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A political scientist explains the real reason Obamacare repeal is so hard

Senators Debate Health Care Bill On Capitol Hill
Hello darkness my old friend
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Dylan Matthews is a senior correspondent and head writer for Vox's Future Perfect section and has worked at Vox since 2014. He is particularly interested in global health and pandemic prevention, anti-poverty efforts, economic policy and theory, and conflicts about the right way to do philanthropy.

On November 9, the morning after Donald Trump was elected president, I was quite confident that Obamacare was done for. Republicans in Congress had passed bill after bill repealing the law, and now they had a president willing and able to sign one of those bills into law. The coverage expansion inaugurated by President Barack Obama had helped millions of people for a few years, and would now come to an end.

Now, the Senate has rejected three separate proposals to repeal the law in full or in part. There’s always a chance they’ll try again, but at the moment, there doesn’t appear to be any plausible way a repeal measure could become law.

If any theory can explain what happened here, it’s that of Paul Pierson, a political scientist at UC Berkeley. In his 1994 book Dismantling the Welfare State? and 1996 paper “The New Politics of the Welfare State,” Pierson sought to explain why even very conservative leaders are unable to roll back big social programs. Ronald Reagan couldn’t get rid of Medicare or Social Security; Margaret Thatcher couldn’t dismantle the National Health Service. Pierson argues that social programs create a new politics, and in particular build a constituency of people benefiting from the programs that is politically powerful and can resist efforts to dismantle them.

Pierson and I spoke in March about his theory and how it applies to the Republican repeal effort; at that point the fight was still going on in the House, but his points remain salient today. A transcript lightly edited for length and clarity follows.

Dylan Matthews

You argue that it’s very hard to unravel social programs once they’re in place. Why is that?

Paul Pierson

The basic argument is that with these social programs — I was starting by thinking about things like Social Security but I think it applies with variation across programs — it’s a lot harder to get the toothpaste back in the tube once it’s out. People who are receiving benefits, they’re going to react pretty strongly to that being taken away from them. A taxpayer is paying for a lot of stuff and cares a little bit about each thing, but the person who’s receiving the benefits is going to care enormously about that.

There is a lot of psychological research that suggests that people react more strongly to things being taken away from them. There’s a kind of negativity bias in the way we respond to changes in our circumstances. So there’s that electoral mechanism that has to do with outraged voters.

But often with programs, there are also big networks of interest groups that can grow up around a program. Those are often very well-organized to protect programs and they’re also going to react strongly to things being taken away. The basic idea is that once these programs are put in place, and of course the longer they’re in place, the stronger those networks are likely to get, the more difficult it’s going to be to roll things back.

Dylan Matthews

The day after the election, on November 9, my assumption, and the assumption of a lot of people, was Obamacare is done for now. They have both the House and the Senate. They have a president who can sign a repeal bill. What are they waiting for? It seems in the past few months like it could still happen, but it’s become much less obvious it will happen. What are the main institutional factors that are driving that shift?

Paul Pierson

It’s not at all clear what’s going to happen, and one big reason is all the dynamics we were talking about at the beginning of this conversation. You’re talking about taking really important benefits away from tens of millions of people. Basically politicians don’t want to do that. There is an important dynamic where for years and years and years, Republicans could vote against the Affordable Care Act and loudly declare they were voting against the Affordable Care Act, knowing that this was all theater, that it wasn’t a real vote.

It was an easy win for them given the districts they represented and the way in which the Affordable Care Act had been portrayed to their most important political audiences.

Now the day after the election, you’ve got to think about actually doing it. The more time that goes by, Obama’s not there anymore, the more this other kind of logic — which is, yes, you’re taking away valuable benefits from very large numbers of people, including large numbers of people in your district. So that’s the first factor that I think has made things more difficult.

The second thing is that, while it’s true that on paper they have unified control of the government, they don’t have a filibuster-proof majority in the Senate. And there’s a lot of diversity in opinion — it’s all conservative opinion, but it’s quite a range of views — within the Republican Congress.

So there are people who are worried about rolling things back too far, and there are people who are worried they aren’t going to roll things back enough. They don’t have a lot of margin for error. They’ve got some margin for error in the House but they’ve got almost no margin for error in the Senate.

There are a bunch of institutional hurdles that remain quite important given the narrow majority they have in the Senate in particular.

But I think bigger dynamic is the first, which is that now you are talking about taking away benefits from probably tens of millions of people over time. Politically, that’s a very, very difficult thing to do.

Activists Erect Faux Shantytown To Draw Attention To Federal Budget Cuts
Medicare is very, very popular.
Scott Olson/Getty Images

Dylan Matthews

This theory seems to imply that universal programs like Medicare are more politically durable than ones like the Obamacare subsidies and Medicaid expansion, which are means-tested. This is the old, controversial “programs for the poor are poor programs” argument.

