The Affordable Care Act is probably the most progressive policy Americans born after the Great Society will witness in their lifetimes. It has saved tens of thousands of Americans from premature death and has already insured more than 12 million people. It has already defined Barack Obama’s legacy and will inevitably be at the center of the 2016 election. So why do so many on the left despise it?
Take “What’s the Matter With Kansas?” author Thomas Frank. In Salon he asks of the Affordable Care Act, “Why didn’t [Obama] propose a proper health care program instead of the confusing jumble we got?” Harvard Medical School’s Dr. Marcia Angell claims that, “Obama gutted the law before it was even passed.” Liberal blogger Lambert Strether, whose Corrente blog has an “Obamacare Clusterfuck” tab, writes, “If Obama, and the Democrats, had truly wanted a universal plan that guaranteed health care for all Americas [sic] as a right, they had the political power to pass it.” Former New Republic senior editor Noam Scheiber criticized the ACA in the New York Times for making it, “all but impossible” for Obama “to build support among whites.”
The ACA critics are right that a public option or a single payer “Medicare for all” program would make our health care system less wasteful and more equitable. But as political scientist Scott Lemieux has repeatedly demonstrated, Obama passed the most liberal bill he could have in the small window when Democrats controlled both chambers of Congress. Claims that the disappointing bill resulted from a failure of nerve or ambition represent little more than wishful thinking.
To understand why the ACA was the best we could get, it’s important to note some distinctive features of the American political system. First, the American system is majoritarian (the party with the most votes in a constituency wins all the seats) rather than proportional (seats are assigned in proportion of the total vote). In a recent paper, political scientists Torben Iversen and David Soskice show that majoritarian systems are more inclined toward center-right parties because the middle class have an incentive to side with the rich. As the chart below shows, majoritarian systems are more likely to have a right-wing government.
Government partisanship by electoral system, 1948–98
Second, there is the Senate, whose very purpose was to cool political passions for reform. Because every state sends two representatives, regardless of the state’s size, it is already stacked in favor of rural interests. The fact that Republicans have begun using the filibuster has made progress even more difficult, since any legislation now requires a 60-vote supermajority rather than a simple majority. In a recent study, five prominent political scientists argued that the status quo bias in the Senate has prevented government action on inequality, benefiting the rich. Given this dynamic, it should be unsurprising that presidents, despite popular illusions to the contrary, have little ability to twist Congress into supporting their policy, as political scientist George Edwards has persuasively shown.
Third, voter turnout is a key variable to creating progressive policy, as I’ve argued repeatedly. However, the United States lags far behind other Organization for Economic Co-operation and Development countries in voter turnout.
Fourth, the failure of campaign-finance reform has also blunted the success of the left, and the ACA is an example: Health care companies spent millions influencing the legislation. Numerous political scientists have noted how money in politics has prevented action on inequality from both parties.
Progressives should see the ACA as a key step toward our aims of a more just society, rather than a betrayal.
There are also important social factors to keep in mind. Racism in the United States, for example, severely constrains progressive possibilities. Scholars, most recently Ian Haney Lopez, have extensively documented how conservative politicians have exploited racism to tear down the safety net. I’ve shown that the levels of Temporary Assistance For Needy Families (TANF) benefits can be in large part predicted by racial animus.
The country’s individualism also poses a challenge: Americans are far more likely to accept individualist narratives of success and failure. They are more likely to blame the poor for their poverty and therefore oppose expanding the social safety net (see chart).
Attitudes about poverty in Europe and the United States
Given these structural and social impediments, you might wonder how anything progressive has ever happened in the United States. And indeed, our safety net is shoddy and increasingly benefits the middle class and the elite. The CBO estimates that in 1979, the bottom quintile received 50 percent of transfer payments, while in 2007, the group received only 35 percent of transfers. In 2010, the Center for Budget and Policy Priorities estimated that the poorest quintile received about 32 percent of entitlement benefits, indicating that the welfare state in the U.S. is generally aimed at the middle class, unlike the Affordable Care Act. These facts make the achievement of the ACA even more remarkable. As the chart below shows, the bill’s benefits are concentrated on the bottom fifth.
The Medicaid expansion provision of the ACA is also a rare example of a government policy that directly benefits the poor, particularly poor people of color. Although progressives now look at the New Deal and the Great Society with rosy optimism, those programs systematically excluded people of color. During the first two decades of its existence, Social Security excluded agricultural and domestic workers, which disproportionately harmed people of color. The postwar GI Bill, which helped to create the American middle class, also cut blacks out almost entirely, leaving them to live in poor neighborhoods. In contrast, people of color benefited immensely from the ACA, as shown below.
Percent uninsured, by group
It’s hard to overstate the political sacrifice the ACA required. Obama spent a hefty amount of political capital on legislation benefitting Americans who don’t give money to political campaigns, don’t garner much sympathy from the media, are disliked by most Americans and rarely vote. He did this even while his inner circle, including Rahm Emanuel and Joe Biden, repeatedly warned him against it. He did it knowing that many in his own party, including high profile members such as Sen. Charles Schumer, would criticize him for not doing more for the middle class. Half of the Senators who passed it have lost their seats, and Democrats may well have lost the House because of it.
The Affordable Care Act is one of the most courageous pieces of legislation in American political history. It is among a very few number of major expansions of the safety net that did not exclude people of color or ignore the fact that existing disparities needed remedy (though this fact was blunted when the Supreme Court struck down the key Medicaid expansion). As 2016 warms up and the sentimental left begins to harp on how ineffectual progressive presidents are, it’s important to remember how difficult it is to build the safety net and give credit where it is due.
The eventual Democratic nominee for president must embrace the legacy of the Affordable Care Act. Indeed, though Republicans initially began referring to the health care law as “Obamacare” to tar the program, this may become a strategic misjudgment. As the law becomes more popular, its association with the Democratic Party will become an asset, not a liability. But it’s not just Democratic politicians who must embrace Obamacare. Progressives should see the ACA as a key step toward our aims of a more just society, rather than a betrayal. Obama acted as a bold, yet pragmatic, politician — not a sellout.