As the death of Obamacare looms like a grim reaper over so many of us with preexisting conditions, lower incomes, or non-traditional forms of employment (Uber, anyone?), it seems worthwhile to examine some the primary obstacles to public acceptance of the Affordable Care Act (ACA/Obamacare).
As the death of Obamacare looms like a grim reaper over so many of us with preexisting conditions, lower incomes, or non-traditional forms of employment (Uber, anyone?), it seems worthwhile to examine some the primary obstacles to public acceptance of the Affordable Care Act (ACA/Obamacare). It’s become a truism, for example, that voters are more likely to support the Affordable Care Act than Obamacare, though they’re actually the same thing. In fact, recent polling finds that more than one-third of Americans don’t realize the terms refer to the same law while more than half of Republicans are unaware that repealing the law would roll back the Medicaid expansion that has significantly increased access to care among the rural poor in deeply red states like Kentucky and Louisiana.
And polling on Obamacare consistently indicates that the provisions of the ACA are wildly more popular than the law itself. So what gives? Why are we seriously considering repealing a law that, generally speaking, does things people like?
One way we can understand the push to repeal the ACA despite widespread public support for its provisions is to examine the extent to which public perception of the law has been defined by its foes. Vocal opponents helped brand the ACA from its first days as wasteful and dangerous. Politifact’s compilation of the “Top 16 Myths” surrounding Obamacare in the wake of the 2012 election is a good refresher on this process, for those not steeped in the minutiae of healthcare rumors and politics. Probably all of us, however, remember the classic “death panels” scare invented by Sarah Palin. Though sensational and ridiculous, Palin’s “death panels” captured the essence of many critiques of the health law: the concern that any government involvement would be dangerous, not only for people’s wallets, but even their health. Indeed, this is House Speaker Paul Ryan’s central problem with the law, that it “puts the federal government squarely in the middle of health care decisions.”[1]
This classic Republican attack on Obamacare – that it represents a form of government over-reach that interrupts the more efficient and natural free-market activity of the private sector – has had an outsized influence in our understanding of the law with serious implications for American politics. The phantom of the state-run health clinic helped facilitate a Republican resurgence organized around repealing the law whose effects are still being felt.
This classic Republican attack on Obamacare – that it represents a form of government over-reach that interrupts the more efficient and natural free-market activity of the private sector – has had an outsized influence in our understanding of the law with serious implications for American politics.
This is actually part of the reason there’s no clear Republican alternative to the ACA; because the attack on Obamacare depends on the imaginary contrast between interventionist state-run insurance and free-market, consumer-driven insurance. Instead of a concrete plan, we’re shown an ad for “A New Path Forward” that leads to… you guessed it: itself. We’ll return to look at the role of the market in healthcare and American capitalism shortly, but first let’s examine the impact of this critique.
Scholars, reporters, and the like usually use “disconfirmation bias” – the idea that we discard information that doesn’t confirm our worldviews – as a way to explain partisan behavior.[2] And while support for the ACA certainly correlates strongly with party affiliation, the mandate that Americans purchase insurance is a uniquely unpopular element in a law whose provisions are popular across party lines, with only 35% of Americans supporting that feature. It’s also the provision that most clearly rejects the free market and consumerist ideologies generally accepted by a majority of Americans, as illustrated in the above charted responses to a 2016 Gallup poll. From this angle, Obamacare isn’t simply an unpleasant item to be ignored; it’s actually unimaginable.
Courtesy of Gallup.
The historian and social theorist Michel-Rolph Trouillot terms these instances of widely held disbelief encounters with the “unthinkable.” He observes that “when reality does not coincide with deeply held beliefs, human beings tend to phrase interpretations that force reality within the scope of these beliefs.” Rather than accepting ideas that challenge their worldview, Trouillot finds that people “devise formulas to repress the unthinkable and to bring it back within the realm of accepted discourse.”[3] For Trouillot, the unthinkable serves to protect ideological systems of power from subversion. The unthinkable not only indicates something unpleasant, but something that, if accepted, might undermine or threaten the foundations of social, political, or economic interaction.
Trouillot’s most compelling case of the unthinkable comes in his analysis of the Haitian Revolution. He finds that the white elites of the slaveowning Caribbean and American South were unable to comprehend an antislavery revolution in the colony of Saint Domingue because their worldview was grounded in the belief that it simply couldn’t happen. They argued that Africans and African Americans were intended for slavery, that they lacked the intellectual capacity to plan and orchestrate a rebellion, and that slavery was good for them. These ideas formed the basis for their claim to property in persons and allowed them to extract enormous value and awesome power from black suffering. They were also utter nonsense, but they led the majority of white Americans and Europeans to look for other explanations for the only successful slave revolt in history. Maybe the revolt had been secretly planned by whites. Maybe the former slaves were in a state of anarchy, subject to their savage instincts. Certainly they would be easily subdued by a small, well-organized French force. As it turns out, no, no, and no.[4]
Generations of politicians and historians have been unable to comprehend the Haitian Revolution and its implications because they’ve consistently failed to examine the racial stereotypes that legitimated white (and not black) power in Haiti. In Trouillot’s words, “the Haitian Revolution thus entered history with the peculiar characteristic of being unthinkable even as it happened.”[5]
Courtesy of Science Direct.
