The seven-year effort to repeal the Affordable Care Act can be summed up in one word: unprecedented. If the Senate’s health care bill becomes law in anything like its current form, it will mark the fastest reversal of an already-implemented social benefit in American history. In less than a decade, we will have seen tens of millions of Americans gain and then lose access to affordable health care coverage.
And the effects won’t be limited to beneficiaries of Obamacare; changes to the Medicaid program will mean that states around the country, including Wisconsin, will have to choose between raising taxes and cutting benefits for millions of aged and disabled Americans.
Yet the attack on Obamacare has already made history in another way. The repeal legislation reveals how powerful interests — rather than voters at the ballot box — shape what government does.
Consider that repealing the ACA would be one of the most unpopular actions ever taken by Congress. Mirroring the national trend, only 29 percent of Wisconsinites support the House version of the bill, while 54 percent oppose it.
Why are congressional Republicans eager to do something so unpopular with voters?
Rigorous research suggests that wealthy Americans and corporations play a disproportionate role in the policymaking process. And when it comes to the Republican Party, as Matt Grossmann and David Hopkins show in their recent book "Asymmetric Politics," ideological activists have increasingly dominated the party’s agenda. This helps to explain why Republicans prioritized repealing Obamacare rather than bipartisan goals like overhauling infrastructure during the Trump administration’s first 100 days.
For conservative activists like Charles and David Koch, repeal has been Priority No. 1; organizations supported by the Koch brothers have poured their energy into recruiting and financing candidates committed to repealing the ACA to facilitate tax cuts for wealthy Americans.
The Kochs’ interest in tax cuts rather than health reform also helps to explain why the House bill is so inconsistent with Republicans’ promises to lower premiums and out-of-pocket spending for voters. In the face of pressure from the largely Koch-funded House Freedom Caucus, Republicans wagered that their constituents’ partisan loyalties would ultimately trump their disapproval of repeal. Given the complexity of the law, a decline in local media coverage of repeal, and Republicans’ use of legislative procedure to distance themselves from the worst effects of the law, it may be harder for voters to hold elected officials accountable.
Yet the wisdom of this bet depends on how other powerful actors in health care politics, especially professionals and providers, choose to exert their influence.
The American Medical Association has long played a significant role in health policy, which includes setting prices for the services doctors provide. It has also proven extraordinarily effective at leveraging relationships between doctors and patients to apply pressure on Congress. In the 1990s, for example, the AMA urged doctors to directly lobby their patients to oppose elements of President Clinton’s health care plan. Since the AMA currently opposes repealing Obamacare, it might do well to employ such robust tactics once again.
Hospital groups, including the Wisconsin Hospital Association, have also warned Senate Republicans about the harm that could come to vulnerable populations as a result of Medicaid cuts. Yet the Senate bill makes deeper cuts to Medicaid than the House legislation. Absent a threat to deprive congressional Republicans with campaign contributions or votes, such warnings will have little practical effect.
To push back against repeal, health care providers should use proven strategies from the past. In 2013, for example, dialysis provider DaVita enlisted its employees to join in a nationwide lobbying effort against a proposed cut in Medicare payments. DaVita brought celebrity patients like NBA star Alonzo Mourning to Capitol Hill for personal meetings. DaVita also communicated directly with its patients and set up social media campaigns urging them to call their members of Congress. Yet unfortunately for its patients, DaVita’s voice has been virtually absent from the repeal debate, despite significant losses it could face as a result of the Republicans’ plan.
Republicans are poised to pass a widely unpopular law that simultaneously honors the wishes of the Koch brothers while ignoring the recommendations of doctors and hospitals. If health care providers fail to use every resource at their disposal, including the lessons of past campaigns, to prevent this outcome, the result would be an unprecedented loss for the sick, the poor, and anyone who needs (or may need) affordable health insurance.
If the few win over the many, it will mean yet another defeat for representative democracy itself.
Philip Rocco is an assistant professor of political science at Marquette University and co-author of "Obamacare Wars: Federalism, State Politics, and the Affordable Care Act," published by the University Press of Kansas in 2016.
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