The mess of health reform: trying to achieve Democratic goals through Republican means

During the congressional debate over the Affordable Care Act (ACA), Republicans successfully undermined overall popular support for the law by characterizing it as a "government takeover" of the American health care system — even though most of its specific provisions remained quite popular with the public.

As many frustrated Democrats pointed out, the ACA was far from the exercise in single-payer socialized medicine implied by Republican critics. In fact, the law's structure is striking for the many ways in which it attempts to avoid conservative accusations of "big government" liberalism.

Republicans favor federalism over nationalization. The ACA creates state-based insurance exchanges and uses state Medicaid partnerships to deliver services.

Republicans favor private sector implementation over increasing government bureaucracy. The ACA delivers benefits mainly through private insurance companies.

Republicans favor free market incentives. The ACA uses internet-based shopping marketplaces, which allows consumers to compare prices and requires insurers to compete for their business.

But the purpose of the ACA reflects a longtime objective of the Democratic Party: using government policy to provide better health care coverage to a greater number of people.

Like most American policy, the ACA uses Republican forms of governance to address Democratic constituency concerns

In our new book, Asymmetric Politics: Ideological Republicans and Group Interest Democrats, we argue that this pattern is typical of American public policy: Political leaders typically pursue the goals of Democratic constituencies using tools and approaches that respond to conservative critiques of big government.

Because the Democratic Party is a coalition of social groups seeking concrete political objectives, Democratic politicians are willing to compromise over the methods of policy implementation in the service of delivering practical benefits to group members. As an ideological movement, the Republican Party characterizes each set of new initiatives as expanding the role of government in violation of constitutional values.

To achieve their substantive objectives, Democrats compromise over the form of policy implementation in an (often futile) effort to appease Republicans and prevent internal dissension

The result is a policy infrastructure built mainly by pragmatic Democrats (and a near-extinct faction of moderate Republicans) that is liberal in its ends but conservative in its means. To achieve their substantive objectives, Democrats compromise over the form of policy implementation in an (often futile) effort to appease Republicans and prevent internal dissension.

During the consideration of the ACA, Democrats offered modifications to the law not only to appeal to a few Republicans but also to address specific concerns voiced by business groups, Congressional Black Caucus members, pro-life Democrats, and unions.

Democratic leaders and activists have plenty of policy goals, but they fail to agree on an ideological vision for a larger government role in society; many Democrats have even internalized conservative criticisms of federal agencies and programs.

As a result, public policy responds to conservative critiques. One example is federalism. The figure below compares the size of the federal workforce to state and local public sector employment since 1946. It shows that the American political system has decentralized the work of government, increasingly shifting it below the national level.

Courtesy of Oxford University Press

Yet these state and local employees are often supported by federal largesse or mandated by federal requirements — and they are not alone. Public policy increasingly relies on private sector government contractors and recipients of competitive grants (usually nonprofits) to deliver services. Although it is difficult to measure the size of this "shadow government" with precision, it now eclipses that of the direct federal workforce.

Courtesy of Oxford University Press

American public policy also relies on the delivery of benefits through subsidized private sector expenditures, such as the individual insurance markets created by the ACA. Data collected by Jacob Hacker and summarized in the figure below confirms that American social welfare spending nearly matches that of large European nations — but a large fraction of our welfare spending passes indirectly through private companies, usually employers.

These decentralized and private sector–dependent forms of American policy are often permanent, once they are included in the initial designs of policy.

Courtesy of Oxford University Press

The ACA is also emblematic of the American state's tendency to rely on tax credits and exclusions, with benefits delivered through a highly complex tax code rather than through direct transfer payments or new government bureaucracies that would attract opposition from conservatives. The graph below compares discretionary federal spending with tax expenditures, or foregone revenue attributable to legislated tax benefits. It shows that these benefits now collectively match those provided by non-entitlement spending.

Courtesy of Oxford University Press

American public policy is the product of compromises between asymmetric parties

Given the polarized character of contemporary American politics, observers often assume that the two parties rigidly adhere to diametrically opposed policy preferences and principles (and are thus unable to find any common ground).

But the content of American public policy shows that the parties have reached a grand compromise of sorts over the past 50 years: Republicans have prevented large new government bureaucracies but not slowed the growth of new policy goals. Democrats have collectively expanded the scope of government authority but have been forced to implement their initiatives in cooperation with the private sector, by relying upon market competition and tax incentives, and by decentralizing services to states, localities, contractors, and grantees.

Critics habitually complain that out-of-touch politicians ignore the will of the citizens they serve. But the American public, which collectively distrusts government in general even as it favors maintaining and even expanding government's specific responsibilities, has mostly gotten its (self-contradictory) way.

There is a cost, however, to this incoherent responsiveness, visible in the ever-more-complicated and imperfectly realized manner in which public policy is created and implemented in the United States. As long as voters continue to prefer a smaller government that tries to solve a growing number of specific social problems, the two major parties will try their best to reconcile these inconsistent demands.

Matt Grossmann is the director of the Institute for Public Policy and Social Research at Michigan State University. David A. Hopkins is an assistant professor of political science at Boston College. They are the authors of Asymmetric Politics: Ideological Republicans and Group Interest Democrats.

Will you support Vox’s explanatory journalism?

Most news outlets make their money through advertising or subscriptions. But when it comes to what we’re trying to do at Vox, there are a couple reasons that we can't rely only on ads and subscriptions to keep the lights on.

First, advertising dollars go up and down with the economy. We often only know a few months out what our advertising revenue will be, which makes it hard to plan ahead.

Second, we’re not in the subscriptions business. Vox is here to help everyone understand the complex issues shaping the world — not just the people who can afford to pay for a subscription. We believe that’s an important part of building a more equal society. We can’t do that if we have a paywall.

That’s why we also turn to you, our readers, to help us keep Vox free. If you also believe that everyone deserves access to trusted high-quality information, will you make a gift to Vox today?

One-Time Monthly Annual

$5/month

$10/month

$25/month

$50/month

Other

$

Yes, I'll give $5/month

Yes, I'll give $5/month

We accept credit card, Apple Pay, and Google Pay. You can also contribute via