Republicans are still trying to repeal Obamacare. Here’s why they are not likely to succeed - The Washington Post

Conservatives are still trying to repeal the Affordable Care Act (ACA) — even after the Republican-majority Congress <a href="https://www.washingtonpost.com/news/monkey-cage/wp/2017/07/19/why-cant-the-senate-repeal-obamacare-because-its-actual-policies-are-popular">failed to overturn the law</a> in 2017. A coalition of conservative groups intends to release a <a href="https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/05/29/the-health-202-conservative-activists-aren-t-giving-up-their-obamacare-repeal-dream/5b0c18101b326b492dd07eb9/?utm_term=.833893f71527">new plan this summer</a>. The groups will <a href="https://www.wsj.com/articles/new-push-to-topple-affordable-care-act-looms-1527240601">reportedly propose</a> ending the law’s expansion of Medicaid (the federal program that helps fund health care for low-income Americans) and convert Medicaid funding into block grants to the states. And just last week the Trump administration’s Justice Department <a href="https://www.cnn.com/2018/06/07/politics/trump-admin-aca/index.html">argued in a legal filing</a> that key provisions of the law — its protections for persons with preexisting conditions — are <a href="https://theincidentaleconomist.com/wordpress/texas-fold-em/">unconstitutional</a>.

Why are Republicans still trying to undo the ACA? We argue in a forthcoming <a href="https://doi.org/10.1215/03616878-6527971">article</a> that the law’s political vulnerabilities and Republican electoral dynamics drive conservative efforts to uproot it.

In the past, conservatives have thrown in the towel

As politicians and political scientists both know, the <a href="https://www.amazon.com/Unhealthy-Politics-Battle-Evidence-Based-Medicine/dp/0691158819/ref=sr_1_1?ie=UTF8&amp;qid=1528305020&amp;sr=8-1&amp;keywords=eric+patashnik">political sustainability of reforms</a> can never be taken for granted. Even so, the duration and intensity of conservative resistance to the ACA is historically unusual. The ACA is a moderate law, modeled on <a href="https://www.csmonitor.com/Business/Robert-Reich/2013/1028/The-irony-of-Republican-disapproval-of-Obamacare">ideas</a> that Republicans once supported, such as insurance purchasing pools. What’s more, many red states refuse to accept the ACA’s funding to expand Medicaid to more of their citizens — such as <a href="http://www.commonwealthfund.org/publications/issue-briefs/2016/apr/medicaid-expansion-texas">Texas</a>, which has a large number of uninsured residents — even though you would think they would want those federal benefits.

To be sure, conservatives (a group that decades ago included both Southern Democrats and many Republicans) often fought against new social programs. But once enacted, conservatives frequently accepted or resigned themselves to their existence. The GOP’s 1936 presidential nominee, <a href="https://en.wikipedia.org/wiki/Alf_Landon">Alf Landon</a>, did call for Social Security’s repeal. Yet by the early 1950s, strong bipartisan majorities supported increasing Social Security benefits.

The response was similar after Congress’s 1965 passage of Medicare, the federal health-care program for senior citizens – to which persons with permanent disabilities were added in 1972. Before Medicare passed, congressional debate was<a href="http://www.asaging.org/blog/political-history-medicare"> ideologically charged</a>; its opponents alleged that the program would lead to “<a href="https://www.amazon.com/Politics-Medicare-Second-Social-Institutions/dp/0202304256">socialized medicine</a>.” But once the law took effect in 1966, <a href="http://press.uchicago.edu/ucp/books/book/chicago/P/bo3644989.html">conservative resistance collapsed</a>. There were no serious efforts to repeal Medicare or challenge its constitutionality. Similarly, Medicaid, which also passed in 1965, encountered little conservative resistance. By 1970, all but two states (Alaska and Arizona) participated in Medicaid.

[Why can’t the Senate repeal Obamacare? Because its policies are actually popular]

So why is the ACA still politically vulnerable?

The answer lies partly in the way the program was designed.

First, unlike Social Security and Medicare, Obamacare does not have a well-defined population of beneficiaries. The ACA is not a single program but, rather, a <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1202111">series of programs, subsidies and regulations</a>. It treats people differently depending upon where they live, where they work, how they get insurance and how much they earn. That complicates efforts to mobilize public support.

So does the ACA’s partial reliance on private insurance to deliver benefits. As Suzanne Mettler argues in her book “<a href="https://read.amazon.com/kp/embed?asin=B005PY34VI&amp;preview=newtab&amp;linkCode=kpe&amp;ref_=cm_sw_r_kb_dp_MntiBbZ68ETTC&amp;tag=thewaspos09-20">The Submerged State</a>,” social programs that channel public authority through private markets may fail to build strong political constituencies.

Second, ACA benefits are not consistently generous enough to build the strong and cohesive national constituency enjoyed by programs such as Social Security. Many families still face rising health-care bills, which hits especially hard for working-class families in the 17 states that have not embraced Medicaid expansion. Other adults may not be able to afford insurance because they earn too much to qualify for substantial (or any) federal support.

Third, conservatives dislike how the law distributes benefits. When used with the traditional Medicaid program, the ACA insures low-income adults. It’s true that <a href="https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work/">nearly eight in 10</a> Medicaid adults live in working families, and <a href="https://www.kff.org/medicaid/issue-brief/understanding-the-intersection-of-medicaid-and-work/">60 percent work themselves</a>. But millions of working-age people on Medicaid are not currently employed, often because of disability, illness or care-giving responsibilities. <a href="http://gophouse.org/rep-cox-medicaid-welfare-work-requirements-promote-self-sufficiency-protect-michigan-taxpayers/">Some conservatives</a> want more Medicaid recipients to work. And so they want to make it harder for people to qualify for benefits.

[Why Republicans struggle over the ACA]

Fourth, conservatives object that ACA benefits are funded largely by taxes on the wealthy. That’s different from programs such as Social Security and Medicare, which rely on “contributory” financing: Workers and their employers pay a percentage of their payroll taxes to help fund the programs. This allows enrollees to claim they earned their benefits.

Republican electoral dynamics fuel conservative opposition

Beyond program design, the radicalization of the Republican Party has made Obamacare vulnerable. As Jacob Hacker and Paul Pierson <a href="https://doi.org/10.1215/03616878-6527935">argue</a>, this is not your grandfather’s Republican Party. Today, activist groups and major donors in the Republican Party encourage conservatives to fight on against social welfare programs, even if success seems unlikely.

What’s more, Republicans have regularly held power in Congress in recent years. Throughout most of the postwar era, <a href="https://www.nationalaffairs.com/public_interest/detail/the-permanent-democratic-congress">astute political observers</a> assumed that Democrats had a permanent congressional majority. Minority status encouraged congressional Republicans to accept half a loaf and move on. Now, as Frances Lee <a href="https://www.washingtonpost.com/news/monkey-cage/wp/2014/01/09/american-politics-is-more-competitive-than-ever-thats-making-partisanship-worse/?utm_term=.6cb2b0f27ca3">notes</a>, majority control is up for grabs in almost every election. That competitiveness encourages the parties to heighten their messaging and discourages conservatives from giving up on ACA repeal.

The war over the ACA is likely to continue until one side or the other wins a decisive electoral victory. That doesn’t seem to be on the horizon.

Last year, Congress succeeded in eliminating the law’s penalty for individuals who do not obtain insurance. The Trump administration has also used its <a href="https://www.vox.com/2017/8/31/16236280/trump-obamacare-outreach-ads">executive powers</a> to try to <a href="http://www.latimes.com/business/hiltzik/la-fi-hiltik-trump-csr-20171013-story.html">unravel</a> the law — for example, by proposing to allow insurers to sell skimpy plans that lack Obamacare’s consumer protections.

And yet conservatives are unlikely to uproot the law in 2018. With Democrat Doug Jones’s victory in Alabama’s special Senate election last year, the Republicans’ Senate majority is only 51 to 49. Majority Leader Mitch McConnell (R-Ky.) has little room to maneuver, since Democrats are unified against repeal.

Moreover, since Congress last tried to undo the ACA, two more states — <a href="https://www.nytimes.com/2018/06/04/health/maine-medicaid-expansion.html">Maine</a> and <a href="https://www.washingtonpost.com/local/virginia-politics/virginia-senate-approves-medicaid-expansion-to-400000-low-income-residents/2018/05/30/5df5e304-640d-11e8-a768-ed043e33f1dc_story.html?utm_term=.65978b48d8de">Virginia</a> — have adopted the Medicaid expansion, enlarging the ACA’s constituency.

[Here’s how local TV news is making it harder to repeal Obamacare]

For now, the ACA remains intact — but expect the skirmishing over its future to continue.

