Health Insurance and the Politics of Resentment
In a previous article, I discussed the ideological principles that underpin Republican attempts to replace the Affordable Care Act (ACA). With the defeat, for now, of these efforts, I’ll turn toward how Democrats can appeal to a wider swath of voters with universal programs as an organizing principle.
Voters have understandable concerns with insurance provided on the ACA exchanges: rising premiums and high out-of-pocket costs. There are many proposals to fix these changes: from the Center for American Progress’s narrow, technical fixes to the House Democratic Coalition’s reforms that allow people to buy into Medicare and expands exchanges subsidies.
These policy proposals have merit. However, I am more interested in countering a stickier ideological concern: middle and working class resentment of the poor due to means-testing.
Means-testing is a useful technical solution to health insurance, specifically, and government programs, generally. It costs less to implement and more efficiently addresses poverty-related barriers to services. Means-testing, however, also breeds resentment against people that receive benefits among those who do not. By definition, means-tested programs like SNAP, WIC, and Head Start tax the middle class to help the poor. As a result, these programs breed backlash. This problem is, in fact, well documented, with Chris Arnade, Joan C Williams, and J.D. Vance writing three varying accounts that reach similar conclusions: means-tested benefits stoke class resentment.
In fact, the ACA is no different. A Kaiser Family Foundation report found that, “[Focus group participants] were also aware of people with lower incomes getting coverage through Medicaid, which they viewed as a better deal, and resented not qualifying for more assistance themselves.”
While Democrats tend to shy away from addressing these types of resentments, this reporting shows a clear opening. Democrats do not need to counter the “elite” conservative position on health insurance that I previously described. Rather, Democrats must speak to the idea that the poor get government assistance, the rich get richer, and the middle class gets screwed.
From 1932 to 1994, Democrats did this. They were the party of universal programs: Social Security, subsidized education, Medicare. Everyone pays in and everyone benefits (eventually) from government assistance. In 1994, however, Bill Clinton shifted the course of the party. The “era of big government” was over. In its place was deficit reduction and greater means-testing. In practice, this did not mean an end to government poverty-reduction programs, rather assistance would be more targeted and, for some programs, more austere. Clinton’s 1996 welfare reform was, perhaps, the most visible and “successful” example of these efforts.
When the ACA was debated in 2009 and 2010, the dual desire to increase health insurance coverage and obtain a favorable CBO score led to relatively austere means-testing: Medicaid for those under 138% of the federal poverty line (FPL) and declining subsides up to 400% FPL. As a result, in 2017, a 50-year old making $48,000 a year would pay nearly $7,000 a year for a silver plan with a $3,500 deductible. This person would be expected to spend 22% of their pre-tax income on health care before insurance kicked in (figures here). No wonder our hypothetical 50-year old would resent someone on Medicaid who has no out-of-pocket expenses.
What can Democrats do to address this resentment? Fortunately, there is a good answer that does not involve stoking them: Universal programs.
Social Security and Medicare are two of the most popular government programs in existence. They are more immune than means-tested programs to demagoguery about the “undeserving poor” due to their universal nature: Everyone pays in to them; everyone receives benefits. Democrats should take the lessons from these two successful and popular programs and embrace a universal message, rather than a targeted one.
It may sound like I’m calling for Democrats to embrace a Bernie-style, Medicare-for-all system, but that’s not actually true. I care less about the specific policy prescription, than the underlying principles.
First, Democrats must make it unequivocally clear that they promote middle class values and aspirations. Fifty years ago, we understood that people do not just want benefits or entitlements from the government. They want fair play and to be able to contribute to national success. Democrats could define success as universal coverage and call on Americans to support that goal.
Second, and more specifically to health care, Democrats should fully embrace rights-based language. Most Americans agree with this. In a recent Pew survey, 60% of Americans said that the federal government has a responsibility to ensure health coverage for all, including a majority of Republicans with incomes under $30,000 a year. Messaging this is easy: Health is a human right, not an entitlement. Americans expect their government to uphold human rights. Therefore, the government should ensure that Americans have health insurance that protects them from bankruptcy and provides access to a wide array of services.
Finally, universal programs benefit everyone. When the middle class are asked to pay 22% of their pre-tax salary before they can benefit from health insurance, it is not surprising that they do not see the value of the ACA. Modifications to the ACA must improve the value proposition for people who do not currently benefit; options include more generous subsidies, increased cost-sharing to reduce out-of-pocket costs, further Medicaid expansion, and/or lowering Medicare’s enrollment age.
This approach implies more spending than the narrow, technical fixes proposed by the Center for American Progress. Yet, the unpopularity of the ACA derives from its technical and means-tested nature, not because of spending.
Democrats will never be able to compete for the support of limited government ideologues. They shouldn’t try. Rather, the way forward is to embrace a universal message that is both supported by, and benefits, all Americans.
