The Affordable Care Act: Implementation Wars Sowed in
Legislative Success
Mark A. Peterson Professor of Public Policy, Political Science, and Law
UCLA Meyer and Renee Luskin School of Public Affairs
Michael M. Davis Lecture Series School of Social Service Administration
University of Chicago October 29, 2013
© Mark A. Peterson
Organization of Presentation
• Background on general implementation processes and the particulars of the ACA
• Indicators of the unusual politics of ACA implementation
• Explanation of the unusual politics of ACA implementation – Macro politics of increasing polarization
– Micro politics of universal coverage • Accentuated by demographic change
– The Significance of timing:
• Convergence of the macro/micro politics with the unique context that permitted passage of health care reform
• Proximity of the convergence to the schedule of redistricting
© Mark A. Peterson
BACKGROUND
Implementation of Enacted Legislation— The General Story
• Implementation stage always of substantive significance and a continuation of politics—winners seek to secure gains, losers try to mitigate losses
• Notice of Public Rule Making (NPRM) process
• Often the complexity of using federal enticements to prompt state/local action, so an additional 51 (+DC) political contexts and implementation processes
41 “Regulatory Provisions” in the Affordable Care Act Curtis Copeland, “Regulations Pursuant to the Patient Protection and Affordable Care Act (P.L. 111-148),”
Congressional Research Service, April 13, 2010.
Type of Provision Number
“Mandatory Regulations” 25
“Discretionary Regulations” 9
Other Regulatory Provisions 7
Federal Agencies Involved in ACA Implementation
Department Agencies
Health and Human Services
Office of Assistant Secretary for Planning & Evaluation (ASPE)
Centers for Medicare & Medicaid Services (CMS)
Centers for Disease Control and Prevention (CDC)
Health Resources and Services Administration (HRSA)
Office of Public Health and Science (OPHS)
Administration for Children and Families (ACF)
Substance Abuse and Mental Health Services Administration (SAMHSA)
Office of the National Coordinator for Health Information Technology (ONC)
Treasury Internal Revenue Service (IRS)
Labor Employee Benefits Security Administration
“New Entities” Created by the Affordable Care Act Curtis Copeland, “New Entities Pursuant to the Patient Protection and Affordable Care Act,”
Congressional Research Service, July 8, 2010.
Type
Number (Entities or Categories) Examples
Created by the Act 16
Center for Medicare and Medicaid Innovation (CMMI)
Independent Medicare Advisory Board (IMAB)
Commission on Key National Indicators
Established by the President 3
National Prevention, Health Promotion and Public Health Council
Interagency Working Group on Health Care Quality
Created by the Secretary of HHS 12 Federal Coordinated Care Office
National Center for Health Workforce Analysis
Created by Other Agencies/ Organizations
13 Preventive Services Task Force
State Advisory Councils
“Authorized” to be Established 2 Patient-Centered Outcomes Research Institute (PCORI)
Federalism Complexities of the ACA
Type Number
Potential Number of Insurance Exchanges 52—50 states, DC, & federal
(Senate version of ACA)
State Expansions of Medicaid
From 51 (in ACA) to Who Knows Given Supreme Court Decision?
Thus political decisions about whether, not just how, to implement
So What Happened?
