The Agenda

Is GOP Opposition to the ACA a Campaign of Self-Sacrifice?

Ezra Klein characterizes the GOP campaign against the Affordable Care Act as “a campaign of self-sacrifice“:

Over the past couple of years, Republicans have responded to minority status by adopting more extreme political tactics. Chief among them is hostage taking: threatening to shut down the government, or breach the debt ceiling, if they don’t get their way.

But now Republicans have taken themselves hostage. They’re threatening to hurt themselves and their states and their voters and their most committed activists if Democrats don’t give them their way on Obamacare. It’s evidence of their extraordinary dedication to the cause, but also to their increasingly extreme view of how American politics works.

But behind all of it is a mounting desperation. Obamacare beat a filibuster. It beat the right’s legal challenge. Its namesake beat the Republican Party’s nominee for president. Come 2014, it will start helping millions of Americans afford health insurance, and come the 2016 election it will have been delivering health care to tens of millions of Americans for almost three years. That’s not the kind of program that just goes away in American politics.

Leaving aside Ezra’s assumption that the benefits of the ACA outweigh the costs, his argument that Republicans are “threatening to hurt themselves and their states and their voters and their most committed activists” rest on a series of assumptions:

(a) that opposition to the Affordable Care Act is likely to prove politically unpopular (the evidence is mixed);

(b) that the coverage expansion provisions of the ACA will benefit non-trivial numbers of people living in states currently governed by Republicans and in congressional districts currently represented by Republicans (barring the consideration of long-term costs, this is true in the sense that there are non-trivial numbers of uninsured individuals who will be eligible for large taxpayer-financed subsidies under the ACA in these states and districts);

and (c) that the coverage expansion provisions of the ACA will benefit Republican voters and conservative activists (this doesn’t seem very likely).

Recall Richard Fenno’s concept of the electoral constituency, as described by John Hudak:

The statistics that appear to suggest that governors are acting contrary to the health care needs of their constituents fail to account for the demographics of the uninsured. While support for or opposition to the president surely affects governors’ views on the health care law, responsiveness to their electoral constituencies plays a central role. University of Rochester professor Richard Fenno describes an elected official’s electoral constituency as a subset of their broader constituency. The electoral constituency is a voting bloc large enough to secure continued electoral success, and politicians primarily cater to this subgroup.

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. [Emphasis added]

A year ago, Gallup conducted a survey which found that “Republicans have greater access to basic necessities,” including health insurance:

The list of 13 items included in the Basic Access Index includes several items relating to health. Republicans are more likely to have health insurance and to have no problem affording healthcare and medicine than are Democrats and independents. The 89% of Republicans who have health insurance, for example, contrasts with 84.7% of Democrats and 78.3% of independents. Similarly, while 13.9% of Republicans said they lack money at times to pay for healthcare or medicine, more Democrats (19.6%) and independents (21.2%) said the same.

Republicans are also more likely to visit the dentist than are Democrats and independents. [Emphasis added]

Unfortunately, these numbers don’t distinguish between those who have publicly-sponsored health insurance and those who have job-based coverage or who purchase coverage on the individual insurance market. Were we to break the numbers out for under-65s, I suspect that the share of Republicans with privately-sponsored health insurance would larger than the share of Democrats.

The authors of the report, Dan Witters, Sangeeta Agrawal, and Frank Newport, went on to observe that Republicans are less likely to struggle to afford food and shelter:

Less than 6% of Republicans report that they didn’t have enough money for shelter at times over the past 12 months, compared with about 10% of Democrats and independents who said the same.

And less than 13% of Republicans struggled to afford food compared with at least 20% of Democrats and independents.

Only 27.9 percent of survey respondents identified as Republicans while 31.3 percent of respondents identified as Democrats, with the remaining 40.8 percent identifying as independent/other. When considering Republican and Democratic electoral constituencies, it is important to recognize that much depends on how uninsured independents are likely to lean politically. It seems plausible that uninsured independents earning low incomes tilt to the Democrats.

