Five myths about the future of Obamacare

Obama signs his health-care reform bill into law. (Marvin Joseph/The Washington Post)
This post is written by Monkey Cage contributor Eric M. Patashnik, professor of public policy and politics at the University of Virginia, and Julian E. Zelizer, the Malcolm Stevenson Forbes, Class of 1941 professor of history and public affairs at Princeton University.
Both liberals and conservatives believe they are seeing the light at the end of the tunnel with the Affordable Care Act. With the HealthCare.gov Web site running more smoothly, liberals are confident that Obamacare will soon be entrenched. Just as Republicans in the 1950s came to accept Social Security to avoid electoral defeats, ACA supporters insist that conservatives are courting political disaster if they continue to oppose the law. Republicans have a different perspective. They point to millions of cancelled insurance policies, ongoing enrollment problems, and repeated implementation delays as signs that the law is on the brink of collapse. The ACA remains fundamentally flawed, they claim, and all these Band-Aid improvements will never repair a program that was defective from the start.
But what do we really know about the dynamics of “policy entrenchment”— that is, whether programs survive after Congress creates them? There are a lot myths and half-truths circulating in our national dialogue about ACA.  It’s time to take stock of what political science research actually tells us.
Myth 1: Government programs never die.
Given how difficult it is to revise an existing law, it might seem that a program’s entrenchment is assured once it has been enacted. In his 1976 book “Are Government Organizations Immortal?” political scientist Herman Kaufman argued that “government activities tend to go on indefinitely.” More recent research demonstrates, however, that policy entrenchment has limits. According to a study by Christopher R. Berry, Barry C. Burden and William G. Howell, a spending program has a 1 percent chance of death every year in its first 10 years of life, after which the probability of termination slowly begins to decline. New policies are trial and error affairs, and they don’t always pan out. Programs can be killed. An example is the Medicare Catastrophic Coverage Act of 1988, which Congress terminated in 1989 when senior citizens soured on the measure. Short of formal repeal, programs can simply fade away, as did Lyndon Johnson’s Model Cities initiative and Richard Nixon’s revenue-sharing program. The main danger the ACA faces is not outright repeal, but the gradual whittling away of its subsidies, regulations and tax provisions.
Myth 2: New policies create a new politics.
It is certainly true that policies can become durable by building supportive clienteles. MIT political scientist Andrea Campbell has shown how Social Security transformed senior citizens into the most active participatory age group in American politics. As we argue in our recent essay in Perspectives on Politics, however, new programs do not create a new politics automatically. To generate a clientele that actively defends its benefits, programs must not only deliver resources, they must change the way recipient groups perceive their social identities and their relationship to the program. If voters don’t see a program as helping them, it is less likely they will storm the barricades when opponents try to take it away. It is remains unclear just how much of a clientele the ACA will produce. The ACA is a far more redistributive reform than many other social programs. Some Americans will be losers. Moreover, as political scientist Jonathan Oberlander points out, “unlike Medicare and Social Security, Obamacare does not have a well-defined population of beneficiaries, and its benefits are diffuse.” The ACA “treats different groups of Americans in different ways and different times,” making it harder to mobilize public support. The ACA can build a constituency, but it may do so less effectively than the most durable entitlement programs.
Myth 3. ‘Deck stacking’ can stop policies from being unraveled.
A major threat to a policy is that the coalition that enacted it may be replaced by a future coalition that opposes it. One solution is to “stack the deck” by creating institutions that make it harder to damage the program in the future. Vanderbilt’s David Lewis has shown that policymakers can make legislation more durable by giving independent commissions control over policy implementation. Yet in the fragmented American political system, in which lobbyists can nearly always find a friendly institutional venue, there are limits to deck stacking. The ACA, for example, created the Independent Payment Advisory Board to require the secretary of Health and Human Services to implement its recommendations unless Congress passes an alternative plan to reduce Medicare costs. Yet the IPAB has not yet been launched due to opposition from industry groups and many members of Congress.
Myth 4: Politicians decide the fate of laws.
Politicians don’t control everything. The reactions of market actors can have a large impact on the fate of public policies. Sometimes business interests promote policy entrenchment because firms adapt to a new law in ways that become costly for them to reverse. One reason why airline deregulation became entrenched, for example, is that it led air carriers to alter their internal governance structures and business plans. Legacy carriers that couldn’t adapt to the harsh realities of market competition either merged with other airlines or went under. The entrenchment of the ACA will depend in part on the financial stakes that hospitals and insurers are developing in the new health care system.
Myth 5: Conflict over laws usually dies down.
Political conflict over a program can last for decades. Congress passed the Voting Rights Act in 1965, and opponents continued to attack the legislation through 2013, when the Supreme Court invalidated one of its central components. The potential for conflicts over existing laws to persist has only increased as a result of partisan polarization. While both the Social Security Act of 1935 and the Medicare Act of 1965 had some bipartisan support on final passage, the ACA was passed on a party-line vote. Forrest Maltzman of George Washington University and Charles Shipan of University of Michigan have shown that the greater the roll call opposition when a bill is passed, the more likely the law is to be amended by a future Congress. An open question is whether partisanship exacerbates the problem of divisive enactment. While systematic research has not been done, there are good reasons to think it might. As David R. Mayhew of Yale argues, while a cross-party opposition to a policy might fade, “a party that loses on a congressional issue and stays angry may have an  incentive to keep the conflict going.”
These five myths suggest that liberals and conservatives alike should be cautious about making sweeping predictions about the future of ACA. The reality is that the dynamics surrounding any program — even the most popular entitlement — are constantly evolving and always contingent. Policy entrenchment is an ongoing process, subject to all the normal forces of politics.