• ACA constitutionality challenged in court by 28 states (Republican governors/attorneys general)—and barely survived U.S. Supreme Court review, with major change in the Medicaid expansion (National Federation of Independent Business v. Sebelius, 2012)
• The House in the 112th and 113th Congresses voted 40 times to repeal the law (party-line votes)
• Constraints on the federal insurance exchange – Funding – Multiple state-level efforts to block exchanges and sign ups – Now: four law suits challenging the legality under the ACA of providing
low-income subsidies in federal health insurance exchanges
• The House GOP leadership tried to make repeal, then delay, then tax changes, etc., in the ACA the requirement to avoid a government shutdown and to raise debt ceiling in October 2013
• Opposition leveraging of the Healthcare.gov rollout problems
Most States Refuse to Establish State-Based Exchanges “State Decisions for Creating Health Insurance Exchanges,” Kaiser Family Foundation, May 28, 2013
http://kff.org/health-reform/state-indicator/health-insurance-exchanges/#
About Half the States Refuse the Medicaid Expansion
Rhetorical Flourish on the ACA (Obamacare) David Stockman, President Reagan’s OMB Director, former Republican Congressman “the worst law ever passed in the last four decades by the federal government.” Ben Carson, MD, professor emeritus, Johns Hopkins University School of Medicine “the worst thing that has happened in this nation since slavery.” Representative John Fleming (R-LA) “The worst law in history.” Rick Perry, Governor of Texas “[the impact of the ACA on young people], I will suggest to you, reaches to the point of being a felony toward them and their future. That is a criminal act, from my perspective.” Senator Ted Cruz (R-TX) “That is a disaster for small business. It’s a disaster for jobs, and it’s a disaster for American families who are struggling.” Representative Michelle Bachmann (R-MN) “we’re saying let’s repeal this failure before it literally kills women, kills children, kills senior citizens.”
Representative Paul Broun, MD (R-GA) “Obama care is going to destroy everything we know as a nation.…I’m a medical doctor! ....it is destroying our economy….it’s destroying America.”
The Central Questions to Address: • Is there something different about the ACA implementation
process? – YES. Not any precedents of which I am aware – Social Security comes closest (1935)
• Court Challenge: Helvering v. Davis; Steward Machine Company v. Davis; Carmichael v. Southern Coal & Coke Co. and Gulf States Paper—1937
– Payroll tax, old-age insurance, unemployment compensation all held to be constitutional (7-2 for first two; 5-4 for unemployment comp.)
• Ongoing Republican opposition? “It would be misleading to write of opposition to social insurance.
Not since 1936, when Republican presidential candidate Alf Landon called for repeal of old age insurance and was beaten badly in the election, has any important public official or private organization urged that the program be ended.”
Martha Derthick, Policymaking for Social Security, 1979, p. 132.
The Central Questions to Address: – Medicare (1965)?
• Rhetorical flourish:
“[If people do not get appropriately mobilized] this program, I promise you, will pass just as surely as the sun will come up tomorrow. And behind it will come other federal programs that will invade every area of freedom as we have known it in this country. Until one day…we will awake to find that we have socialism. And if you don’t do this, one of these days you and I are going to spend our sunset years telling our children and our children’s children what it once was like in America when men were free.”
Ronald Reagan, 1962—before enactment—speech distributed by the American Medical Association—in opposition to the proposed Medicare program (which, at the time, would provide only hospital coverage to only senior citizens)
• Medicare Modernization Act (MMA) of 2003
The Central Question to Address:
• Is there something different about the ACA implementation process? – YES. Not any precedents of which I am aware – Social Security – Medicare – No Child Left Behind Act (2001)
• State, local, and school district resistance – Legislative—30 states “requested” changes, 8 states opposed – In court based primarily on “unfunded mandate,” but lost in Court
of Appeals (Pontiac School District, et al. v. Secretary of the U.S. Department of Education, 2008)
• Ongoing opposition is bipartisan in both Congress and in the states
• Why is the ACA implementation process different?
And Why Given That… • The real motive of the repeal movement: Just 2 of the ACA’s
10 Titles – Title I—Quality, Affordable Health Care for All Americans
– Title II—Role of Public Programs • Subtitle A—Improve Access to Medicaid
• The Title I Provisions are arguably the most “Republican” health care reform plan to take center stage in national policy making—they do not have Democratic origins
– Use of only private/commercial health insurance carriers
– Creation of health insurance exchanges to promote market competition—for individuals, families, & small businesses
– Tax subsidies for low-income individuals/families
– “Cadillac” tax on expensive, “excessively” comprehensive health insurance plans
– Personal responsibility / individual mandate
EXPLAINING THE UNUSUAL POLTICS OF ACA IMPLEMENTATION
From Chapter 9 Leadership: A History of Constraints and New Windows of Opportunity
From Chapter 9 Leadership: A History of Constraints and New Windows of Opportunity
A Political-Institutional Context that for the first time in history:
- Made it possible to get floor votes in the House and Senate
- Made it possible to overcome the Senate filibuster
-Made it possible to enact health care reform
-And to achieve enactment with only Democratic votes, if necessary
BUT….