Note also that, according to Gallup, a substantial majority of Americans rate their own health coverage as excellent or good:

Most Americans (82%) continue to rate the quality of the healthcare they receive as excellent or good. The 40% who rate their care as excellent ties for the highest since Gallup started asking the question annually in 2001.

So who are the Republican voters and conservative activists Ezra has in mind? They would have to be drawn from the 11 percent of Republicans who are uninsured, some substantial number of whom are presumably uninsured by choice, and the 13.9 percent of Republicans “who lack money at times to pay for healthcare or medicine.” One wonders, however, if this slice of the Republican electorate is active in contested GOP primaries, or if those who belong to it have the leisure time or the inclination to devote time and effort to activism. Moreover, some of these Republicans might be so ideologically committed that they below to single-earner households out of traditionalist conviction, in which case they might be particularly concerned about the threat of what they might see as statism and centralization to religious liberty.

In April, the Kaiser Family Foundation releaed a comprehensive analysis of public opinion on the health law:

Overall, the public remains as divided as ever when it comes to their overall evaluations of the health law. This month, 35 percent report a favorable view, 40 percent an unfavorable view, and a full 24 percent report they have no opinion on the law, continuing a recent trend of particularly high shares not offering an opinion. Partisans remain quite divided, with a majority of Democrats in favor (57 percent) and most Republicans opposed (67 percent).

In terms of the law’s political future, just over half of Americans (53 percent) continue to say that they approve of efforts by opponents to change or stop the law “so it has less impact on taxpayers, employers, and health care providers”, a view which theoretically encompasses a range of positions from hard-core repeal supporters to those who believe the law only needs minor tweaks. One in three (including more than half of Democrats) believe that the law’s opponents should accept that it is the law of the land and stop trying to block its implementation, down somewhat from January (33 percent now compared to 40 percent at the start of the year).

Still, a majority of Americans continue to oppose the idea of stopping the law by defunding it in Congress. Overall, 58 percent say they disapprove of cutting off funding as a way to stop some or all of the law from being put into place, 31 percent approve. While Republicans are significantly more likely than Democrats or independents to give their blessings to this tactic (51 percent do), 37 percent disapprove of defunding the law.

These findings lend credence to the thesis that defunding is not necessarily the shrewdest political strategy, a conclusion endorsed by influential conservatives like Oklahoma Sen. Tom Coburn and NR’s Ramesh Ponnuru. But the 53 percent that approve of efforts to “change or stop the law” is a politically tempting target.

Republican voters would benefit from health-system reform of some kind. Health-system reform that made medical insurance that protects households against financial risk more widely available would prove particularly beneficial. It is far from clear that the Affordable Care Scenario represents the best case scenario for Republican voters, which tends to undermine the “campaign of self-sacrifice thesis.”

Among liberals, there is a popular meme that Republicans are more welfare-dependent and poor and dysfunctional than Democrats, which largely flows from the distinction between so-called red and blue states. But this line of thinking neglects the paradox identified by Andrew Gelman et al.:

Rich people in rich states are socially and economically more lib­eral than rich people in poor states. But only in recent decades has this translated into Democratic dominance in the coasts. What’s new is polarization—the increasingly ideological nature of poli­ tics. Both parties are now more cohesive on issues than they were in the days of Richard Nixon, Gerald Ford, Jimmy Carter, and even Ronald Reagan. Liberal Democrats face off against conserva­ tive Republicans in Congress with little middle ground, and voters within each party are also more likely to agree with each other on issues ranging from taxes to gay rights to foreign policy. Again, the paradox is that polarization is going in one direction for voters and the other direction for states.

The resolution of the paradox is that the more polarized playing field has driven rich conservative voters in poor states toward the Republicans and rich liberals in rich states toward the Democrats, thus turning the South red and New England and the West Coast blue and setting up a national map that is divided by culture rather than class, with blue-collar West Virginia moving from solidly Democratic (one of the ten states that went for Michael Dukakis in 1988) to safely Republican and suburban Connecticut going the other way.