<a href="http://watson.brown.edu/people/faculty/patashnik">Eric Patashnik</a> is director of the master of public affairs program and Julis-Rabinowitz Professor of Public Policy and Political Science at Brown University.

<a href="https://www.med.unc.edu/socialmed/people/jonathan-oberlander/">Jonathan Oberlander</a> is professor and chair of social medicine and professor of health policy and management at the University of North Carolina at Chapel Hill.

Eric Patashnik is a professor of public policy and political science at Brown University.

Eric Patashnik

Jonathan Oberlander

The Washington Post

Monkey Cage

Democracy is the art of running the circus from the monkey cage. -- H.L. Mencken

Post Politics from The Washington Post is the source for political news headlines, in-depth politics coverage and political opinion, plus breaking news on the biden administration and White House, Congress, the Supreme Court, elections and more.

Politics

People love to hate Congress. This new book reminds us why we should treasure it. - The Washington Post

Very little about current headlines would make a political observer impressed with today’s Congress. House Speaker <a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=https://paulryan.house.gov/&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNGUi0SjdQHgfrqWlHUhfvoDORUBGg" href="https://paulryan.house.gov/" target="_blank">Paul D. Ryan</a> (R-Wis.) is searching for the votes to <a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=https://www.washingtonpost.com/powerpost/conservative-pressure-groups-throw-weight-behind-gop-health-care-deal/2017/04/26/918ad730-2a82-11e7-a616-d7c8a68c1a66_story.html?utm_term%3D.d713e04f8d83&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNFlNTBf2FzOpWPY2IyBjjFptjhy9A" href="https://www.washingtonpost.com/powerpost/conservative-pressure-groups-throw-weight-behind-gop-health-care-deal/2017/04/26/918ad730-2a82-11e7-a616-d7c8a68c1a66_story.html?utm_term=.d713e04f8d83" target="_blank">repeal and replace</a> the Affordable Care Act and pass a <a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=http://www.cnbc.com/2017/04/28/house-has-the-votes-for-bill-to-avert-government-shutdown.html&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNFD0gBQA33nUEAS5Cujl6I8NaK3YA" href="http://www.cnbc.com/2017/04/28/house-has-the-votes-for-bill-to-avert-government-shutdown.html" target="_blank">long-term spending bill to keep the government open</a>. There is at best <a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=https://www.washingtonpost.com/news/monkey-cage/wp/2017/04/27/why-wont-congress-investigate-the-trump-campaigns-ties-to-russia/&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNGveqkXXdBjsfE7zxIf0d5bRT8Z3g" href="https://www.washingtonpost.com/news/monkey-cage/wp/2017/04/27/why-wont-congress-investigate-the-trump-campaigns-ties-to-russia/" target="_blank">a halfhearted attempt</a> in Congress to investigate potential contacts between the Trump campaign and Russia.

But even if the contemporary Congress appears relatively ineffectual, we should not lose sight of the lasting, consequential influence of Congress on American life. To see that influence, the place to turn is Yale University political scientist <a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=http://campuspress.yale.edu/davidmayhew/&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNFICt6BQM81f8KsT5SOV1mFcFsasg" href="http://campuspress.yale.edu/davidmayhew/" target="_blank">David R. Mayhew’s</a> excellent new book “<a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=https://www.amazon.com/Imprint-Congress-Henry-Stimson-Lectures/dp/0300215703&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNFk3mbELSZ2HSUK8yeWpOfmBQem5w" href="https://www.amazon.com/Imprint-Congress-Henry-Stimson-Lectures/dp/0300215703" target="_blank">The Imprint of Congress</a>.”

Mayhew is our most distinguished scholar of Congress, the author of many landmark works, including “<a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=https://www.amazon.com/Divided-Govern-Lawmaking-Investigations-1946-2002/dp/0300102887/ref%3Dsr_1_sc_1?s%3Dbooks%26ie%3DUTF8%26qid%3D1493260951%26sr%3D1-1-spell%26keywords%3Ddividd%2Bwe%2Bgovenr&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNFKw0bE1d9P7Izae_1TgvPjyMKAog" href="https://www.amazon.com/Divided-Govern-Lawmaking-Investigations-1946-2002/dp/0300102887/ref=sr_1_sc_1?s=books&amp;ie=UTF8&amp;qid=1493260951&amp;sr=1-1-spell&amp;keywords=dividd+we+govenr" target="_blank">Divided We Govern</a>.” His latest book weaves together themes from his lifetime of scholarship on representation and lawmaking along with many fresh insights to produce his most comprehensive statement yet on the mark that Congress has made on American politics and society.

Unlike observers who examine Congress’ failure to pass proposals urged by experts, Mayhew does not focus on what Congress “should” have done. Rather, he looks at what Congress actually did (for better and for worse) over the span of American history. Mayhew examines the participation of the government in 13 large political and intellectual “impulses,” which capture the country’s biggest policymaking endeavors — from launching the new nation to building an industrial economy to constructing a welfare state to controlling the debt and deficit. This figure displays them:

Mayhew’s investigation turns up five key lessons about Congress and policymaking.

1.  Many aspects of U.S. government performance are generic and typical, not exceptional

Mayhew observes that impulses frequently occur in many countries at roughly the same time, not only in the United States. For example, the postwar drive for civil rights and the termination of white-only immigration policies took place in many democracies. Similarly, the shift toward economic <a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=https://en.wikipedia.org/wiki/Neoliberalism&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNErzAfBRAe5fwg3Py8y4D8zJHWsKw" href="https://en.wikipedia.org/wiki/Neoliberalism" target="_blank">neoliberalism</a> during the 1970s was a global phenomenon. To be sure, U.S. public policy is distinctive in some key respects. As Mayhew writes about the <a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=https://www.amazon.com/Divided-Welfare-State-Private-Benefits/dp/0521013283/ref%3Dsr_1_4?ie%3DUTF8%26qid%3D1493262290%26sr%3D8-4%26keywords%3Djacob%2Bhacker&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNFUGX2vuX7QP3jFscGKw9tiDQMXtA" href="https://www.amazon.com/Divided-Welfare-State-Private-Benefits/dp/0521013283/ref=sr_1_4?ie=UTF8&amp;qid=1493262290&amp;sr=8-4&amp;keywords=jacob+hacker" target="_blank">American welfare state,</a> “The United States came to social provision late, has kept its public spending relatively low, and has nourished a mix of pensions and health insurance that depends uncommonly on the private sector.” But in many domains, American exceptionalism is hard to detect.

2. The common claim that polarization is at an all-time high is “bizarre”

Mayhew suggests that observers make two mistakes when they discuss <a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=https://www.washingtonpost.com/news/monkey-cage/wp/2015/03/15/everything-you-need-to-know-about-our-polarized-politics-in-the-palm-of-your-hand/?utm_term%3D.46a07240a15d&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNHo5LudC2X6FPvinf1BmZeJuYsPXw" href="https://www.washingtonpost.com/news/monkey-cage/wp/2015/03/15/everything-you-need-to-know-about-our-polarized-politics-in-the-palm-of-your-hand/?utm_term=.46a07240a15d" target="_blank">polarization</a>. First, they fail to recognize that political antagonisms can occur along many lines in society, not just partisan ones. Second, people fail to remember the past. “Have we forgotten the 1850s through the 1870s?,” he asks. “In the 1850s the sectional sides drifted toward killing each other — then they killed each other. The <a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=http://www.history.com/topics/american-civil-war&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNE0Q5_phoBg_VEk6BY8FovmwKKPFA" href="http://www.history.com/topics/american-civil-war" target="_blank">Civil War</a> brought some 750,000 deaths, which would be about 7.5 million deaths as a share of the population today. It is hard to get more polarized than that.” In more recent memory, Mayhew observes, the <a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=https://www.britannica.com/topic/McCarthyism&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNE4qhC-q0NqGeVUoHkaxgyj5ZR7hw" href="https://www.britannica.com/topic/McCarthyism" target="_blank">McCarthy</a> and Vietnam eras featured intense polarization, too.

3. Congress has been an inventive policymaker

Congress is rarely described as inventive, yet through the years Congress has participated in political impulses by crafting novel designs, such as <a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=https://www.nap.edu/read/4980/chapter/2&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNEyFMzf6HeqkQURyIqdGmvdzBAPew" href="https://www.nap.edu/read/4980/chapter/2" target="_blank">land grant colleges</a>, the <a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=https://www.amazon.com/Putting-Trust-Budget-Commitment-Institutional/dp/0521777488/ref%3Dasap_bc?ie%3DUTF8&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNEbitfEP6S0NIKXm6R_0eD6lG7iCw" href="https://www.amazon.com/Putting-Trust-Budget-Commitment-Institutional/dp/0521777488/ref=asap_bc?ie=UTF8" target="_blank">Highway Trust Fund</a> and the <a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=https://www.epa.gov/laws-regulations/history-clean-water-act&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNHGfIIfV6opdoeFTpyaokWdBGaUww" href="https://www.epa.gov/laws-regulations/history-clean-water-act" target="_blank">Clean Water Act</a>. This isn’t always easy, given the need to resolve partisan or ideological conflicts. The bureaucracy often seeks to make government more rational and orderly, but Congress should be credited for reaching further and generating creative responses to political impulses.

