ positions on health care.

Republicans often depend on white and wealthier voters for electoral success. Democrats’ electoral constituencies have a larger percentage of non-white and/or lower income voters. White and wealthier individuals are insured at dramatically higher rates. The national average for non-elderly uninsured is 18%. The rate for white Americans is only 14%. However, black Americans and Latino Americans are uninsured at rates of 22% and 32%, respectively. As one would expect, there is an inverse relationship between income and the rate of uninsured.

It should go without saying that champions of the ACA believe that it will have significant system-wide benefits, which will eventually flow to Medicare beneficiaries and people who currently have job-sponsored coverage. But in the medium-term, the Medicaid expansion and the exchanges will prove a boon to what we might describe as the core of the Obama coalition, which is why the fact that it will benefit a substantial number of people might not be that politically salient — the politically salient question is whether or not it will benefit a substantial number of swing voters, and that remains to be seen. 

If this sounds cynical, keep in mind that I’m bracketing the more substantive questions. A more “left-wing” health reform effort, e.g., the creation of a single-payer system financed by steeply progressive taxes, would have benefited a more diverse, inclusive constituency, at least in the short term, so narrowness isn’t in itself a flaw. After all, it tends to be fiscal conservatives who favor means-testing. But this narrowness might make the ACA more vulnerable than its champions think. 


The Agenda

NRO’s domestic-policy blog, by Reihan Salam.