Paul Pierson

I think basically that argument is right and maybe has become truer over time because the amount of clout that low-income voters have in our politics has declined. The idea for the poor is going to be a poor program — I think that’s not a bad basic rule of thumb.

The argument I made in the book was that doesn’t necessarily mean that if you start with two social programs, it’s the means-tested program that will get cut disproportionately, because presumably some of that political weakness is already built into the program. It’s already going to be smaller.

There was a time when conservatives said, “It’s the middle-class welfare state that we don’t like, those are things that should be done privately. The public sector should be diminished so all it’s doing is stuff for people who we couldn’t meet their needs through the private sector.” Though actually I think Republicans are changing on this, and the changes they’re talking about to the Affordable Care Act reveal this.

So I think the argument about means-testing and its effect on retrenchment is complicated. I don’t think it’s straightforward that these programs are always going to be the ones where you see the biggest cuts. But at the moment, it’s pretty clear that that’s where the energies of those pushing for retrenchment are focused.

Dylan Matthews

It strikes me that one thing that might have changed in recent decades, that makes rolling back social programs more possible than it once was, is that the parties are a lot better sorted by ideology. There would have been a lot of Republicans who voted for Obamacare and wanted to preserve it in the late 1970s.

Paul Pierson

I think it’s a huge deal that that has changed. It has a whole series of effects. One is that it means for most of the people who are going to be voting on this, who you need to vote for repeal or whatever they put in, overwhelmingly these are people who come from heavily Republican districts or heavily Republican states. They all opposed the ACA if they were in Congress at the time.

So even if they have constituents who benefited from the ACA, they might favor something different. A lot of their voters do not fall in that camp; probably the majority of their voters do not fall in that camp. They are also going to have to run for reelection in primaries dominated by activists and people who are sufficiently engaged that they turn out in low-turnout elections. A lot of those people will be very, very angry if they don’t take action on the Affordable Care Act. That’s a really new development that I think has a big effect.

For most members of Congress, unless you’re in a closely held seat, and most of them are not, that’s probably not something that’s going to keep you up at night. Whereas bucking the party on repealing the Affordable Care Act sets you up for a lot of trouble, potentially. It sets you up for a primary challenge, it sets you up for a lot of recrimination and payback from party leadership and the Trump administration. I think the political calculations look pretty different in a hyperpartisan era.

Dylan Matthews

You used a lot of international examples in your book and paper. You have the example of Margaret Thatcher privatizing public housing as rare politically popular retrenchment. Are there any parallels from other industrialized democracies that are useful here? I can’t think of a country, other than maybe Australia in the ’70s, that did a big rollback on health care.

Paul Pierson

I think in general, there’s a strong consensus that this remains very, very difficult to do in most democracies. It doesn’t mean you can’t make changes in social programs, but when do you, you usually have to find a way to do it over an extended period of time.

I can’t think of any comparative precedent for coming in and taking health insurance away from tens of millions of people. That’s just a really big number.

Obama Continues Talks With Congressional Leaders On Deficit At White House
Obama, Reid, and Pelosi made a lot of compromises with industry to get Obamacare through.
Alex Wong/Getty Images

Dylan Matthews

Obama made a super-concerted effort to get Big Pharma and America's Health Insurance Plans (the lobbying arm of the insurance industry) and a lot of other stakeholders on board, who had killed a lot of previous attempts at health care reform.

I’m wondering whether the things that were necessary to get Obamacare through in the first place also weaken it when Republicans try to roll it back. Something that had done less to appease those interest groups — maybe by doing more to expand public insurance programs like Medicaid and Medicare — might have been harder to pass initially, but once passed might have been better at creating its own constituencies.

Paul Pierson

That’s an interesting idea. I think you’re right in describing what the politics were. They cut a bunch of deals with powerful interest groups in order to either get them to support the legislation, or at least get them to be close to neutral. Anything that made it harder to pass the bill probably means you get no bill. It’s hard to imagine a scenario in which you come closer to not getting a bill and yet you got one.

I would imagine if you asked people who had been part of that effort about the political calculations they made, they would probably say, and quite credibly, “Had we not made the concessions we made, you would not have gotten the Affordable Care Act.”

There are a lot of things about the design of the Affordable Care Act that I think made it hard to sell to people. But it sure seems like people are appreciating the ACA more now than they did over the last past seven years.

There’s probably a lot to learn about American politics from that. Maybe it just has to do with the messiness and ugliness of compromise — it’s not inspirational when you compromise, even if you compromise to do something that I think has done an enormous amount for millions of Americans.