MACRO POLITICS OF POLARIZATION
Support of the President’s Legislative Positions in the Senate by Members of the Opposition Party—
Percentage Support and Difference with President’s Party (Based on Congressional Quarterly Support Scores)
0
10
20
30
40
50
60
70
80
1953 1957 1961 1965 1969 1973 1977 1981 1985 1989 1993 1997 2001 2005 2009
Opposition Party Support Party Difference in Support
Support of the President’s Legislative Positions in the House of Representatives by Members of the Opposition Party—
Percentage Support and Difference with President’s Party (Based on Congressional Quarterly Support Scores)
0
10
20
30
40
50
60
70
1953 1957 1961 1965 1969 1973 1977 1981 1985 1989 1993 1997 2001 2005 2009
Opposition Party Support Party Difference in Support
Long-Term Changes in Party Ideology in House Source of Chart: Matt Eckel and Jeb Koogler, “Yes Virginia, They Really Are More Extreme,” Foreign Policy
Watch (fpwatch.com), August 17, 2011
The Public’s Rising Partisan Divide—“Sorting” from 1987 to 2012 “Partisan Polarization in Bush, Obama Years,” Pew Research Center, June 4, 2012 (http://www.people-
press.org/2012/06/04/partisan-polarization-surges-in-bush-obama-years/; accessed 8-22-12)
The Public’s Rising Partisan Divide—
1987, 2012 “Partisan Polarization in Bush, Obama Years,” Pew Research Center, June 4,
2012 (http://www.people-press.org/2012/06/04/partisan-
polarization-surges-in-bush-obama-years/; accessed 8-22-12)
Historical Frequency of Filibuster Motions, Votes on Cloture, and Cloture Being Invoked
Source: Senate Action on Cloture Motions, United States Senate, http://www.senate.gov/pagelayout/reference/cloture_motions/clotureCounts.htm
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-10
Num
ber
Motions Filed Cloture Votes Cloture Invoked
GOP Minority
GOP Minority
GO
P M
inor
ity
GOP Minority
GOP Minority
MICRO POLITICS OF UNIVERSAL COVERAGE
Democratic and Republican Support for Selected Issues, 1935 to 2010
Year Admini-stration House Senate
Dem GOP Dem GOP
Social Security Act 1935 FDR 284 (89%)
81 (79%)
60 (88%)
16 (64%)
Social Security Amendments (Medicare/Medicaid) 1965 LBJ 247
(85%) 66
(47%) 55
(81%) 13
(41%)
The Pepper Commission (15 members, 12 from Congress) 1990 Bush I 3
(75%) 0
(0%) 3
(75%) 0
(0%)
Universal Coverage/ Employer Mandate (whip count--Yes, Likely Yes)
July 1994 Clinton 47
(84%)
1 (2%)
[Jeffords]
S-CHIP Reauthorization (Children’s Health Insurance) 2007 Bush II 222
(95%) 43
(22%) 45
(92%) 17
(35%)
S-CHIP Reauthorization (Children’s Health Insurance) 2009 Obama 250
(98%) 40
(23%) 55
(98%) 9
(22%)
Affordable Care Act 2010 Obama 219 (87%)
0 (0%)
60 (100%)
0 (0%)
Democratic and Republican Support for Selected Issues, 1935 to 2010
Year Admini-stration House Senate
Dem GOP Dem GOP
Social Security Act 1935 FDR 284 (89%)
81 (79%)
60 (88%)
16 (64%)
Social Security Amendments (Medicare/Medicaid) 1965 LBJ 247
(85%) 66
(47%) 55
(81%) 13
(41%)
The Pepper Commission (15 members, 12 from Congress) 1990 Bush I 3
(75%) 0
(0%) 3
(75%) 0
(0%)