Participant estimates of social class mobility on each of the six items (dark gray bars) compared to population data (light gray bars) on actual mobility. Brackets indicate 95% confidence intervals around the estimate.
Trouillot’s notion of the unthinkable provides a useful lens through which to view opposition to the ACA. From this perspective, the ACA is unthinkable, not due to its actual policies, but because it threatens the idea of free market consumerism around which our society is organized. As the above chart from the aptly-titled paper, “Americans overestimate social class mobility” indicates, we consistently tell ourselves that hard work and frugality breed success; that the American Dream is available to all willing to work; that free market capitalism is truly American and increases social mobility. The logic inspiring Obamacare, however, is that all Americans deserve to be able to access affordable healthcare, but that individual aspiration isn’t enough to achieve that end. Many people need help getting that access, and because insurance companies don’t necessarily act in the best interest of their customers, insurance plans themselves ought to meet basic benchmarks.[6]
Trouillot’s notion of the unthinkable provides a useful lens through which to view opposition to the ACA. From this perspective, the ACA is unthinkable, not due to its actual policies, but because it threatens the idea of free market consumerism around which our society is organized.
In short, we’ve been unable to adequately evaluate the ACA, at least in part, because it has been packaged as (and in some ways represents) a threat to widely accepted American cultural norms.
Rather than question these norms, like whether social mobility is really as possible as we imagine, many of us have found it much easier to reject Obamacare itself as unthinkable. Thus, we can collectively accept the many of the provisions of the ACA while rejecting the idea of the law and the individual mandate that makes it possible.
The Market
Public figures like Speaker Ryan and advocates from right-leaning think tanks claim that Obamacare represents government over-reach, a sort of un-American experiment with socialism that ought to be replaced by a free market system. A policy brief circulated by the Heritage Foundation makes this argument succinctly, that “consumers should have the ability to choose how to meet their health insurance needs in a free market for insurance.”[7] James Pethokoukis, of the American Enterprise Institute, echoes this claim that “Government — through the tax code, regulatory code, and social insurance programs — has sabotaged market forces that, if allowed to work, would create a healthcare system with more choice, coverage, quality, value, and efficiency.”[8] Mike Pence also makes essentially this point, justifying the looming Republican repeal as necessary for a “smooth transition to a market-based health care reform system.” The goal, it seems, is to legislate a market-based health insurance system, representing an apparently opposite approach to the one enshrined in the ACA. In fact, even supporters of the law argue that it employs a “free market approach,” in contrast to the “socialized medicine” of other Western democracies, which they tout as a selling-point.[9]
To evaluate these competing claims, we should work through what we mean by the term market. If we mean a space where companies compete with one another, then the ACA certainly employs market functions to distribute insurance. There’s no actual Obamacare insurance. Every insurance policy sold after the passage of the ACA has been sold by private companies, most of them by the same insurance companies operating before the bill’s passage (here’s a short video explainer, if some of this is new to you). So it does use a market system.
Perhaps those pushing for repeal want, not just a market where insurance companies are free to compete for customers, but a “free” market without any regulation whatsoever. Obamacare certainly wouldn’t stand up to this test, as it regulates the types of coverage and costs of plans and provides subsidies for lower-income consumers paid for by taxing the very wealthy. Yet the Heritage piece hardly smacks of total deregulation, noting that “if given proper time and space by an all-too-intrusive federal government, states can act on their own to open their insurance markets.”[10] Speaker Ryan also appears to fail the “free” market test, stating in a CNN town hall recently that “we want to have tax credits that give everybody a shot at buying, take their tax credit and go buy a health plan of their choosing.” Of course, the Vox chart below illustrates how this approach disproportionately helps the wealthy, but we digress.[11]
The point here is that basically no one is really talking about a “free,” unregulated healthcare system.
Even if we decided to employ a truly “free” market model by liquidating local, state, and federal institutions, we’d still fail to address the power of the “Cartel” – big businesses capable of controlling production and consumption for short-term gains – which significantly contribute to rising healthcare costs.[12] We’d also have failed to control for variations in health infrastructure, and thus pricing, based on location. Indeed, one of the signature failings of the ACA was the inability to make sure that insurers offered plans on the healthcare exchanges, which has a good deal to do with local health infrastructure (hospitals, clinics, doctors, pharmacies, risk factors, employment rates, etc.) and very little to do with the ACA itself.
In fact, as economic historians like Karl Polanyi have long argued, “regulation and markets, in effect, grew up together. The self-regulating market was unknown.” Or in English, the “free” market hasn’t ever existed. It’s just pretend, a way for the rich and powerful to protect and expand their wealth at the expense of those around them.[13]
The critique of Obamacare as a uniquely interventionist rejection of the “free” market just doesn’t hold water.