4. The 1950s and early 1960s were a fertile period for domestic legislation

Mayhew’s canvassing of Congress’ performance turns up some notable surprises. One is how much Congress contributed to the post-World War II drive for economic growth. Congress did a great deal during the Truman, Eisenhower and Kennedy administrations, although this is not always recognized. While the executive branch took the lead in managing the economy — generally relying on Keynesian ideas — Congress gave us the <a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=https://www.nsf.gov/&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNGrmfMBaehKj5yLiLLG7jMqHJXeIw" href="https://www.nsf.gov/" target="_blank">National Science Foundation</a>, the <a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=https://www.fhwa.dot.gov/interstate/history.cfm&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNGoB5NiwDAU6GrkrSTMaxWxTUg1-Q" href="https://www.fhwa.dot.gov/interstate/history.cfm" target="_blank">interstate highway system</a>, the <a data-saferedirecturl="https://www.google.com/url?hl=en&amp;q=https://www.seaway.dot.gov/about/great-lakes-st-lawrence-seaway-system&amp;source=gmail&amp;ust=1493566130443000&amp;usg=AFQjCNE0Zfo2LgkTGzXpCKcvlSmVvvniDQ" href="https://www.seaway.dot.gov/about/great-lakes-st-lawrence-seaway-system" target="_blank">St. Lawrence Seaway</a> and more.

5. People may not like Congress, but it helps make our political system stable

Mayhew’s central argument is that while Congress is frequently disparaged, it helps make the American political system more stable and more legitimate in the eyes of citizens. “Often, when Congress is doing nothing at all, to the despair of partisans, intellectuals, and the media, it is actually responding to an unresolved electorate with a perfect ear,” Mayhew writes. When Congress has taken action in one of these 13 impulses, it has typically brought the public along. It does this by enacting bills by wide margins, thereby signaling consensus. It also has responded to public demands for government benefits, from the distribution of land in the 19th century to Social Security checks today.

Mayhew acknowledges that the “striking messiness of congressional activity” creates nightmares for agencies and can undermine policy coherence. The defects of Congress are on exhibit daily, and Mayhew’s book is not intended to suggest those defects aren’t real or important.

But Mayhew’s book is an important reminder that however awful Congress is to watch, its capacity to balance the presidency and represent a diverse society helps maintain the legitimacy of the American regime.

Eric Patashnik is the director of the public policy program and professor of political science at the Watson Institute for International and Public Affairs at Brown University.

Obamacare is the law of the land. But it’s still vulnerable. - The Washington Post

Jenny

House Speaker Paul D. Ryan’s (R-Wis.) decision to <a href="https://www.washingtonpost.com/powerpost/house-leaders-prepare-to-vote-friday-on-health-care-reform/2017/03/24/736f1cd6-1081-11e7-9d5a-a83e627dc120_story.html?hpid=hp_rhp-banner-main_housevote715a-banner%3Ahomepage%2Fstory&amp;utm_term=.2d22ba02642d">pull</a> legislation to reconfigure the nation’s health-care system is a major setback to President Trump and the GOP. For seven years, Republicans promised to repeal and replace Obamacare. Their failure to deliver on this promise exposes <a href="https://www.nytimes.com/interactive/2017/03/24/us/politics/republicans-opposed-health-care-bill.html?_r=1">intraparty divisions</a> that will not be easily healed.

[With AHCA defeat, some Democrats see chance to push for universal coverage]

But there is more to the story than just the GOP’s prospects as a governing majority. The failure of the American Health Care Act (AHCA) has three broader lessons as well.

Lesson No. 1: Radical changes to social welfare programs are <a href="https://www.washingtonpost.com/news/monkey-cage/wp/2015/04/06/five-key-lessons-about-the-welfare-state/?utm_term=.9d430575dd99">rare</a>.

As the political scientist Paul Pierson has <a href="https://www.amazon.com/Dismantling-Welfare-State-Retrenchment-Comparative/dp/0521555701/ref=sr_1_1?ie=UTF8&amp;qid=1490401661&amp;sr=8-1&amp;keywords=paul+pierson+dismantling">argued</a>, dismantling social programs is risky for politicians who want to be reelected. There are exceptions, of course, such as the 1996 <a href="https://www.brookings.edu/book/ending-welfare-as-we-know-it/">abolition of Aid to Families With Dependent Children</a> — a.k.a. “welfare reform.” But Obamacare is not welfare. Moreover, the AHCA’s negative impact on insurance coverage and affordability was so dramatic that House Republican leaders simply couldn’t structure the vote on the bill in a way that would protect their members from constituents’ wrath.

Many Republicans believed they could dismantle the ACA because it <a href="https://www.degruyter.com/downloadpdf/j/for.2015.13.issue-1/for-2015-0010/for-2015-0010.pdf">has not achieved</a> the popularity of programs like Social Security. Because ACA was passed on a party-line vote, unlike Social Security in 1935 and Medicare in 1965, and because many Americans blamed the law for rising insurance premiums, Republicans thought they could push for dramatic changes.

Yet repealing and replacing the ACA <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1614438#t=article">was always easier said than done</a>. In reality, the ACA had succeeded in key respects and developed a sizable constituency. The ACA helped more than 20 million Americans gain coverage. It required insurers to cover essential health benefits, such as maternity services, and protected people with preexisting health conditions from discrimination by insurance companies. When those benefits were threatened, Obamacare’s beneficiaries realized that they had a real stake in the program.

What President Barack Obama could not do — instill a sense of identity among ACA recipients — Trump and the Republican Congress may have accomplished.

Lesson No. 2: Congress (at least part of it) isn’t immune to reality.

In a world of “alternative facts,” it is easy to assume that members of Congress will just make things up to support whatever they want to do. But the failure of the AHCA shows that facts still matter.

A bit of context: In 2013, Eric Patashnik and <a href="https://politicalscience.sfsu.edu/people/25282/justin-peck">Justin Peck</a> <a href="https://www.amazon.com/Does-Policy-Analysis-Matter-Effectiveness/dp/0520287401/ref=sr_1_1?ie=UTF8&amp;qid=1490405695&amp;sr=8-1&amp;keywords=lee+friedmanhttps://www.amazon.com/Does-Policy-Analysis-Matter-Effectiveness/dp/0520287401/ref=sr_1_1?ie=UTF8&amp;qid=1490405695&amp;sr=8-1&amp;keywords=lee+friedman">conducted</a> a survey of more than 150 policy analysts who work for government agencies, think tanks and other organizations. The survey asked them to assess Congress’s performance, and respondents generally gave Congress poor marks. For example, these experts said that Congress tends not to care about the economic efficiency of legislative proposals, discounts lessons from other nations, and struggles to confront the trade-offs inherent in legislating. (One such trade-off involving the ACA: Repealing the penalties associated with the individual mandate would likely produce an increase in the number of uninsured.)

What the experts said Congress does care about is public opinion, interest group views and the assessments of the Congressional Budget Office. And each of those was decidedly against the Republican health-care bill. Only <a href="http://thehill.com/policy/healthcare/325448-poll-majority-of-voters-disapprove-of-gop-obamacare-repeal-plan">17 percent of the public </a>supported it, interest groups overwhelming <a href="http://thehill.com/policy/healthcare/325448-poll-majority-of-voters-disapprove-of-gop-obamacare-repeal-plan">opposed</a> it, and a CBO <a href="http://www.cnbc.com/2017/03/23/new-cbo-estimate-shows-smaller-savings-from-revised-gop-obamacare-replacement-plan-similar-coverage-losses-as-prior-bill.html">report</a> that said that it would cause 24 million people to lose coverage by 2026 and drive up premium costs substantially for older Americans. No wonder the AHCA had difficulty gaining majority support. Congress is clearly not a research bureau, but facts still matter to many lawmakers.

Lesson No. 3: Obamacare is still vulnerable.

Republicans have conceded that the ACA will be the law of the land for the “<a href="http://thehill.com/policy/healthcare/325700-ryan-we-came-close-but-came-up-short-on-healthcare-bill">foreseeable future</a>.” Republicans may also face political risks if they actively seek to “<a href="https://www.washingtonpost.com/national/health-science/affordable-care-act-remains-law-of-the-land-but-trump-vows-to-explode-it/2017/03/24/4b7a2530-10c3-11e7-ab07-07d9f521f6b5_story.html?utm_term=.3f70092e04f4">explode</a>” the individual insurance market, as Trump has promised. Republicans hope that they can blame Democrats for future problems with the ACA, but this remains to be seen.