Universal Coverage/ Employer Mandate (whip count--Yes, Likely Yes)
July 1994 Clinton 47
(84%)
1 (2%)
[Jeffords]
S-CHIP Reauthorization (Children’s Health Insurance) 2007 Bush II 222
(95%) 43
(22%) 45
(92%) 17
(35%)
S-CHIP Reauthorization (Children’s Health Insurance) 2009 Obama 250
(98%) 40
(23%) 55
(98%) 9
(22%)
Affordable Care Act 2010 Obama 219 (87%)
0 (0%)
60 (100%)
0 (0%)
Ideological Positions on House Roll Call Votes, 89th Congress (1965-66)—Johnson Voteview.com (Royce Carroll, Jeff Lewis, James Lo, Nolan McCarty, Keith Poole, and Howard Rosenthal)
0 5
10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90
-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1
Num
ber o
f Rep
rese
ntat
ives
Left to Right Ideology Scale (DW-Nominate Scores—1st Dimension)
Democrats
Republicans
GOP Yea on Medicare/Medicaid
Ideological Positions on Senate Roll Call Votes, 89th Congress (1965-66)—Johnson Voteview.com (Royce Carroll, Jeff Lewis, James Lo, Nolan McCarty, Keith Poole, and Howard Rosenthal)
0
5
10
15
20
-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1
Num
ber o
f Sen
ator
s
Left to Right Ideology Scale (DW-Nominate Scores—1st Dimension)
Democrats Republicans GOP Yeas '65 Medicare/Medicaid
Democratic and Republican Support for Selected Issues, 1935 to 2010
Year Admini-stration House Senate
Dem GOP Dem GOP
Social Security Act 1935 FDR 284 (89%)
81 (79%)
60 (88%)
16 (64%)
Social Security Amendments (Medicare/Medicaid) 1965 LBJ 247
(85%) 66
(47%) 55
(81%) 13
(41%)
The Pepper Commission (15 members, 12 from Congress) 1990 Bush I 3
(75%) 0
(0%) 3
(75%) 0
(0%)
Universal Coverage/ Employer Mandate (whip count--Yes, Likely Yes)
July 1994 Clinton 47
(84%)
1 (2%)
[Jeffords]
S-CHIP Reauthorization (Children’s Health Insurance) 2007 Bush II 222
(95%) 43
(22%) 45
(92%) 17
(35%)
S-CHIP Reauthorization (Children’s Health Insurance) 2009 Obama 250
(98%) 40
(23%) 55
(98%) 9
(22%)
Affordable Care Act 2010 Obama 219 (87%)
0 (0%)
60 (100%)
0 (0%)
Ideological Positions on House Roll Call Votes, 111th Congress (2009-10)—Obama Voteview.com (Royce Carroll, Jeff Lewis, James Lo, Nolan McCarty, Keith Poole, and Howard Rosenthal)
0 5
10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90
-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1
Num
ber o
f Rep
rese
ntat
ives
Left to Right Ideology Scale (DW-Nominate Scores—1st Dimension)
Democrats
Republicans
Ideological Positions on House Roll Call Votes, 111th Congress (2009-10)—Obama Voteview.com (Royce Carroll, Jeff Lewis, James Lo, Nolan McCarty, Keith Poole, and Howard Rosenthal)
0 5
10 15 20 25 30 35 40 45 50 55 60 65 70
-0.2 -0.1 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Num
ber o
f Rep
rese
ntat
ives
Left to Right Ideology Scale (DW-Nominate Scores—1st Dimension)
Republicans
GOP '65 Yea Medicare/Medicaid
GOP '07 Yea S-CHIP
GOP '09 Yea S-CHIP
Ideological Positions on Senate Roll Call Votes, 111th Congress (2009-10)—Obama Voteview.com (Royce Carroll, Jeff Lewis, James Lo, Nolan McCarty, Keith Poole, and Howard Rosenthal)
0
5
10
15
20
25
30
