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This blog is the second in a three-part series on the path forward on health reform. To be clear, the main focus of this series is thinking about a political path forward on reform rather than describing a policy proposal (as important as that is).
In the first blog in the series, I laid out the goals of reform in broad brushstrokes—coverage for all, improved access and quality, better health, cost containment and consumer protection. I also discussed the importance of two related overarching goals that are not specific to health care—the importance of demonstrating that collective action can change public policy and that changes in public policy can make people’s lives better. Part one concluded by observing that while our goals remain unchanged, how far we can advance those goals is shaped by the political circumstances at any given moment (e.g. sometimes not moving backwards is a win).
This second installment will look at four important factors that are likely to shape the political opportunity for federal-level health care reform in the near future. These factors are in some sense generic — they relate to any public policy campaign, not just health policy — but I will relate them specifically to health care wherever possible. The four factors are structural features of the U.S. government, public opinion, interest group dynamics and the congressional vote count.
Brexit notwithstanding, passing legislation in parliamentary systems is easier than in the U.S. Our multi- step process, institutional divisions between House and Senate, and super-majority rule in the Senate are all among the factors that make it challenging to pass any bill, not just a health care bill, through Congress and get it signed into law. This is by design as the framers of the Constitution feared government action more than government inaction. Not only that, but it is just a fact of life that it is always harder to build consensus for change than it is to block that change. The supporters of change have to more or less agree on everything. Opponents only have to agree on the fact of opposition even if their reasons for opposing a bill are varied.
Support for the idea that it is a federal government responsibility to guarantee health coverage has increased substantially over the past few years. However, so far this mostly reflects the recovery of ground lost during and following passage of the ACA. The attacks on the ACA coupled with its troubled roll out caused support for government guaranteed care to take a nose dive. Since then support has climbed back into its normal historical range. While it is true that a few polls have found higher levels of support, others have found much lower levels.
Overall, after reviewing essentially every poll we could find in the public domain, Community Catalyst concluded that current levels of support were roughly consistent with the historical average. Whether support will continue to climb is impossible to say at this point. It is also not clear how durable that support is. Some polls have found people moving readily from support to opposition if increased taxes, elimination of private insurance or increased waiting times for care are mentioned.
Another factor to consider is the tendency of support to drop when a proposal faces sustained attack. This was the experienced of the Clinton health reform effort, which was launched with popular support but then soon found itself upside down in the polls as opponents took aim at it. Something similar happened with a single payer ballot question in California around the same time. Supporters slightly outnumbered opponents in early polling, but in the final, voting opponents outnumbered supporters by 73-27. More recently, voters in Colorado rejected a single payer plan by an even larger majority 79-21.
Finally, one challenge with sustaining popular support is that people tend to fear the unknown. They are more motivated by potential for loss than opportunity for gain—a phenomenon behavioral economists call “loss aversion.” Fear of the power of loss aversion to undermine support for change is why “If you like your plan you can keep it,” was such a prominent part of the ACA campaign.
Any plan to create a guaranteed right to health coverage backed by public financing—whether single- payer or a multi-payer/mixed system—will require tax increases, involve an expansion of the welfare state and shift money from richer to poorer people. That is a feature not a bug. But it is a feature that tends to trigger the opposition of what many observers consider the most powerful lobbying force in the country: big business.
Overcoming the opposition to tax increases and expansion of economic rights becomes either more possible or much more difficult depending on the positions of another group of powerful actors—namely the large economic actors in health care: hospitals, doctors, insurers and drug companies. These health care groups are likely to be supportive of measures that expand coverage (or at worst neutral) but will be opposed to measures that reduce their payments. Recently, we saw this illustrated in a positive way by the widespread opposition among health care providers to ACA repeal. However, coverage expansion proposals that seek to simultaneously raise taxes and reduce payment rates are likely to face a very tough road. Health care stakeholders are also likely to be supportive of at least some measures to advance the access and quality goals laid out in part one of this series. An important point that I will come back to in part three.
Political control of the White House and Congress obviously greatly affects the opportunity for reform. With Donald Trump in the White House and both houses of Congress controlled by Republicans, there was no opportunity for progress. Instead, there was an intense fight to protect the ACA and Medicaid. With Congress divided, active repeal efforts have halted but could revive depending on the electoral outcome in 2020.
But simple control of Congress is not the only thing that matters. Historically, big successful health reforms—Medicare and Medicaid and the ACA—have only been possible with large Democratic majorities in Congress. When Medicare and Medicaid passed, Democrats had a 2 to 1 majority in both the House and the Senate. For the ACA the Senate split was 60 /40. To return to the margin they enjoyed in 2009, Democrats would need to hold all of their current seats and win 13 seats of the 21 Republican seats that in are up in 2020. Narrower margins, particularly in Senate, have tended to produce policy failure—as illustrated by both the failure of the Clinton plan and ACA repeal.
Any plan to achieve the goals laid out in part one must reckon with the challenges described here. Of course, bills get passed all the time despite the inherent structural barriers. But passing health care legislation over the determined opposition of both big business groups and big health care is a much rarer phenomenon—arguably happening only once in history, in 1965, when Democrats had 2 to 1majorities in the House and Senate. Even then, the legislation they passed offered many financial benefits to health care stakeholders and largely avoided triggering loss aversion among the general public, unlike many current proposals.
Given all these barriers, is it possible to achieve the goals laid out in part one? I believe the answer is yes, and the final installment of this blog series will discuss a path to getting it done.