Republicans can, however, <a href="http://www.huffingtonpost.com/entry/donald-trump-obamacare-subsidies_us_582f72b1e4b030997bbf6a92">do much</a> to undermine the ACA, especially its health insurance exchanges, whose stability in some states is precarious. For example, the administration could use its executive authority to weaken enforcement of the individual mandate or simply pull ads to encourage people to sign up for coverage. Moreover, any such action may be harder for voters to perceive, thereby creating space for Republicans to weaken Obamacare without a clear political price.

In short, the ACA evaded repeal, but its fortunes during the Trump administration <a href="https://www.nytimes.com/2017/03/24/upshot/trumps-choice-on-obamacare-sabotage-or-co-opt.html?_r=0">remain uncertain</a>. How far are Republicans willing to go to undermine the ACA through administrative and legal actions? Will the ACA’s insurance exchanges stabilize or unravel in some states? Will the GOP again try to cut Medicaid to help offset tax cuts and infrastructure spending?

We don’t know the answers to those questions. What we can say is that the health care debate is not over. More conflict over the government’s role in health care lies ahead.

<a href="http://watson.brown.edu/people/faculty/patashnik">Eric Patashnik</a> is director of the Public Policy Program and Professor of Political Science at Brown University.

<a href="https://www.med.unc.edu/socialmed/people/jonathan-oberlander">Jonathan Oberlander</a> is professor and chair of Social Medicine and professor of Health Policy &amp; Management at the University of North Carolina-Chapel Hill.

Why even the strongest Republican efforts can’t defeat the welfare state - The Washington Post

While Donald Trump vowed during his presidential campaign not to govern like a tea party radical — “I’m not going to cut Social Security like every other Republican, and I’m not going to cut Medicare or Medicaid,” <a href="https://urldefense.proofpoint.com/v2/url?u=http-3A__thehill.com_policy_healthcare_308225-2Dtrumps-2Dvow-2Don-2Dmedicare-2Din-2Ddoubt-2Dafter-2Dhhs-2Dchoice&amp;d=DgMGaQ&amp;c=RAhzPLrCAq19eJdrcQiUVEwFYoMRqGDAXQ_puw5tYjg&amp;r=GzTF0gS-jX9DEUKWLuqpeffZfRRJ1oPJGeR6_2yf5n8&amp;m=5TD98BF4CwWdw7IERfhCijAxDQxuIMxgE7yCkp1mprU&amp;s=W2WB_hgHGMIejen0GugdvMSDwK_JrxLQJYgsYi-yweY&amp;e=">he vowed last year</a> — his most recent Cabinet appointments suggest otherwise. The president-elect has been announcing picks who will most likely move hard right on the budget, just as top congressional Republicans such as House Speaker Paul D. Ryan (Wis.) want. At Health and Human Services, Rep. Tom Price (R-Ga.), a staunch critic of the Affordable Care Act and the traditional Medicare and Medicaid programs, is slated to be in charge of their implementation. Ben Carson, who has no experience with urban policy but has expressed radical positions on social safety net programs, may be heading the Department of Housing and Urban Development. And Chief of Staff Reince Priebus has been working closely with congressional Republicans who are determined to cut social spending significantly.

[Do Trump’s Cabinet picks want to run the government — or dismantle it?]

Thus there is reason to believe that the Trump administration, despite Trump’s campaign promises, could deliver on the longstanding conservative goals of not only repealing Obamacare (which Trump pledged to do) but also transforming Medicaid into block grants, turning Medicare into a “premium support” system (ending the program’s traditional open-ended commitment to pay for medical services) and sharply cutting funding for Great Society programs, including food stamps. “I’ve been working on these issues since 1972,” <a href="https://urldefense.proofpoint.com/v2/url?u=http-3A__www.vox.com_policy-2Dand-2Dpolitics_2016_11_22_13641654_paul-2Dryan-2Dtrump-2Dpoverty-2Dsafety-2Dnethttp-3A_www.vox.com_policy-2Dand-2Dpolitics_2016_11_22_13641654_paul-2Dryan-2Dtrump-2Dpoverty-2Dsafety-2Dnet&amp;d=DgMGaQ&amp;c=RAhzPLrCAq19eJdrcQiUVEwFYoMRqGDAXQ_puw5tYjg&amp;r=GzTF0gS-jX9DEUKWLuqpeffZfRRJ1oPJGeR6_2yf5n8&amp;m=5TD98BF4CwWdw7IERfhCijAxDQxuIMxgE7yCkp1mprU&amp;s=8fsDf8D2Z5RldTmm8SR36Yd2I9OE9m5jWT9DNljlDTQ&amp;e=">Robert Greenstein</a>, the president of the Center on Budget and Policy Priorities, said in a recent interview. “This is by far the gravest threat to the safety net, and to low-income people, that I’ve seen in my close to half a century of working on these issues.”

But if Republicans pursue a retrenchment agenda, they will quickly learn that shredding the safety net is much harder than it seems.

Just as liberals in power often discover that it is difficult to expand the scope of government, conservatives in power have traditionally found that dismantling existing programs can be daunting even under favorable circumstances. This is perhaps why a seasoned politician such as Senate Majority Leader Mitch McConnell (R-Ky.) is already signaling his reluctance to push forward on restructuring health care for seniors, while House Minority Leader Nancy Pelosi (D-Calif.) is itching for a fight.

For a preview of what a revived Republican war on welfare might look like, conservatives who hope Trump’s win will usher in their budget-cutting agenda should consider what happened when Ronald Reagan was elected president in 1980 and Republicans gained control of the Senate. In contrast to 2016, that election created the perception that Reagan’s victory over President Jimmy Carter was a triumph for small government. Reagan, who cut his teeth in the conservative movement, appeared to have a mandate to undermine the discredited legacy of liberalism.

But when Reagan moved to dismantle the welfare state, he encountered tremendous resistance. In 1981, he <a href="http://www.nytimes.com/1981/05/13/us/first-major-cuts-in-social-security-proposed-in-detailed-reagan-plan.html?pagewanted=all">pushed</a> for a reduction in early retirement benefits in Social Security. Democrats pounced. Led by Speaker Tip O’Neill (Mass.), the Democrats mounted a furious campaign to paint Republicans as heartless and unfair. Rep. Claude Pepper (D-Fla.), the chairman of the Select Committee on Aging, termed the plan ”insidious” and ”cruel.” The campaign worked. Reagan backed down. When Reagan started talking about Medicare reform, Democrats counterpunched again. “I, for one,” O’Neill said, “am not going to stand by silently and let the Republicans add intolerable medical expenses to the budgets of millions of older Americans already struggling to get by.” As Paul Pierson has shown in a <a href="https://www.amazon.com/Dismantling-Welfare-State-Retrenchment-Comparative/dp/0521555701/ref=sr_1_sc_1?ie=UTF8&amp;qid=1480957979&amp;sr=8-1-spell&amp;keywords=dismanlting+hte+welfare+state">landmark study</a> of the failure of Reagan and British Prime Minister Margaret Thatcher to claw back the welfare state, retrenchment is risky business for elected officials. It is one thing to attack Big Government in the abstract, and quite another to withdraw benefits from actual constituents.

Other Republicans have also seen their plans to cut the welfare state go down in flames. When President Dwight Eisenhower’s secretary of health, education and welfare, Oveta Culp Hobby, went after Social Security’s unique tax system with the support of Sen. Carl Curtis (R-Neb.), the program’s defenders stopped the plan in its tracks. Eisenhower ended up expanding Social Security coverage and wrote his brother that, “Should any political party attempt to abolish social security, unemployment insurance, and eliminate labor laws and farm program you would not hear of that party again in our political history.” When President George W. Bush tried to spend his “political capital” after the 2004 election by privatizing Social Security, with a Republican Congress to support him, the plan quickly fizzled despite a major public push by the White House.

Conservative assaults on public policy frequently trigger a political backlash among activists who were dormant until that moment, meaning they end up encountering resistance their instigators weren’t prepared for. Liberals, for instance, created groups such as the National Coalition for the Homeless to protect the interests of disadvantaged and marginalized Americans.

The Senate also provides a key line of defense for the welfare state. Unless Republicans employ the “nuclear option,” a parliamentary move that would empower a simple majority to limit or eliminate the filibuster, Senate Democrats still can use the filibuster to stymie proposals outside the budget reconciliation process. If McConnell ultimately signs on to the Medicare restructuring agenda, incoming Senate Minority Leader Charles E. Schumer (D-N.Y.) will be adept at using the procedural tools at his disposal to obstruct the bill’s progress. While Senate Democrats can no longer filibuster Cabinet appointments — a decision by Sen. Harry M. Reid (D-Nev.) that the party is probably coming to regret — the narrow Republican majority means that they have to pick off only a few members of the GOP to block a nomination, although there is little precedent for the Senate halting a Cabinet nomination on social policy grounds.