-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1
Num
ber o
f Sen
ator
s
Left to Right Ideology Scale (DW-Nominate Scores—1st Dimension)
Democrats
Republicans
Ideological Positions on Senate Roll Call Votes, 111th Congress (2009-10)—Obama Voteview.com (Royce Carroll, Jeff Lewis, James Lo, Nolan McCarty, Keith Poole, and Howard Rosenthal)
0
2
4
6
8
10
12
14
-0.2 -0.1 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
Num
ber o
f Sen
ator
s
Left to Right Ideology Scale (DW-Nominate Scores—1st Dimension)
Republicans 2009-2010 GOP '65 Yea Medicare/Medicaid GOP Yea '07 SCHIP GOP Yea '09 CHIP GOP '93 HEART Cosponsors
Figure 7. Ideological Positions on Senate Roll Call Votes, 111th Congress (2009-10)— Obama, With the Addition of Republican Cosponsors of 1993 GOP Reform Plan
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30
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Num
ber o
f Sen
ator
s
Left to Right Ideology Scale (DW-Nominate Scores—1st Dimension)
Democrats
Republicans
DW-Nominate Scores of the 20 Republican Co-Sponsors of “Health Equity and Access Reform Today Act of 1993” (vertical line = median)
Scores of the 6 who served in the 111th Congress (vertical line = median)
© Mark A. Peterson
Democratic and Republican Support for Selected Issues, 1935 to 2010
Year Admini-stration House Senate
Dem GOP Dem GOP
Social Security Act 1935 FDR 284 (89%)
81 (79%)
60 (88%)
16 (64%)
Social Security Amendments (Medicare/Medicaid) 1965 LBJ 247
(85%) 66
(47%) 55
(81%) 13
(41%)
The Pepper Commission (15 members, 12 from Congress) 1990 Bush I 3
(75%) 0
(0%) 3
(75%) 0
(0%)
Universal Coverage/ Employer Mandate (whip count--Yes, Likely Yes)
July 1994 Clinton 47
(84%)
1 (2%)
[Jeffords]
S-CHIP Reauthorization (Children’s Health Insurance) 2007 Bush II 222
(95%) 43
(22%) 45
(92%) 17
(35%)
S-CHIP Reauthorization (Children’s Health Insurance) 2009 Obama 250
(98%) 40
(23%) 55
(98%) 9
(22%)
Affordable Care Act 2010 Obama 219 (87%)
0 (0%)
60 (100%)
0 (0%)
Democratic and Republican Support for Selected Issues, 1935 to 2010
Year Admini-stration House Senate
Dem GOP Dem GOP
Social Security Act 1935 FDR 284 (89%)
81 (79%)
60 (88%)
16 (64%)
Social Security Amendments (Medicare/Medicaid) 1965 LBJ 247
(85%) 66
(47%) 55
(81%) 13
(41%)
The Pepper Commission (15 members, 12 from Congress) 1990 Bush I 3
(75%) 0
(0%) 3
(75%) 0
(0%) **Note the 1990-91 Senate Finance and Labor and Human Resources Bi-Partisan Bi-Committee Effort Universal Coverage/ Employer Mandate (whip count--Yes, Likely Yes)
July 1994 Clinton 47
(84%)
1 (2%)
[Jeffords]
S-CHIP Reauthorization (Children’s Health Insurance) 2007 Bush II 222
(95%) 43
(22%) 45
(92%) 17
(35%)
S-CHIP Reauthorization (Children’s Health Insurance) 2009 Obama 250
(98%) 40
(23%) 55
(98%) 9
(22%)
Affordable Care Act 2010 Obama 219 (87%)
0 (0%)
60 (100%)
0 (0%)
Democratic and Republican Support for Selected Issues, 1935 to 2010
Year Admini-stration House Senate
Dem GOP Dem GOP
Social Security Act 1935 FDR 284 (89%)
81 (79%)
60 (88%)
16 (64%)
Social Security Amendments (Medicare/Medicaid) 1965 LBJ 247
