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The Democratic Strategist

Political Strategy for a Permanent Democratic Majority

A Mini-Break from the Campaign: Improving on the ACA

Democrats everywhere have work to do in order to make the most of the unprecedented opportunity presented by the 2016 election. But there is nonetheless a need for thinking longer-term, beyond 2016, to reconnect with core Democratic party values as we chart a better future for America.

So take a mini-break with Matt Grossman and David A. Hopkins, authors of Asymmetric Politics: Ideological Republicans and Group Interest Democrats, who have an interesting post up at Vox, “Health reform: trying to achieve Democratic goals through Republican means: American policy compromises Democrats’ pragmatic goals with Republicans’ ideological objections.”

Grossman and Hopkins explain,

During the congressional debate over the Affordable Care Act (ACA), Republicans successfully undermined overall popular support for the law by characterizing it as a “government takeover” of the American health care system — even though most of its specific provisions remained quite popular with the public.

As many frustrated Democrats pointed out, the ACA was far from the exercise in single-payer socialized medicine implied by Republican critics. In fact, the law’s structure is striking for the many ways in which it attempts to avoid conservative accusations of “big government” liberalism.

Republicans favor federalism over nationalization. The ACA creates state-based insurance exchanges and uses state Medicaid partnerships to deliver services.

Republicans favor private sector implementation over increasing government bureaucracy. The ACA delivers benefits mainly through private insurance companies.

Republicans favor free market incentives. The ACA uses internet-based shopping marketplaces, which allows consumers to compare prices and requires insurers to compete for their business.

In an earlier era, back when Republicans would actually negotiate in good faith, the ACA would have been considered a moderate Republican bill, grudgingly suported by Democrats. Many Democrats would still describe it that way, even though nearly all of today’s Republicans bash the ACA at every opportunity.

Hopkins and Grossman go on to argue that Democrats are trapped in a frame of Republican making. “Political leaders typically pursue the goals of Democratic constituencies using tools and approaches that respond to conservative critiques of big government…the Republican Party characterizes each set of new initiatives as expanding the role of government in violation of constitutional values.”

To pass the ACA, Democrats had to adjust, not only to their constituent group concerns, but also to conservative criticism, to get anything passed. “Democrats have even internalized conservative criticisms of federal agencies and programs,” say the authors, “As a result, public policy responds to conservative critiques.”

Grossman and Hopkins present some startling charts, showing that “big government” in the sense of a dominant federal sector, is largely a myth. The actual increase federal employees since 1946 has been miniscule in both real and percentage terms. Most of the growth in the government workforce has been at the state and local level, which Republicans certaimly prefer to a growing federal sector. Worse, they show that, despite the perception of ‘big government’ domination, a lot of what should be in the public sector has been privatized

Public policy increasingly relies on private sector government contractors and recipients of competitive grants (usually nonprofits) to deliver services. Although it is difficult to measure the size of this “shadow government” with precision, it now eclipses that of the direct federal workforce.

While federal government and goveernment grantee employment and the military personnel, has been fairly stable since 1990, there has been an enormous uptick in spending on federal contractors. More gravy for the private sector.

The authors present data showing that, “American social welfare spending nearly matches that of large European nations — but a large fraction of our welfare spending passes indirectly through private companies, usually employers.” America’s “subsidized private welfare expenditure” share of gross domestic product is enormous compared to that of other nations, which opens up irresistible turf for private sector corruption. We get the knee-jerk parroting of the “big government is wasteful/corrupt” meme in the media, while the private sector often loots taxpayers, with very little in the way of media accountability.

To provide an example of wasteful spending in health care, I recently had an asthma attack which required about 3 hours of routine hospital treatment and monitoring, nothing all that extraordinary. The bill was over $8K, with the profits being gobbled up by various private sector health contractors. Three months later, my out-of-pocket share remains unclear. Shortly afterwards, my nationally-respected health insurer dumped me because of my new zip code.

A few years before that, I cut my hand on a broken glass and had to get some stitiches at a different hospital. When the bill came, I noticed a $60 charge for “tray removal.” I asked the billing office what that meant, and the staff responded, “That’s when they took off the first bandages and put them in a tray and emptied it.” No doubt, millions of Americans have similar stories.

Grossman and Hopkins write, “Democrats have collectively expanded the scope of government authority but have been forced to implement their initiatives in cooperation with the private sector, by relying upon market competition and tax incentives, and by decentralizing services to states, localities, contractors, and grantees.”

On balance, the Affordable Care Act has been a step forward in terms of providing health security for additional millions of Americans who had been denied decent coverage, although a number of Republican governors and state legislatures have weakened the ACA by refusing to accept Medicaid Expansion.

Democrats must create a consensus that quality health care for all Americans should be the top national security priority. All evidence suggests that the private sector can’t meet this challenge. Democratic presidential nominee Hillary Clinton favors reforms that strengthen the ACA’s coverage to include every citizen and every illness and condition. After electing Clinton and a working Democratic majority of congress, Democrats and progressives should urge Clinton to press the case for a single-payer health care system.

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