To be sure, there are Republicans among beneficiaries of transfer programs that benefit those under the age of 62, as Tino Sanandaji observes — but Republicans are underrepresented in the ranks of the transfer-dependent. Of course, this picture would change if we included tax expenditures like the mortgage interest deduction, but of course the MID has a very different political valence and structure.

So I return to my pet thesis: the problem isn’t that Republicans aren’t being responsive to the interests of their voters. Rather, the real political problem is that the core Republican electorate looks less and less like the country as a whole (i.e., the core Republican electorate is less dependent on transfers, more likely to be a part of married households, and more likely to be privately insured), and this makes it harder for GOP policymakers to craft policies that are responsive to the interests of swing voters. While Ezra’s charge that Republicans are harming the interests of their own voters and activists isn’t very strong, one could more plausibly claim that Republicans are neglecting the interests of people who don’t vote for them, and this tendency is both wrongheaded on normative grounds and politically self-defeating over the long-term. 

One of the most sophisticated discussions I’ve read of coalition politics is Will Wilkinson’s cynical take from earlier this week:

Coalitional party politics cannot have one main thrust, but if it did it would be that parties want to appear to benefit the interest groups that make up their coalitions, because, other things being equal, voters prefer the party they believe most likely to help people like them. This gets us at the question at hand in a cleaner, less tendentious way. Democrats want to redistribute downward because trying to do so helps get them elected, and Republicans don’t because it doesn’t. Republican populists basically argue that if the GOP were to throw the working-class a little more red meat, working-class folks will become a little more likely to vote Republican. It’s probably true, but myopic partisan self-interest recommends against rewarding people who tend to vote for the other party. The “libertarian” version of Republican populism says maybe it wouldn’t be necessary to throw transfers at the poor and working classes in order to gain their allegiance if only the GOP would commit itself to making a good show of sticking it to the trusts. This idea is almost as fanciful as an “almost spotless” stimulus. The GOP isn’t going in for principled anti-corporatism for the same reason it’s not inclined to go in for bigger transfers for the poor and working classes. Political parties risk punishing their allies and rewarding their enemies only as a gambit of desperate last resort when faced with the terrifying prospect of imminent long-term annihilation. The Republicans aren’t staring into that abyss, yet.

That said, it remains that egalitarian anti-corporatism is a genuinely excellent, genuinely egalitarian idea. I would prefer to see it combined with a really solid scheme of social insurance. But we never see this combination because neither party is interested in it. Many Democratic partisans are even less interested in anti-cronyism than many Republicans, unless they think it will hurt Republican fund-raising, and that just goes to show that Democratic egalitarianism is as opportunistic and superficial as the Republican love of liberty. [Emphasis added]

Escaping this trap — that is, persuading conservative voters to back conservative causes that “reward people who tend to vote for the other party” — is an uphill battle, but I’m sorry to say that it’s kind of crucial to the future of this country. If you believe as I do that the best way to combat entrenched poverty is to foster a more inclusive economy, i.e., an economy in which you don’t have large numbers of less-skilled workers living in isolated, high-poverty communities, you have to take measures like wage subsidies seriously. These measures will generally mean that resources will have to flow from high-functioning, two-earner household taxpayers that face the rising of medical care and higher education and housing within easy commuting distance of good job opportunities to struggling people with weak social ties who exist on the margins of the formal labor market. This flow should work much better than it does now, and the goal should be that benefits to households in the former camp will outweigh the costs.  

To acknowledge the libertarian populist critique, I absolutely think it’s possible to better the lives of poor and marginalized people by, for example, deregulating labor markets, lowering tariff barriers, reforming local land-use regulations, etc. I consider these measures very high priorities. But Republican lawmakers have to be concerned about the well-being about people outside of their electoral constituencies if these efforts are going to succeed.


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