The ACA Is the Beginning, Not the End

Back on April 17, I wrote in my Vox article, "7 Reasons Why Today's Left Should Be Optimistic":

Over time, the left has accomplished many things, from building out the social safety net to cleaning up the environment to protecting public health to securing equal rights for women, black people, and gay people. These and many other gains of the left have a very important thing in common: They are “sticky.” That’s a term borrowed from economics that means, simply, they will be hard to reverse. They provide benefits that people do not want to lose — and, what’s more, they shift norms of what is right and wrong.

Social Security and Medicare are great examples of policies that once seemed radical and now are simply a part of life. The Affordable Care Act’s core innovations may turn out that way, as well, despite the controversy that has dogged the program from its inception — and the declared intent of the current administration to eliminate it.

The ACA has provided benefits to millions who don’t want them taken away, and helped to establish the principle that every American has a right to health care, guaranteed by the government. That’s why the Republican attempt to radically downsize the program hit a buzzsaw. To be sure, Republicans will keep trying, and they’ll do some damage. But they will not be able to “repeal and replace” with a fundamentally less generous program.

Instead, it’s more likely that the ACA, either under that name or another, will get more generous over time. As conservative columnist Charles Krauthammer recently noted: “A broad national consensus is developing that health care is indeed a right. This is historically new. And it carries immense implications for the future. It suggests that we may be heading inexorably to a government-run, single-payer system.”

Krauthammer was despairing, but the left should be heartened by the observation. Indeed, at this point, Trump and the GOP have been reduced to hoping that if they neglect the ACA, it will collapse on its own — yet that doesn’t seem to be happening (knock wood). The very desperation of this “strategy” is a sign that Krauthammer may well be prescient about where American health care policy is headed. 

So it has turned out. Repealing the ACA turned out to be way, way, way harder than Trump and the GOP anticipated and ultimately it failed. Now is a good time to emphasize a basic characteristic of American public opinion that Trump and the GOP failed to understand and the left would do well to remember.

The dominant ideology in America combines what political scientists Christopher Ellis and James Stimson refer to as “symbolic conservatism” (honoring tradition, distrusting novelty, embracing the conservative label) with “operational liberalism” (wanting government to do more and spend more in a wide variety of areas). In their definitive book, Ideology in America, they characterize symbolic conservatism as:

            …fundamentally different from culturally conservative politics as defined by the religious right. It is respect for basic values: hard work, striving, caution, prudence, family, tradition, God, citizenship and the American flag….[I]t is the mainstream culture….It is woven into the fabric of how ordinary Americans live their lives.

And on operational liberalism they note:

            Social Security is…no exception. Most Americans like most government programs. Most of the time, on average, we want government to do more and spend more. It is no accident we have created the programs of the welfare state. They were created—and are sustained—by massive public support.

Thus, there was no insuperable ideological obstacle to the ACA and, indeed, there is no insuperable ideological obstacle to a substantially expanded role for government in health and other areas in the future. Indeed, such an expansion would be fully in accord with Americans’ durable commitment to operational liberalism.

Of course these expanded government programs will not happen all at once. Far from it. Like the programs of the past, they will be phased in gradually over time, in fits and starts, frequently in inefficient and suboptimal forms (like the ACA!). That’s the messy business of politics in a democracy. But happen they will and once enacted they will be hard to get rid of; instead, just as in the past, the programs will be modified, improved and even expanded. The reason is simple: people like programs that make their lives better and are far more likely to respond to program defects by demanding they be fixed than by demanding programs be eliminated.

Just like with the ACA.