Volume 8, Issue 1

This historical essay looks at the changing meaning of health insurance over time and explains how broad economic and political forces have created that meaning at any one time but that these forces interact with the contingencies of the moment to produce a particular outcome. That outcome in turn influences the subsequent development of health insurance.

On December 24, 2009, the United States Senate passed H.R. 3590, the Patient Protection and Affordable Care Act, by a vote of 60-39. Final passage was the culmination of over a month of behind-the-scenes negotiations and strategy sessions coordinated by Senate Majority Leader Harry Reid (D-NV). In this paper, I trace and evaluate Harry Reid’s coalition-building efforts on health care reform in the months leading up to the Christmas Eve vote using concepts drawn from the political science literature on legislative leadership. I conclude that Reid adopted precisely the transactional, "keep-the-chains-moving" leadership posture that matched both the institution he leads and his limited personal investment in the issue of health care prior to 2009. Efforts to paint Reid's performance on this issue as a failure of leadership ignore the extent to which contextual factors in the Senate were stacked against reform.

This essay uses the case of the "medical evidence gap" to illustrate how polarization and party competition can undermine efforts to solve a societal problem. Policy experts associated with both parties agree that the lack of hard evidence about what treatments work best for patients with different conditions is a significant health care problem, and that greater investments in "comparative effectiveness research" (CER) would enable patients, providers, and payers to make more informed decisions. Until recently, CER was a technocratic, third-tier issue. Over the past year, however, CER became highly politicized because it got caught up in the partisan struggle over universal health care reform. The story of how CER morphed into a symbol of crude rationing schemes and government interference with the doctor-patient relationship offers a cautionary lesson about the limits of pragmatic governance in an era of polarization.

The debate and the outcome in the Obama Administration's drive to enact national health care reform illustrate the conditional nature of democratic governance in the United States, a blend of partisan policy maximization and elite mobilization strategies that exploit core public policy preferences. The public's core policy preferences have, for some time, favored expanding access to health insurance, regulating private insurers to ensure reliable coverage, and increasing certain taxes to pay for these programs. Yet the intensely divisive debate over reform generated several notable gaps between proposed policies and public opinion for two reasons.First, Democratic policymakers and their supporters pushed for certain specific means for pursuing these broad policy goals—namely, mandates on individuals to obtain health insurance coverage and the imposition of an excise tax on high-end health insurance plans—that the public opposed. Second, core public support for reform flipped into majority opposition in reaction to carefully crafted messages aimed at frightening Americans and especially by partisan polarization that cued Republican voters into opposition while they unnerved independents. The result suggests a critical change in American democracy, originating in transformations at the elite level and involving, specifically, increased incentives to attempt to move the public in the direction of policy goals favored by elites policies and to rally their partisan base, rather than to respond to public wishes.

Both Bill Clinton and Barack Obama struggled to overcome widespread and persistent myths about their proposals to reform the American health care system. Their difficulties highlight the influence of factual misinformation in national politics and the extent to which it correlates with citizens' political views. In this essay, I explain how greater elite polarization and the growth in media choice have reinforced the partisan divide in factual beliefs. To illustrate these points, I analyze debates over health care reform in 1993–1994 and 2009–2010, tracing the spread of false claims about reform proposals from Bill Clinton and Barack Obama and analyzing the prevalence of misinformation in public opinion. Since false beliefs are extremely difficult to correct, I conclude by arguing that increasing the reputational costs for dishonest elites might be a more effective approach to improving democratic discourse.

The congressional election of 2006 was arguably a "Housequake." But how momentous have the changes been for how the House operates and the policy it produces? An answer to that question requires particular attention to two interrelated institutional factors: leadership and partisanship. A closer look at three episodes involving the Appropriations Committee—the breakdown of the markup process in 2008 and battles over open rules and "motions to recommit" in 2009—reveals the extent to which the struggle for partisan advantage is trumping norms that buttress the institutional role of Appropriations and of the House. Congress needs both partisan and bipartisan capacity, but the latter is in a dangerously weakened state.

The high-stakes debate over health care reform captured the public's attention for nearly a year. Options ranging from fully nationalized insurance to maintaining the status quo were considered, though little consensus as to the appropriate solution emerged. Most surveys indicated an agreement that a problem existed with the current health care system and a clear and consistent majority favored taking some action on health care reform. However, clear public support for any specific reform proposal was difficult to muster since most individuals also indicated satisfaction with their own health care. This paper explores this disconnect in public opinion within the context of loss aversion. We note that even as elites actively attempted to frame the issue to counteract the public's loss averse tendencies, these strategies met with little success in generating support for Obama's reform plan. However, we also argue that these loss averse tendencies will now work against any Republican efforts to repeal the health reform legislation.

We use multilevel modeling to estimate support for health-care reform by age, income, and state. Opposition to reform is concentrated among higher-income voters and those over 65. Attitudes do not vary much by state. Unfortunately, our poll data only go to 2004, but we suspect that much can be learned from the relative positions of different demographic groups and different states, despite swings in national opinion. We speculate on the political implications of these findings.

Though the Obama health reform has become law and many think it revolutionizes our health care system, the reality is that it will do very little about our two biggest problems, costs and quality. Our costs are the highest in the world, and our quality is mediocre at best. We are getting coverage of three-fourths of our uninsured, but nothing in the bill will force physicians to follow protocols to move care more toward science and away from art, and the cuts promised in Medicare payments to hospitals and physicians are no more likely to occur in the future than they have been in the past. Not angering powerful interests meant not really cutting their earnings or telling them how to practice. New taxes and employer inducements to provide insurance or pay a fine were an inevitable product of lacking the political muscle to cut costs while having taken the bold step of reforming the insurance industry. That reform committed the president to an individual mandate to buy insurance, the only way of protecting insurance companies against adverse selection of sick patients once they give up refusal to cover pre-existing conditions. Our permeable political system, our health care history and ideological intransigencies make it hard to adopt truly comprehensive reform that controls costs and assures quality care.

This article reviews Daniel Galvin's Presidential Party Building (Princeton University Press, 2010).