None of this is to say that President Obama’s legacy and many Great Society programs are not at serious risk. They are. Reagan’s era lacked a unified Republican Congress to work with, which we have now. And the Republican caucus today is also far more ideologically conservative than the Robert J. Dole GOP of the 1980s.

More worrying yet, Obamacare has not generated the broad support of programs such as Social Security. In a <a href="http://kff.org/health-reform/press-release/after-the-election-the-public-remains-sharply-divided-on-future-of-the-affordable-care-act/">post-election poll</a>, 45 percent of Americans had an unfavorable view of the ACA, and the low-income citizens who have gained the most under the law have not been mobilized into a robust constituency. While senior citizens jealously guard their Medicare benefits, the proposal to turn Medicare into a “premium-support” system is extremely complicated, creating strategic opportunities for the GOP to reduce the visibility of Medicare cutbacks and diffuse political accountability among voters. In sum, liberals should not assume the welfare state is invulnerable.

Democrats will need to marshal all of their political resources for coming battles over welfare. Not only will they need to activate the groups that have come to the defense of New Deal and Great Society programs in the past, but they will also need to do more to engage constituencies that have not yet come to the fore. This will mean highlighting the damage that dismantling programs will do to the lower- and middle-class voters Trump won in the election, clearly explaining the tangible benefits that already come from these policies, and doing the hard work of explaining how seemingly arcane moves, such as transforming programs into block grants, would erode entitlement protections. If they can accomplish all this, then, as Reagan learned, Democrats might just have a chance to hold back the rising Republican tide, giving them the chance to develop more effective and durable social policies for the 21st century.

Julian E. Zelizer is a historian at Princeton University and author of multiple books including "Burning Down the House: Newt Gingrich and the Rise of the New Republican Party." He is the co-editor of the new, "Myth America: Historians Take on the Biggest Legends and Lies About Our Past" (Basic Books). 

Julian Zelizer

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Conservatives worry that Obamacare is a ‘super-statute.’ It isn’t quite one yet. - The Washington Post

The Supreme Court’s decision in <a href="http://www.washingtonpost.com/politics/courts_law/obamacare-survives-supreme-court-challenge/2015/06/25/af87608e-188a-11e5-93b7-5eddc056ad8a_story.html">King v. Burwell</a> is an enormous victory for the Obama administration and the <a href="http://www.hhs.gov/healthcare/rights/">Affordable Care Act</a>. By upholding the provision of subsidies in the 34 states that rely on the federal insurance exchange, the court ensured that 6.4 million Americans would not lose access to affordable coverage. Instead of dealing a devastating blow to Americans with ACA insurance plans, the court handed Obamacare opponents a crushing defeat. The last serious legal challenge to Obamacare is over.

Republicans have had three major opportunities to overturn the ACA — the <a href="http://www.washingtonpost.com/politics/supreme-court-to-rule-thursday-on-health-care-law/2012/06/28/gJQAarRm8V_story.html">2012 Supreme Court case on the individual mandate</a>, the 2012 presidential election, and King v. Burwell. They have lost them all. Meanwhile, more than 10 million Americans have <a href="http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-06-02.html">gained coverage</a> through the ACA’s health insurance exchanges, and <a href="http://aspe.hhs.gov/health/reports/2015/MedicaidEnrollment/ib_MedicaidEnrollment.pdf">millions more</a> have coverage because off the law’s Medicaid expansion.

Yet the ACA in 2015 is not where health-reform supporters envisioned it would be in 2010. Obamacare is a limited law, <a href="http://www.thenation.com/article/177299/why-left-should-defend-obamacare">full of compromises</a> that were necessary to secure its enactment. Back in 2010, liberals reassured themselves that the law’s shortcomings — the absence of a public insurance option, inadequate subsidies for people whose incomes were not very low, an insurance coverage expansion far short of universal health care — could be redressed over time. Once the ACA took root, advocates would turn to the task of improving the law. As former senator <a href="https://en.wikipedia.org/wiki/Tom_Harkin">Tom Harkin</a> (D-Iowa) said in 2010, the ACA was a “<a href="http://money.usnews.com/money/personal-finance/articles/2015/03/06/what-first-time-buyers-should-look-for-in-a-starter-home">starter home</a> …[with] plenty of room for additions and improvements.”

Instead, Democrats have spent the past five years fending off <a href="http://thinkprogress.org/health/2014/03/23/3417482/gop-opposition/">GOP attacks</a> on Obamacare in Congress, in the courts and in the states. They have been forced into waging a defensive struggle despite Obamacare’s impressive record. It is of course <a href="http://www.commonwealthfund.org/publications/in-brief/2015/may/affordable-care-act-at-five">too early</a> to draw firm conclusions about all of the ACA’s effects. But the law already has considerable achievements to its credit, including a <a href="http://hrms.urban.org/briefs/Gains-in-Health-Insurance-Coverage-under-the-ACA-as-of-March-2015.html">substantial reduction</a> in the size of the <a href="http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201506.pdf">uninsured population</a>. It also has defied opponents’ dire predictions — the health insurance exchanges have been stable after a rocky start, the ACA has <a href="http://www.brookings.edu/blogs/health360/posts/2015/03/20-aca-five-years-employment-impact-burtless">not wrecked</a> the U.S. economy or <a href="http://www.urban.org/research/publication/little-evidence-aca-increasing-part-time-work-so-far">hurt employment</a>, the costs of the ACA’s insurance expansion have been <a href="http://www.washingtonpost.com/blogs/wonkblog/wp/2015/03/09/obamacares-cost-is-falling-as-fewer-receive-coverage-under-health-care-law-cbo-says/">far lower than expected</a>, and medical care costs have grown at rates lower than the historical average. ACA measures have produced <a href="http://files.kff.org/attachment/issue-brief-how-much-of-the-medicare-spending-slowdown-can-be-explained-insights-and-analysis-from-2014">significant Medicare savings</a>, though exactly how much credit the ACA should receive for the continued slowdown in national health care spending (which started before the law’s enactment) remains <a href="http://www.urban.org/sites/default/files/alfresco/publication-pdfs/2000176-The-Widespread-Slowdown-in-Health-Spending-Growth-Implications-for-Future-Spending-Projections-and-the-Cost-of-the-Affordable-Care-Act-ACA-Implementation-1.pdf">impossible to determine</a>.

Moreover, President Obama’s 2012 reelection ensured that the ACA would have strong backing in the White House. And yet health-reform supporters have been fighting just to keep the ACA’s “starter home” foundation intact. In part, that is because Obamacare proved <a href="http://www.theatlantic.com/national/archive/2012/06/from-off-the-wall-to-on-the-wall-how-the-mandate-challenge-went-mainstream/258040/">more vulnerable to legal challenges than reformers anticipated</a>. Even though the law has survived two Supreme Court challenges, the cases contributed to the uncertainty surrounding the law and prolonged controversy over its legitimacy. The court’s 2012 decision effectively making Medicaid expansion a state option blew a major hole in the ACA’s coverage expansion strategy, leaving millions of <a href="http://kff.org/health-reform/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid-an-update/">low-income Americans uninsured</a>.

The sustained ACA debate also reflects an era of extraordinary <a href="http://www.washingtonpost.com/blogs/monkey-cage/wp/2015/03/15/everything-you-need-to-know-about-our-polarized-politics-in-the-palm-of-your-hand/">partisan polarization</a> in which it may be harder for new programs to secure political legitimacy. When laws pass on party-line votes, as the ACA did, and lawmakers have an incentive to keep ideological fights alive to stave off primary challenges, enactment victories can become less authoritative and final. <a href="http://journals.cambridge.org/action/displayAbstract?fromPage=online&amp;aid=9122047&amp;fileId=S1537592713002831">The battle can always be rejoined another day</a>.

Republican resistance to Obamacare at the state level, both in terms of <a href="http://kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/">refusing to establish health insurance exchanges</a> and rejecting <a href="http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/">Medicaid expansion</a>, has been much stronger <a href="http://jhppl.dukejournals.org/content/39/1/97.full.pdf+html">than Democrats expected</a>. Americans have not embraced the ACA the way proponents hoped, and <a href="http://kff.org/interactive/tracking-opinions-aca/#?response=Favorable--Unfavorable&amp;aRange=twoYear">public opinion on the law</a> remains sharply divided along partisan lines.