To be sure, there are real problems with the way the ACA exchanges operate. These shortcomings might be easily addressed, however, if we had a functional Congress willing to amend the law to give Americans better access to more efficient government and healthcare. Instead, we have politicians and public figures who employ “free” market language for political leverage to deploy their own vision of regulation, one that disproportionately shifts benefits to the very wealthy at the expense of everyone else.[14]
We have politicians and public figures who employ “free” market language for political leverage to deploy their own vision of regulation, one that disproportionately shifts benefits to the very wealthy at the expense of everyone else.
While painting Obamacare as unthinkable might work in the short term, it’s becoming increasingly difficult to allude to the American Dream of individual social mobility in any meaningful way. Indeed, the trend towards social stagnation linked to geography has become so pronounced that economist Raj Chetty joked of his 2015 study that “your chances of achieving the American Dream are almost two times higher … if you are growing up in Canada than in the United States.” Where you live matters; it helps determine the opportunities at your disposal. The absence of a “free” market is simply a red herring which, as inequality and social mobility continue to grow, politicians use at their own peril.[15]
Conclusion
All of this brings us back to the initial question: Why are we talking about repealing a law whose provisions people like? If we’re serious about delivering quality, affordable care, it would be much simpler to amend the existing law to allow, for example, health insurers to compete across state lines. Of course, that still wouldn’t address many of the health infrastructure issues like drug company and hospital pricing practices that contribute significantly to rising health costs, but these too could be easily addressed within the framework of the existing law. We might even keep hospitals, especially those with nonprofit designations, from garnishing the wages of impoverished patients to pad their bottom line.
Our healthcare system has real, identifiable problems that have nothing to do with Obamacare. And we could fix those problems. But instead, our politicians are laser-focused on repealing Obamacare in a way that gives a massive tax break to the very wealthy at the expense of everyone else, as illustrated in this graphic from the Tax Policy Center. The negative bars in the first three tax brackets means that you should expect negative tax breaks, or in other words, a tax increase, if you’re a member of this tax bracket. And all this while significantly increasing premiums and decreasing coverage.
Courtesy of the Tax Policy Center.
And in fact, Trump voters overwhelmingly support much of the ACA, as shown in this survey of Trump voters by the Kaiser Family Foundation.
Courtesy of the Kaiser Family Foundation.
Republicans are playing a dangerous game here. As the American Dream continues to give way to rising inequality, voters will no longer tolerate mere talk about the “free” market or “draining the swamp” to justify policies that benefit the few at the expense of the many. The material conditions in which they live—their dwindling bank accounts and job prospects—simply won’t allow it.
William Horne is a PhD candidate at The George Washington University researching the relationship of race to labor, freedom, and capitalism in post-Civil War Louisiana. His dissertation, “Carceral State: Baton Rouge and its Plantation Environs Across Emancipation,” examines the ways in which white supremacy and capitalism each depended on restricting black freedom in the aftermath of slavery. He can be contacted here.
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[2] Kari Edwards and Edward Smith, “A Disconfirmation Bias in the Evaluation of Arguments,” Journal of Personality and Social Psychology, (1996, Vol. 71): 5-24.
[3] Michel-Rolph Trouillot, Silencing the Past: Power and the Production of History (Beacon Press, 1995), 72.
[4] Trouillot, 90-94. For a more detailed look at the Haitian Revolution, C.L.R. James’ classic Black Jacobins is an indispensable resource. C.L.R. James, Black Jacobins: Toussaint L’Ouverture and the San Domingo Revolution (Vintage Books, 1989).
[12] The idea of the “Cartel” is an important feature of Leftist economists’ critiques of the atomized vision of exchange touted by supporters of the “free” market. I’ve chosen Rosa Luxemburg’s Reform or Revolution as an insightful example of this critique since she pairs credit and the Cartel as destabilizing, non-state forces that work against the interests of laborers and consumers alike. Rosa Luxemburg, Reform or Revolution and Other Writings (Dover Publications, 2006), 12-17.
[13] Karl Polanyi, The Great Transformation: The Political and Economic Origins of Our Time (Beacon Press, 2001), 71. For Polanyi’s critique of classical liberal free market ideology, see especially Chapter 6, “The Self-Regulating Market and the Fictitious Commodities: Labor, Land, and Money” and Chapter 11, “Man, Nature, and Productive Organization.” In shorter form, Noam Chomsky’s “Free Market Fantasies: Capitalism in the Real World” makes much the same point, as does Nicole Aschoff’s “The Free Market Fantasy.”
[15] Raj Chetty, Nathaniel Hendren, and Lawrence F. Katz, “The Effects of Exposure to Better Neighborhoods on Children: New Evidence from the Moving to Opportunity Experiment,” National Bureau of Economic Research Working Paper No. 21156, Issued in May 2015, accessed at http://www.nber.org/papers/w21156.
William Horne is a PhD candidate at The George Washington University researching the relationship of race to labor, freedom, and capitalism in post-Civil War Louisiana. His dissertation, “Carceral State: Baton Rouge and its Plantation Environs Across Emancipation,” examines the ways in which white supremacy and capitalism each depended on restricting black freedom in the aftermath of slavery. He can be contacted here.
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