(85%) 66
(47%) 55
(81%) 13
(41%)
The Pepper Commission (15 members, 12 from Congress) 1990 Bush I 3
(75%) 0
(0%) 3
(75%) 0
(0%) **Note the 1990-91 Senate Finance and Labor and Human Resources Bi-Partisan Bi-Committee Effort Universal Coverage/ Employer Mandate (whip count--Yes, Likely Yes)
July 1994 Clinton 47
(84%) 1
(2%) [Jeffords]
S-CHIP Reauthorization (Children’s Health Insurance) 2007 Bush II 222
(95%) 43
(22%) 45
(92%) 17
(35%)
S-CHIP Reauthorization (Children’s Health Insurance) 2009 Obama 250
(98%) 40
(23%) 55
(98%) 9
(22%)
Affordable Care Act 2010 Obama 219 (87%)
0 (0%)
60 (100%)
0 (0%)
Democratic and Republican Support for Selected Issues, 1935 to 2010
Year Admini-stration House Senate
Dem GOP Dem GOP
Social Security Act 1935 FDR 284 (89%)
81 (79%)
60 (88%)
16 (64%)
Social Security Amendments (Medicare/Medicaid) 1965 LBJ 247
(85%) 66
(47%) 55
(81%) 13
(41%)
The Pepper Commission (15 members, 12 from Congress) 1990 Bush I 3
(75%) 0
(0%) 3
(75%) 0
(0%) **Note the 1990-91 Senate Finance and Labor and Human Resources Bi-Partisan Bi-Committee Effort Universal Coverage/ Employer Mandate (whip count--Yes, Likely Yes)
July 1994 Clinton 47
(84%) 1
(2%) [Jeffords]
S-CHIP Reauthorization (Children’s Health Insurance) 2007 Bush II 222
(95%) 43
(22%) 45
(92%) 17
(35%)
S-CHIP Reauthorization (Children’s Health Insurance) 2009 Obama 250
(98%) 40
(23%) 55
(98%) 9
(22%)
Affordable Care Act 2010 Obama 219 (87%)
0 (0%)
60 (100%)
0 (0%)
What is Pronounced About Universal Coverage? It Activates Simultaneously Four Points of Tension in U.S. Politics
(Federalist v. Anti-federalist, Hamilton v. Jefferson)
• The Appropriate Size and Scope of Government – Public-Section Revenues as Percent of GDP
– Regulatory Scope
• The Use of Government-Enforced Coercion – Taxation
– Employer Mandate
– Individual Mandate
• The Appropriate Role of the National Government Relative to the States in the System of Federalism – Exclude the states (Social Security, Medicare)
– Compel states to do what they otherwise would not do on their own
• Inclusiveness that Brings in the “Undeserving” – “Unearned” benefits (perceived like welfare, unlike Social Security & Medicare)
– Intensified by Immigration and Demographic Shifts (African-American President)
© Mark A. Peterson
Demographic Shift
Jeffrey S. Passel and D’Vera Cohn, “U.S. Population Projections: 2005-2050,” Pew Research Center, February 11, 2008, p. 9.
Immigration and a Changing Population
0
5
10
15
Imm
igra
nts
as
Pe
rce
nta
ge
o
f P
op
ula
tio
n
1860-1920
1970--Baby Boom
Today
Composition of the Immigration Population
Ruth Ellen Wasem, “U.S. Immigration Policy: Chart Book of Key Trends,” Congressional Research Service, March 7, 2013, p. 4.
The Rise of the Tea Party (Theda Skocpol and Vanessa Williamson, The Tea Party and the Remaking of
Republican Conservatism, 2013, p. 141.)
“The tea party is a grass-roots movement of people deeply dissatisfied with the United States’ social, cultural, and economic evolution over several decades.”