Now that the ACA has triumphed again in the Supreme Court, health reform advocates can turn to the formidable task of strengthening the law. Twenty-one states still have not expanded Medicaid. The ACA cannot realize its promise of ensuring affordable care as long as so many states — including those with large uninsured populations like Florida and Texas — are holdouts. To be sure, a growing list of GOP-led states has embraced Medicaid expansion. Over time, political pressure on state governments from a hospital industry that <a href="http://www.washingtonpost.com/local/virginia-hospitals-are-lobbying-for-an-expansion-of-medicaid/2014/02/04/632e0eb8-8d0d-11e3-98ab-fe5228217bd1_story.html">very much wants</a> fewer uninsured patients will intensify. And perhaps with King settled, more Republicans will drop their opposition to Medicaid expansion.

Another task is enrolling more eligible individuals into subsidized coverage in the health insurance exchanges. As impressive as the ACA’s coverage gains have been to date, there are still more than 30 million people in the United States without health coverage. Having presumably enrolled many of the people who most wanted coverage, signing up less motivated consumers <a href="http://www.nytimes.com/2015/05/21/upshot/penalty-for-not-buying-health-insurance-might-be-too-light.html?abt=0002&amp;abg=1">remains a challenge</a> (though the growing tax penalty for not obtaining insurance will add motivation in coming years).

Then there is the issue of affordability. Insurance plans in the exchanges offer limited, high-deductible coverage that leaves many Americans exposed to rising medical costs. <a href="http://www.commonwealthfund.org/publications/issue-briefs/2015/may/problem-of-underinsurance">Underinsurance</a> could replace uninsurance as a problem unless reformers succeed in improving the comprehensiveness of health plans.

Ensuring that the underlying rate of medical cost growth stays under control — which will in turn help make coverage affordable — should be a priority. Fixing the so-called “<a href="http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=129">family glitch</a>,” which has left many families without subsidized coverage, would be another important step.

Back in 2010, many progressives saw a Medicare-like “<a href="http://www.washingtonpost.com/blogs/wonkblog/wp/2013/03/22/whatever-happened-to-the-public-option/">public option</a>” insurance plan that would compete with private insurers as central to reform, only to see it fail to clear the Senate. Such a plan has no chance of passing Congress anytime soon. But states could experiment with adding a public option to their marketplaces through state innovation waivers that begin in 2017. If successful, that model could spread to other states. However, <a href="http://www.vanderbilt.edu/csdi/events/volden_csdi_paper.pdf">political science research on the mechanisms of “policy diffusion”</a> suggests that political entrepreneurs will need to overcome the tendency of policymakers to ignore lessons about the effects of other governments’ policies that do not fit their worldview.

Finally, perhaps the most difficult long-term challenge is to build bipartisan support for the ACA. If the partisan war over Obamacare is to end, Republicans will have to accept that it is here to stay and focus on reforming rather than repealing it. Just as <a href="http://www.ssa.gov/history/ikestmts.html">President Dwight Eisenhower gave his stamp of approval to Social Security</a>, so too could a future GOP president grant the ACA bipartisan legitimacy. That seems like a remote prospect at the moment. But at some point, the GOP’s rhetoric will have to come to terms with Obamacare as reality.

The fight to realize the ACA’s aspirations is not over. The 2016 elections loom, and just as there are opportunities for Democrats to strengthen the law, a Republican president and Congress could take steps to weaken it in 2017. In the meantime, Democrats’ defensive struggle to protect the ACA continues. More budget battles could lie ahead during the Obama’s administration’s final 18 months, as Republicans continue to target the ACA. Republican opposition to federal agencies that are producing information on evidence-based medicine puts them <a href="http://www.washingtonpost.com/blogs/monkey-cage/wp/2015/06/22/here-are-the-5-reasons-republicans-are-trying-to-cut-research-on-evidence-based-medicine/">at risk</a> of being undermined. As political scientist <a href="http://politicalscience.yale.edu/people/jacob-hacker">Jacob Hacker</a> <a href="http://www.democracyjournal.org/18/6772.php?page=all">argues</a>, the GOP could also target the redistributive-financing mechanisms that pay for the ACA’s expansion of coverage to low-income Americans.

While more and more Americans are receiving benefits from the ACA, the law’s <a href="http://www.batten.virginia.edu/sites/default/files/publications/Patashnik-Zelizer.pdf">inherited design remains an obstacle to constituency building</a> and the generation of self-reinforcing “policy feedback.” <a href="http://www.degruyter.com/view/j/for.2015.13.issue-1/for-2015-0010/for-2015-0010.xml?rskey=tGu8Wc&amp;result=1">Unlike Social Security</a>, Obamacare does not have a well-defined population of beneficiaries, and its benefits are diffuse. The ACA <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1202111">is not so much a program as a series of programs, regulations, and mandates</a>. It treats different groups of Americans in different ways at different times, which complicates efforts to mobilize public support.

Legal scholar <a href="http://www.law.yale.edu/faculty/WEskridge.htm">William Eskridge, Jr</a>. and political scientist <a href="https://its.law.nyu.edu/facultyprofiles/profile.cfm?personID=19914">John Ferejohn</a> coined the phrase “<a href="http://scholarship.law.duke.edu/cgi/viewcontent.cgi?article=1108&amp;context=dlj#FA0">super-statute</a>” to describe laws that establish a new normative or institutional framework, “stick” in the culture and transform the course of policymaking going forward. In his King v. Burwell dissent, Justice <a href="https://en.wikipedia.org/wiki/Antonin_Scalia">Antonin Scalia</a> touched upon this idea, writing “Perhaps the Patient Protection and Affordable Care Act will attain the enduring status of the Social Security Act or the Taft-Hartley Act; perhaps not.”

The ACA may one day become a super-statute—but it is not quite there yet.

<a href="https://www.med.unc.edu/socialmed/people/jonathan-oberlander">Jonathan Oberlander</a> is professor and Vice Chair of Social Medicine and Health Policy &amp; Management at the University of North Carolina-Chapel Hill.

<a href="http://batten.virginia.edu/content/faculty-research/faculty/eric-m-patashnik">Eric Patashnik</a> is Professor of Public Policy and Politics and Director of the Center for Health Policy at the University of Virginia.

Here are the 5 reasons Republicans are trying to cut research on evidence-based medicine - The Washington Post

A woman sitting in a chair is having her arm prepared for minor surgery; a physician is applying a tourniquet, an assistant stands ready with a basin. The woman holds a cloth over her lap to protect her clothing. (Print by Abraham Bosse via National Library of Medicine) 

What’s the best way to treat prostate cancer? What are the benefits and risks of different rehabilitation options for survivors of stroke? Unfortunately, the answer to these and similar questions often is: Nobody knows. The United States spends $3 trillion annually on health care — much of it funded by taxpayers through programs such as <a href="http://kff.org/medicare/fact-sheet/medicare-spending-and-financing-fact-sheet/">Medicare </a>— yet only a limited amount of information exists about what treatments work best for which patients. Although estimates vary, some experts think that <a href="http://www.ncbi.nlm.nih.gov/books/NBK64784/">less than half</a> of all medical care is based on clear scientific evidence.

The good news is that the federal government is now making a <a href="http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=28">significant investment</a> in health services and patient-centered outcomes research to identify waste and improve the safety, effectiveness and quality of care. The bad news is that House Republicans are trying to <a href="http://news.sciencemag.org/funding/2015/06/house-bill-would-give-nih-1-1-billion-more-2016">abolish</a> one of the main agencies carrying out this research, the <a href="http://www.ahrq.gov/">Agency for Healthcare Research and Quality</a> (AHRQ), and cut the funding of another, the <a href="http://www.pcori.org/">Patient-Centered Outcomes Research Institute</a> (PCORI). The puzzle is why.

One possible reason is that Republicans oppose taxpayer funding of all scientific research as a matter of principle. Yet the same <a href="http://appropriations.house.gov/news/documentsingle.aspx?DocumentID=394272">House Appropriations Committee draft bill</a> that targets health services research also provides a $1.1 billion increase in the budget of the National Institutes of Health.

A second possible reason is that Republicans are uninterested in <a href="http://coalition4evidence.org/">evidence-based policymaking</a>. But both Democrats and Republicans argue that better information is needed to make government more effective. For example, Rep. Paul Ryan (R-Wis.) and Sen. Patty Murray (D-Wash.) recently introduced the <a href="http://www.murray.senate.gov/public/index.cfm/2015/4/evidence-based-policy-murray-ryan-introduce-bill-to-expand-data-use-in-evaluating-federal-programs-tax-expenditures">Evidence-Based Policymaking Commission Act of 2015</a> to evaluate the effectiveness of federal programs.

What makes the situation even more perplexing is that evidence-based medicine has a solid Republican pedigree. Perhaps the most important advocate of an increased federal role in paying for research on the clinical effectiveness of treatments has been <a href="http://content.healthaffairs.org/content/25/6/w572.abstract">Gail R. Wilensky</a>, a Republican economist who served as George H.W. Bush’s Medicare director.

