This is hard – Obama on Healthcare.

Healthcare policy is such a curiosity, but the political landscape of it is downright fascinating. Over the past few months, with a meaningful ability of the Republican Party to repeal the Affordable Care Act (“ACA”), we’ve all been reviewing two things: first, the successes and failures of the ACA, and; second, what happens after any repeal.

This has forced me to review our approach to this debate and how its metrics have changed over time. How do we measure success of the ACA? Is it that more people are covered? Or is it by how expensive coverage is? Further, we have poll numbers about favorability of the ACA, but how do we break that down between people who do not like government dabbling at all, people who think the ACA did not go far enough (i.e., people who originally wanted a single payer system and still do), and those who do not like the ACA as it has been portrayed by politicians, but nonetheless like the benefits they’ve derived by its implementation.

If I can recommend two good listens, they would each be Vox podcasts. The first is The Weeds episode where Sarah Kliff interviews folks in Kentucky about why they voted to Trump relative to their thoughts on the ACA. There are a lot of interesting revelations here. Primarily:

  • There are a lot of people who like the benefits they’ve received from state expansion of Medicaid as a result of the ACA, but it is coined by a different state-specific name, and therefore do not associate their likes with the ACA.
  • There are a lot of people who do make that connection but are hedging their bets against Trump, i.e., they think that Trump either will not be able/try to repeal the ACA or that, if he does, it will be better.
  • Most interestingly (in my opinion), was the woman, Kathy, who has been signing people up for the ACA and is disappointed in the fact that it’s so difficult to navigate and so much more expensive when it comes to the working poor — those who make enough money not to qualify for poverty-based programs for Medicaid but don’t have the dollars on hand to eat the cost of increased premiums, nor the time to navigate the requirements of the ACA. Essentially she feels it’s wrong the people who do not work have access to an easier single payer system (though she doesn’t call it that) but those who are working and struggling have to deal with this additional bureaucratic stressor.

I think I really took for granted in my own wonkish bubble just how much Republican market arguments didn’t resonate with many of their voters. This splits in a few ways.

The first is that a lot of people who voted for Trump – who might not actually be historically Republican voters – don’t give a lick about free markets or government power abuses, and really just resent the encumbrance and preserved unfairness of their new healthcare decision-making tree. This is the more populist faction found primarily in rural, southern areas (Robert Leonard has an excellent article detailing how the south has a more determinative populist streak than anything.)

The second is we have a lot of people who have crafted an identity around this Republican orthodoxy in that they want to identify Republican and have internalized the arguments around freer markets and freer people (a sentiment I still largely agree with, though have lightened up on, especially with healthcare, but I digress.) However, on daily terms, their desires translate to the opposite:  like Kathy, they practically want the ease of access and lower costs provided by programs like Medicaid, but philosophically oppose the underlying proposition that this requires turning healthcare into a single-payer public good.

This is in stark contrast to the narrative that Republicans have crafted in the past. Only time will tell if this will harm them, since all voters seemingly have short memories (I’m not immune to this, myself.) I do think it’s going to be a difficult balancing act to reconcile their Constitutional arguments against the ACA – the principled attack that this is an unconstitutional extension of government power regardless of what the Supreme Court says – with their newfound vigor in repealing the ACA but then committing to replace it with something else. That’s government involvement by any name; the question is whether they name it something that sells better to the bloc committed to this narrative.

Similarly, on top of the above, the question remains what the replacement will be. Let’s set aside the repeal-and-delay tactic for the moment. If we have an entire bloc of people that traditionally vote Republican on principled grounds, the Republicans presumably want to keep them. That requires some adherence to a narrative that presents a limited government, fiscally responsible, constitutionally-ordained approach.

The wrinkle is the folks who generally like the benefits received by single-payer, Medicaid-esque options. If you want to replace the ACA with something that gives them those benefits, you need to wrap that up in a narrative that is couched in the above precepts for both the true believers and those who find it important to identify as Republican regardless of actual policy.

Here is where I’d like to insert my second suggestion, which is yet another Weeds podcast, this time an interview with President Obama and his reflections on the ACA as well as his long-term expectations for Republicans. We actually get to hear from Kathy, who asks Obama directly about the concerns mentioned in the original Weeds Podcast. I think this is an excellent deep dive. If anything, the implementation of the ACA let us see a lot of the incentives at play both as a market and politically. I think there are a lot of lessons to be learned from it, especially for those who are wonkish and intent on mulling over solutions to its failures.

Moving on, you have this this populist group that is very outcome-oriented. The kicker for them will be whether or not their lives feel better in the short term. This is probably the largest hurdle:

  • Short term results in policy initiatives is difficult;
  • This is especially true with healthcare policy, at least good healthcare policy, because you’re often dabbling in a long game;
  • As the Democrats have learned, success is heavily dependent on people making the tie between your policy and their sense of a better quality of life. Democrats hedged the ACA on the understanding that people, once covered, would accept the ACA because of the improvement in their lives. This proved untrue not just because, for many people, the increased sense of unfairness overwhelmed any real benefits, but also because the tangled web of the ACA made it difficult to tie even those real benefits back to the ACA.

In short, the Republicans did a really good job of taking the burdens of the healthcare industry and thrusting them wholly on the ACA. There’s just a lot of tough nuts to crack in healthcare, and the ACA has its failings for sure, but Republicans were able to take all hurdles and frame them as Democratic failures. In contrast, Democrats did a really bad job of distinguishing between what was actually caused by the ACA, and illuminating the ways in which the ACA specifically caused better healthcare coverage.

I think the salient point here is that most Americans implicitly view healthcare as a public good. It would be vastly unpopular and politically impossible to get rid of Medicaid and Medicare. The latter is exceptionally popular, and is basically single payer for retirees. It doesn’t suffer from the same image problems of Medicaid because we don’t view seniors as people who should be working.

Medicaid might not be visually popular, but we know getting rid of it would have political backlash once broad swaths of impoverished people no longer had access to that safety net. States in particular are likely to fight back against this, even Republican-majority ones, because at best the cost would be need to be covered by states. More likely, you’d just have a lot of folks experiencing true burns, not hypothetical ones, and feeling galvanized to push back. As we saw this election, that threat can be real.

Likewise, it’s clear based on our post-mortem of the Obama presidency that even conservative-leaning, or at least Republican-identifying, Americans, as well as Trump voters, desire access to a Medicaid-esque system that has lower barriers to entry and lower costs than the ACA scheme they’ve just been thrust into. It will be interesting to see if Republicans actually try to manage these competing demands, and if this means recasting their position in a frugal-yet-involved light or simply repealing and hoping to delay the political implications until later elections, thus spreading the political cost to Democrats as ACA failures.

It could also be a long-term attempt to defeat the narrative that government healthcare is at all helpful, allowing the establishment to recoup and recover after populist usurpation (slight editorial comment on my part.) If everything fails just right and at just the right time, more orthodox Republicans could see a new opening for bona fide privatization.

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