Sen McConnell stands next to a printed stack of Obamacare’s 20,000 pages of rules and regulations
This is not the second coming of Medicare.
By Jay Cost
With the Supreme Court decision upholding President Obama’s
health care law last summer and his reelection in November, liberals are
triumphant, convinced that Obamacare is here to stay. When pressed on
this matter, they point to the political success of Medicare to show how
quickly new entitlements become entrenched.
But the politics of Obamacare, and Medicare for that matter, are much more complicated than some would have us believe. In fact, a careful analysis of both demonstrates that there are important differences, which ultimately will make Obamacare considerably more susceptible to reform than Medicare ever was.
To appreciate these differences, it is appropriate to set aside ideological commitments and think of politics in America through the logic James Madison set out in Federalist 10: American politics ultimately comes down to the mobilization and maintenance of political factions within the structures the Constitution has established. This intuition remains true today, and an appreciation of the factional politics of American social welfare policy should help conservative reformers understand how exactly they can fix some of the problems Obamacare has created.
Medicare was a broadly popular program at the time of its enactment. In late 1964 the Gallup poll found that the public overwhelmingly approved of what would become Medicare Part A, a hospital insurance program financed through expanded Social Security taxes. These numbers were basically unchanged from a survey taken in the spring of 1961, despite relentless lobbying by the American Medical Association in the intervening years to move public opinion against such a program. This broad, enduring support for the program is a big reason why roughly half of House Republicans supported the program on final passage. They did not want to be seen on the wrong side of an initiative that had such strong support.
But the politics of Obamacare, and Medicare for that matter, are much more complicated than some would have us believe. In fact, a careful analysis of both demonstrates that there are important differences, which ultimately will make Obamacare considerably more susceptible to reform than Medicare ever was.
To appreciate these differences, it is appropriate to set aside ideological commitments and think of politics in America through the logic James Madison set out in Federalist 10: American politics ultimately comes down to the mobilization and maintenance of political factions within the structures the Constitution has established. This intuition remains true today, and an appreciation of the factional politics of American social welfare policy should help conservative reformers understand how exactly they can fix some of the problems Obamacare has created.
Medicare was a broadly popular program at the time of its enactment. In late 1964 the Gallup poll found that the public overwhelmingly approved of what would become Medicare Part A, a hospital insurance program financed through expanded Social Security taxes. These numbers were basically unchanged from a survey taken in the spring of 1961, despite relentless lobbying by the American Medical Association in the intervening years to move public opinion against such a program. This broad, enduring support for the program is a big reason why roughly half of House Republicans supported the program on final passage. They did not want to be seen on the wrong side of an initiative that had such strong support.
Importantly, it was this support that helped Medicare survive one
budget crisis after another. The program was designed primarily with an
eye to political durability rather than efficiency or even
sustainability. In particular, it imposed no real controls on the amount
that medical providers could charge the government, partly out of fear
of a boycott by doctors and hospitals. As such, in 1968 and 1969
Medicare was growing at an annual rate of over 40 percent, inducing
Senate Finance Committee chairman Russell Long to label it a “runaway
program.”
For the next generation, legislators would have to address periodic
crises in Medicare, yet none posed an existential threat to the program.
The most that can be said is that, starting in the 1990s, conservatives
began advocating structural reforms to modernize the program, bringing
it more in line with today’s private-sector health insurance. At no
point has the idea of repealing Medicare gained traction, nor has the
government’s commitment to medical care for the aged ever been seriously
challenged, despite the demagogic claims of liberal Democrats.
Why was Medicare so popular? To put it simply, LBJ shoehorned it into
the Social Security program, which itself had been a stroke of
political genius by Franklin Roosevelt. By using a universal, social
insurance model, the programs have created a sense of public ownership
and not of welfare. Everybody pays in; everybody benefits.
Medicare, moreover, like Social Security, diffuses costs broadly but
concentrates benefits. The average worker paid a small price for
Medicare when it was first passed, via a slightly higher payroll tax,
but this was not very noticeable given how quickly wages were increasing
in the middle 1960s. Meanwhile, the elderly, doctors, and hospitals all
reaped windfalls from the program in the early years.
This, naturally, is what sowed the seeds of the chronic financing
crises of the program: It is simply too good a deal, from a budgetary
standpoint. But from a political standpoint, creating a sense of
ownership, spreading the costs, and concentrating the benefits are
sure-fire ways to guarantee political survival in our Madisonian system.