In 2008, former House speaker Newt Gingrich (R-Ga.) <a href="http://www.nytimes.com/2008/10/24/opinion/24beane.html">published</a> an op-ed with <a href="http://oakland.athletics.mlb.com/oak/team/executive_bio.jsp?loc=beane">Billy Beane</a>, the “<a href="http://www.sonypictures.com/movies/moneyball/">Moneyball</a><a href="http://www.sonypictures.com/movies/moneyball/">“</a> general manager of the Oakland A’s, and Sen. John F. Kerry (D-Mass.) in which they lamented that “a doctor today can get more data on the starting third baseman on his fantasy baseball team than on the effectiveness of life-and-death medical procedures. Studies have shown that most health care is not based on clinical studies of what works best and what does not — be it a test, treatment, drug or technology.”

Republicans have turned against government funding of evidence-based medicine research for five reasons.

Federal investment in this research (although it predated the 2008 election) became closely tied to the Obama administration’s health-care reform agenda, because big funding increases were tucked into the 2009 stimulus legislation and the Affordable Care Act — two measures the GOP strongly opposed. An increased federal role in comparative effectiveness research, together with payments to physicians for voluntary counseling to Medicare patients about end-of-life options and the creation of the <a href="http://www.ama-assn.org/ama/pub/advocacy/topics/independent-payment-advisory-board.page?">Independent Payment Advisory Board</a> (another agency the GOP wishes to kill) contributed to the “death panels” myth, which Republicans have used to frame health-care reform as “rationing.” As University of Maryland political scientist <a href="http://gvpt.umd.edu/facultyprofile/Lee/Frances">Frances E. Lee</a> argues, partisan conflict over technocratic issues such as medical research is often “opportunistic and focused on electoral advantage.” As she <a href="http://www.amazon.com/Beyond-Ideology-Politics-Principles-Partisanship/dp/0226470768/ref=sr_1_1?ie=UTF8&amp;qid=1434809695&amp;sr=8-1&amp;keywords=frances+lee">writes</a>, “The politics of good government, ironically, is hardball.”

Although evidence-based medicine might seem likely to have bipartisan support, it has become a partisan issue among voters. In 2010, <a href="http://politicalscience.yale.edu/people/alan-gerber">Alan Gerber</a>, <a href="http://orion.luc.edu/~ddoherty/">David Doherty,</a> <a href="http://politicalscience.olemiss.edu/conor-m-dowling/">Conor Dowling</a> and I conducted a <a href="http://content.healthaffairs.org/content/29/10/1872.full.pdf+html">national survey</a> to gauge public support for government funding of research on the effectiveness of treatments. Among those who reported not voting in 2008, there was not a large difference in support across Democrats and Republicans, but there were significant partisan differences among voters. Republican voters were much less supportive than Democrats. During the debates over the stimulus bill and health-care reform, the two parties took opposing stands on the federal government’s role in this effort, which led to the significant partisan split among politically engaged citizens.

Research on the effectiveness of different treatments is a threat to the incomes of some health industry stakeholders. In 1994, the Agency for Health Care Policy and Research (the precursor to AHRQ) issued a report concluding that there was little evidence to support back surgery over nonsurgical alternatives for many cases of lower-back pain. Back surgeons <a href="http://www.washingtonmonthly.com/features/2007/0710.brownlee.html">went ballistic</a>, and successfully lobbied Republicans in Congress (who associated the agency with the Clinton health-care reform plan) to <a href="http://content.healthaffairs.org/content/early/2003/06/25/hlthaff.w3.283.full.pdf">slash the agency’s budget and curb its authority</a>. Although some health IT companies see the value of AHRQ and PCORI, there are powerful interest groups that wouldn’t mind if the agencies were weakened.

The public is not engaged. Although patients, caregivers, and family members would benefit from better information about the effectiveness of treatments, the benefits of a stronger base of medical evidence are too diffuse to mobilize ordinary citizens. AHRQ and PCORI are public-interest agencies that lack a natural constituency.

Republicans have attacked government funding of evidence-based medicine research because there is little political penalty to doing so. The penalty would be higher if Republicans feared getting on the wrong side of doctors. In our survey research, we found that when it comes to the role of evidence in patient decisions as well as in the allocation of health-care money, the public believes that “<a href="http://jhppl.dukejournals.org/content/early/2013/10/28/03616878-2395208.abstract">doctors know best</a>.”  The public views doctors as trusted agents of their interests; when respondents are told that doctors support government funding of evidence-based medicine research, the argument of opponents that study findings will be used as a pretext for rationing <a href="http://content.healthaffairs.org/content/29/10/1872.full">loses its sting.</a>

Clearly most doctors do believe in the need for research on evidence-based medicine (although medical societies frequently protest when studies question the efficacy of treatments used by their members). “Cutting funding to AHRQ would be a huge mistake in our mission to improve the quality & efficiency of healthcare,” <a href="http://www.healthcareitnews.com/news/house-draft-budget-would-eliminate-ahrq">tweeted</a> one surgeon. But the physician community has not organized around the issue.

There is a good chance the proposed cuts to evidence-based medicine research won’t be enacted in this appropriations cycle. Nonetheless, the episode is a reminder that information is a powerful resource in government — one that can be destroyed when people aren’t looking.

<a href="http://batten.virginia.edu/content/faculty-research/faculty/eric-m-patashnik">Eric M. Patashnik</a> is professor of public policy and politics and director of the Center for Health Policy at the University of Virginia. He is also nonresident senior fellow at the Brookings Institution and a fellow of the National Academy of Public Administration.

Five key lessons about the welfare state - The Washington Post

During the 1980s, <a href="https://www.whitehouse.gov/1600/presidents/ronaldreagan">Ronald Reagan</a> and <a href="http://www.biography.com/people/margaret-thatcher-9504796">Margaret Thatcher</a> won elections while promising to curb spending on social programs. The conditions seemed right: liberals had lost power, and organized labor was in decline. Yet both Reagan and Thatcher largely failed.

In 1994, <a href="http://polisci.berkeley.edu/people/person/paul-pierson">Paul Pierson</a> published a terrific book, “<a href="http://www.amazon.com/Dismantling-Welfare-State-Retrenchment-Comparative/dp/0521555701">Dismantling the Welfare State</a>,” that explained why. Pierson showed how social programs generate their own constituencies. Defenders of these programs, such as the <a href="http://www.aarp.org/">AARP.</a> become powerful because they represent beneficiaries who have more to lose from reform than taxpayers stand to gain. Hemmed in by the long-term commitments these programs have made and by their devoted supporters, politicians find they have limited maneuvering room.

Yet the belief that welfare state spending is unsustainable and that programs must be retrenched lives on. Earlier this month, House and Senate Republicans passed <a href="http://www.washingtonpost.com/politics/house-republicans-try-to-rally-caucus-to-pass-fiscal-outline/2015/03/17/9860b89c-cc9f-11e4-a2a7-9517a3a70506_story.html">budget resolutions</a> that would block grant <a href="http://medicaid.gov/">Medicaid</a>, cut <a href="http://www.fns.usda.gov/snap/supplemental-nutrition-assistance-program-snap">food stamps</a>, and restructure <a href="https://www.medicare.gov/">Medicare</a>. Budget resolutions do not have the force of law, but they signal a desired policy direction. Is the welfare state as resilient as it was back in the 1980s? Or are things different today?

In the new issue of the journal <a href="http://journals.cambridge.org/action/displayJournal?jid=PSC">PS</a>, I edited a <a href="http://journals.cambridge.org/download.php?file=%2FPSC%2FPSC48_02%2FS1049096514002169a.pdf&amp;code=009d8ce26eb1ad00d4063bbf512011e1">symposium</a> celebrating the 20th anniversary of Pierson’s book. Leading scholars took a fresh look at the durability of the welfare state. Here are five lessons they draw.

1) Radical reform rarely happens. Reform is unpopular not only with beneficiaries but also with interest groups that have a stake in the programs, such as hospitals who receive Medicaid funding. Frontal assaults on core social entitlements seldom succeed, and spending in wealthy democracies on health and old age continues to climb, as this graph from Jane Gingrich demonstrates:

As <a href="http://www.magd.ox.ac.uk/member-of-staff/jane-gingrich/">Gingrich</a> <a href="http://journals.cambridge.org/download.php?file=%2FPSC%2FPSC48_02%2FS1049096514002194a.pdf&amp;code=a2dad2a2bef91a9f388169c5ae3c5095">observes</a>, the increase in social spending is all the more remarkable given that governments have divested themselves of many other responsibilities during this time — such as by reducing state ownership of industries.