Fareed Zakaria, “A Republican Party No One Could Control,” The Washington Post, October 10, 2013.
“But the kamikaze caucus, trying to block the president by any means necessary, is reflecting the desperation among Republicans convinced that Obama and his urbanized, racially diverse supporters are transforming America into something unrecognizable….These voters, Stanley Greenberg wrote, think ‘big government is meant to create rights and dependency and electoral support from mostly minorities who will reward the Democratic Party with their votes.’...Obamacare represents a tipping point toward a permanent Democratic advantage built on dependency and demographic change.”
Ronald Brownstein, “What the GOP Fears,” Los Angeles Times, October 11, 2013, p. A17.
Tea Party Fear of President Obama (Christopher Parker and Matt Barreto, Change They Can’t Believe In, 2013, p. 52.)
The Role of Obama and His Race
Michael Tesler, “The Spillover of Racialization into Health Care: How President Obama Polarized Public Opinion by Racial Attitudes and Race,” American Journal of Political Science (July 2012): 696.
“[H]ealth care opinions were more racialized after Obama became the most visible spokesperson for reform. With partisanship, ideology, and tax policy preferences (used here as a proxy for limited government) held constant, moving from the least to most racially resentful increased the predicted proportion of white respondents saying that health care should be left up to individuals by just over 30 percentage points in December 2007….[U]sing [data from multiple surveys], the debate over President Obama’s health care proposals appears to have altered the ingredients of mass opinion about this issue; racial attitudes became more important in white American’s beliefs about health care relative to nonracial considerations like partisanship and ideology.” (italics added)
2010 Election—Tea Party Additions to House of Representatives for the 112th Congress
(Chart from Theda Skocpol and Vanessa Williamson, The Tea Party and the Remaking of Republican Conservatism, Oxford, 2013, p. 169.)
TIMING
Convergence of Three Political Forces and Addition of ACA— (Contrast with Nixon CHIP 1974 and Clinton HSA 1994)
Micropolitics of Universalism
Best Political-Institutional Context for Passage of Health Care Reform— BUT Entirely Party Based
2010 Decennial Census and Redistricting
The Rise and Influence of the Tea Party
© Mark A. Peterson
“Unearned”
“Undeserving”
Black/”foreign” President
Democrats only
Republicans in 2010 Election + 63 in H of R + 6 in Senate + 6 governors + 700 state legislators
Convergence of Three Political Forces and Addition of ACA— (Contrast with Nixon CHIP 1974 and Clinton HSA 1994)
Micropolitics of Universalism
Best Political-Institutional Context for Passage of Health Care Reform— BUT Entirely Party Based
2010 Decennial Census and Redistricting
The Rise and Influence of the Tea Party
© Mark A. Peterson
“Unearned”
“Undeserving”
Black/”foreign” President
Democrats only
Republicans in 2010 Election + 63 in H of R + 6 in Senate + 6 governors + 700 state legislators
2012 Election—Popular Votes and House Seats
State Obama Vote Percentage (Two-Party)
House Democratic Vote Percentage
(Two-Party)
House Democratic Seat Percentage
National 52% (4.98 million margin)
50.6% (1.44 million margin)
46%
Michigan 54.8% 52.3% 36%
Pennsylvania 52.3% 50.8% 28%
Ohio 51.5% 47.9% 25%
Virginia 52.0% 49.0% 27%
Cook Political Report estimate: Democrats would need to win 56.8% of the national two-party vote to capture a majority of House seats
Summary
• The war-like politics of the ACA’s implementation is unique in modern U.S. history
• It results from a confluence of: – Enduring tensions associated with universal coverage – Historically high partisan polarization – The nation’s demographic transformation – Attributes specific to the ACA and President Obama
• Because of the timing of enactment relative to redistricting, opponents will likely have a beachhead for continued opposition no matter the results of the 2014 and 2016 elections
• Implementation of the ACA will become secure only if the program ultimately works