Not all programs are so politically successful. It depends on the
interplay of factions, especially politicians’ ability to transform
diverse groups into defenders or attackers of existing programs. At the
other end of the spectrum of success from Medicare is the Catastrophic
Health Coverage Act (CHCA) of 1988, which was the product of a peculiar
coalition of the Reagan administration and congressional Democrats, who
controlled both houses. Like Medicare before it, the bill passed with
overwhelming support, garnering majorities of both parties in the House.
But unlike Medicare, it lacked a popular base of support. Under the
CHCA, Medicare beneficiaries would fund an expansion in the benefits
offered by Medicare Part A to people with long-term hospital or extended
care needs. What happened next surprised just about everybody: Medicare
beneficiaries rebelled against the higher premiums required for the
extended coverage, and political pressure forced a Democratic Congress
and Republican president (this time George H.W. Bush) to repeal the
program. The problem was that the noticeably increased costs were
distributed among all Medicare recipients, but the benefits went only
to those who needed subsidized long-term care, far too small a faction
to sustain the new benefits.
Medicare and the CHCA met opposite political fates. What about
Obamacare? Liberals have convinced themselves that, simply by virtue of
its passage and endorsement by the Supreme Court, it will be just like
Medicare. But there are important political differences
between Obamacare and Medicare, and equally notable similarities with
the CHCA.
For starters, Obamacare looks much more like the CHCA in that it
imposes costs on discrete factions in society. Most prominent are those
who will lose their coverage through their employer and be forced into
the new exchanges. It is always politically dangerous for a program to
affect a particular constituency in such a negative way. Add to this the
growing complaints from the business community about the burdens of the
program, along with the wariness of senior citizens whose Medicare will
lose $700 billion in funding, and one can discern a political coalition
out there ready to coalesce if and when these potential harms are
realized. For all of its fiscal irresponsibility from the time of its
creation, Medicare never forced people off their existing insurance as
Obamacare will, nor was the Medicare payroll tax significant enough to
elicit a response from younger workers or businesses.
Still, this is not to say that the politics of Obamacare perfectly
match the politics of the CHCA—far from it. In theory, all Medicare
recipients were potential beneficiaries of the CHCA. None would have to
worry about being bankrupted by a prolonged hospital stay. Yet only a
narrow slice of this group would ever realize the benefit, whereas all
realized the costs. Not so with Obamacare, which will extend benefits to
millions of Americans, even if in a cumbersome and inefficient manner.
Once these benefits come online—as they will, thanks to the president’s
reelection—Obamacare will have political leverage that CHCA lacked. Our
Madisonian system works by providing multiple factions within society a
veto over public policy changes, and it is likely that the beneficiaries
of Obamacare will be able to prevent full-blown repeal.
Thus, the outlook for Obamacare probably lies somewhere between the
extremes of Medicare and the CHCA. The program lacks the political power
of Medicare, which in turn means it is probably not immune to
substantial reforms. But it has created a client base that is much
larger than that of the CHCA, which means it will almost certainly
survive.
What, then, is the way forward for conservative reformers?
The answer might be found south of the Mason-Dixon line, in Arkansas. As Avik Roy of Forbes
has reported, Democratic governor Mike Beebe has worked out a deal with
Washington in which the state will expand coverage to the poor, but not
through Medicaid. Instead, it will do so via an expansion of the new
insurance exchanges. The driver behind this arrangement was the
Republican-controlled state legislature, which pushed for a deal with
the Obama administration.
Herein lies a path for reform. Even if the expansion of coverage is
permanent, Obamacare is creating an infrastructure through which
conservatives may be able to realize their reform goal of a freer
marketplace that drives down costs and provides consumers with greater
flexibility. As Arkansas has shown, the exchanges are a potential
mechanism for such outcomes, and the Obama administration’s desire for
full implementation has created an opening for renegotiation.
It is not hard to envision future reforms that peel back the onerous
regulations of Obamacare, lowering the costs to the government, while
keeping the 30 million or so new beneficiaries under the federal
umbrella. From a Madisonian perspective, if the central political
problem of Obamacare was that it created too many losers alongside its
winners, then a successful conservative alternative would be a
free-market approach that makes these losers whole again without
depriving the winners of their new gains.
This is a real possibility. Indeed, as Avik Roy and Douglas
Holtz-Eakin, former director of the Congressional Budget Office, argued
recently at Reuters, “The great irony of Obama’s triumph . . . is that
it can pave the way for Republicans to adopt a comprehensive,
market-oriented health care agenda.”
Put simply, the battle over health care is far from over—and the
ultimate outcome depends in part on how thoroughly conservative
reformers understand the unique coalitional politics of Obamacare.
http://tinyurl.com/ap7zgzp
No comments:
Post a Comment