To be sure, some countries have imposed cutbacks in social spending. But retrenchment initiatives have not always been durable. For example, cuts that were introduced in Sweden in reaction to an economic crisis in the early and mid-1990s were restored several years later. As <a href="https://politicalscience.unc.edu/people/faculty/faculty-directory-a-c/john-stephens">John Stephens</a> <a href="http://journals.cambridge.org/download.php?file=%2FPSC%2FPSC48_02%2FS1049096514002182a.pdf&amp;code=a2dad2a2bef91a9f3a840b894cced959">writes:</a>

The central insight that strong public support for the welfare state makes it an “immovable object,” which however, is confronted with an ‘irresistible force’ in demographic and economic change, is as true now as it was 20 years ago.

2) Successful reform entails avoiding blame. While most social programs have remained stable, some have been vulnerable to reform. Building on the pioneering work of <a href="http://explore.georgetown.edu/people/weaverrk/?PageTemplateID=364">R. Kent Weaver</a>, scholars have identified strategies that retrenchment advocates can use to escape blame for negative outcomes. The keys are to reduce the visibility of cutbacks, divide constituencies, and diffuse political accountability. For example, <a href="http://web.mit.edu/polisci/people/faculty/andrea-campbell.html">Andrea Campbell</a> <a href="http://journals.cambridge.org/download.php?file=%2FPSC%2FPSC48_02%2FS1049096514002200a.pdf&amp;code=a2dad2a2bef91a9fe6bbfbf916a408e1">suggests</a> that decentralization — pushing program responsibility down from the federal to state and local governments — can decrease benefits.

3) Failed reforms don’t mean no changes at all. While few social programs have been dismantled, <a href="http://www.gov.harvard.edu/people/faculty/peter-hall">Peter Hall</a> <a href="http://journals.cambridge.org/download.php?file=%2FPSC%2FPSC48_02%2FS1049096514002212a.pdf&amp;code=5ded1de11436b11bb38b329bcd41b762">argues</a> that the welfare states in the United States and Britain nonetheless look different today than they did in the early 1980s:

In particular, ‘welfare’ has been replaced by ‘<a href="http://en.wikipedia.org/wiki/Workfare_in_the_United_Kingdom">workfare</a>’ in both the United States and Britain—and in many European states where the receipt of social benefits has been tied to participation in training or employment.

Hall observes that the rhetoric of social policy has been transformed as well: debates about social policy today focus more on efficiency, and less on social justice, than they used to. As Pierson <a href="http://journals.cambridge.org/download.php?file=%2FPSC%2FPSC48_02%2FS1049096514002224a.pdf&amp;code=ba1ea1c5599761514c8f885f98070afa">argues</a>, “To say that the assault on welfare state largely failed is not to say that neoliberalism did.”

4) Critics of the welfare state sometimes “win” simply by preventing change. The structure of welfare state programs may remain constant, but the social world is constantly evolving. <a href="http://isps.yale.edu/team/director#.VRlrmPnF98M">Jacob Hacker</a> introduced the concept of “policy drift” to describe the failure to revise a policy to keep its effects constant in the face of environmental change.

Welfare state opponents sometimes can achieve their goals simply by blocking efforts to combat drift, such as preventing hikes in the federal minimum wage (which is not indexed for inflation). And as <a href="http://government.arts.cornell.edu/faculty/mettler/">Suzanne Mettler</a> <a href="http://journals.cambridge.org/download.php?file=%2FPSC%2FPSC48_02%2FS1049096514002170a.pdf&amp;code=ba1ea1c559976151ff41ae708a1ef5e1">notes</a>, many major social welfare programs were created by Congresses with large Democratic majorities. The current <a href="http://www.gop.gov/">Republican Congress</a> is less inclined to renew and repair programs whose basic purposes its members may not support.

In sum, even when a social program lives on, its social impact may diminish.

5) The welfare state can be outflanked.  The welfare state contains important programs, but it is still only a small piece of the American political economy.  Reflecting on changes since the 1980s, Pierson <a href="http://journals.cambridge.org/download.php?file=%2FPSC%2FPSC48_02%2FS1049096514002224a.pdf&amp;code=2cf68943f79de8526dc05fe2f918880a"> argues</a> that the “solidity” of the welfare state — especially in the United States — “now looks something like a Maginot Line.”

Rather than directly assaulting the welfare state, those seeking to remake the American political economy have mostly outflanked it, relying heavily on tactics of gridlock-inducing policy drift to produce major changes in taxes, industrial relations, corporate governance, and financial regulation that have been highly beneficial to the most affluent.

We now know that the welfare state can survive without strong labor movements. What is less clear is whether the broadly shared prosperity and security that was a byproduct of the post-war political economy can be restored.

Political scientist Martha Derthick has died - The Washington Post

Martha Derthick (Miller Center, University of Virginia)

My colleague Martha Derthick, one of the nation’s most distinguished scholars of American government and public policy, passed away Jan. 12. As her <a href="http://www.washingtonpost.com/national/martha-derthick-authority-on-social-security-dies-at-81/2015/01/24/6858070e-a31e-11e4-9f89-561284a573f8_story.html"> obituary</a> in The Washington Post highlights, Martha had an illustrious career in both academia and at the Brookings Institution. Many of her books are modern classics, including the prize-winning “<a href="http://www.amazon.com/Policymaking-Social-Security-Martha-Derthick/dp/0815718152/ref=sr_1_1?ie=UTF8&amp;qid=1422151683&amp;sr=8-1&amp;keywords=policymaking+for+social+security">Policymaking for Social Security</a>” and “<a href="http://www.amazon.com/Politics-Deregulation-Martha-Derthick/dp/0815718179/ref=sr_1_3?ie=UTF8&amp;qid=1422151711&amp;sr=8-3&amp;keywords=martha+derthick">The Politics of Deregulation</a>” (with <a href="http://www.pol.illinois.edu/people/p-quirk">Paul J. Quirk</a>).

Martha regarded herself more as a journalist than as a social scientist, yet she possessed a profound understanding of democratic politics. As I wrote in a <a href="http://apsanet3b.inetu.net/imgtest/ReconsideringPolicymakingSocialSecurity-Patashnik.pdf"> symposium</a> (with contributions from <a href="http://polisci.berkeley.edu/people/person/paul-pierson"> Paul Pierson</a>, <a href="http://dusp.mit.edu/faculty/deborah-stone">Deborah Stone</a>, <a href="http://explore.georgetown.edu/people/weaverrk/?PageTemplateID=364">Kent Weaver</a> and Martha herself) on the 25th anniversary of “Policymaking for Social Security,” Derthick’s work combined a policy analyst’s command of the technical details of government programs with a political scientist’s skill at investigating the value choices and material conflicts at the heart of politics. Long before “path dependence” became an important topic of study in political science, her work explored how preexisting policies constrain the options available to future officeholders. She was a conservative, a believer in the virtues of decentralized government, yet she devoted her career to investigating how the nation’s vast welfare-regulatory state functions.

Rather than recount Martha’s many scholarly accomplishments, I thought I’d share a few of her most memorable quotations:

The influence of public opinion on the program, though real, is manifested indirectly, in actions of the policymakers that anticipate public reaction and respond to what they believe the public prefers; and even then influence runs in both directions. Policymakers have presented the program so as to induce a favorable mass response. (1979)

[T]he dominant pattern of policymaking in our federalism of pervasively shared functions seems to me, not so much checking and balancing by design of the people, but opportunistic cost shift and benefit distribution by design of elected officeholders in the context of a general obfuscation of responsibility and the constitutionalization of everything. (1992).

[C]ongress is not by nature inclined to shape policy on a comprehensive scale. It does not value rationality and consistency as presidential policymakers do. It does not do grand designs.  (1990)

On the tension between America’s constitutional system and effective public administration:

[T]he most cherished structural features of American government pose obstacles to good administration. Democracy, which entails regular and frequent elections, fosters instability in policy guidance. The laws that agencies administer are subject to constant revision as officeholders change and seek to serve and satisfy a heterogeneous and ever-changing society. (1990)

On the power of ideas in American politics:

The major virtue of the current American political system, at least by comparison with the past, probably lies in the resources and rewards it offers for overcoming particularism. Responsive to mass sentiment almost since its founding, the political system seems to be more so than ever today, when mass education and communication and new technologies make it possible for such sentiment to be formed, expressed and measured with unprecedented speed. At the same time, expert analysis, oriented toward broad conceptions of the public interest, is more thoroughly institutionalized in and addressed to the national government than ever before. This creates an unprecedented potential for linking the forces of expert analysis and mass sentiment as the basis for action—and political leaders who by luck or skill mange to achieve that union have a good chance of defeating narrow, particularistic interests. (1985; with Paul J. Quirk).