American Health Care Policy through the Advocacy Coalition Framework
A Brief History of Health, Freedom, and Belief
For over seventy-five years, presidents from Republican Richard Nixon to Democrat Barack Obama have attempted sweeping health care reform on the national stage, all while state-level actors have tried to do the same on a smaller scale. Almost all of these initiatives have failed due to their confined resources, intractable difference in beliefs, or bad timing. The current moment in U.S. health policy is charged with emotional zeal, as the conservative government dismantles the Patient Protection and Affordable Care Act (PPACA, or abbreviated ACA) piece by piece. Meanwhile, a rising populist left calls for drastic reform not seen since Lyndon B. Johnson. At the heart of this policy landscape, a battle over what role government must play in the health care arena and what consequences its expansion could have guides the evolution of medicine in the United States. Using the Advocacy Coalition Framework (ACF), both analysts and lay people can better understand the sides of this conflict and its shifting battle lines.
The Advocacy Coalition Framework & Health Care Policy
ACF explains how people turn their beliefs into policy, organizing with like-minded allies to take control of the mechanisms of governance. Organizing around shared beliefs, these advocacy coalitions are composed of different kinds of policy actors, from the policy entrepreneurs who “sell” solutions to problems to the general public. ACF provides a clear lens to examine the shifting beliefs about medicine, individual liberty and common good that have come to define the struggle over health care, and what might come next in health reform.
ACF establishes a hierarchy of beliefs central to the policy-making process — deep core beliefs, policy core beliefs, and secondary aspects. Deep core beliefs are akin to religious convictions, dealing with abstract concepts like the nature of humanity or one’s role in society, making them somewhat hard to directly translate into concrete policy decision. Policy core beliefs are hard to change as well, but are more specific to how institutions should be arranged and money spent. Secondary beliefs apply to the gritty details of policy-making, like the differences between two regulations, and tend to change more over time. These three categories all factor into the health care debate, but the most successful policy entrepreneurs shifted the dialogue by striking specifically at the deep core beliefs, aiming for the very ideological core of the voter.
Health Policy Development Post-WWII
Health policy advocacy coalitions superficially fall along partisan divisions in the United States, but the reality is messier. Conservatives generally argue that big government should remain distant from health care, while liberals assert that the government needs to intervene to expand access and drive down costs. However, different semi-discreet advocacy coalitions feud over access to policy-making subsystems within parties.
For example, the contemporary Democratic Party is cleaved between moderate ACA reformers and Medicare for All advocates. At the same time, powerful lobbying groups exert influence on coalitions regardless of party line. The American Medical Association (AMA) is one of the largest lobbying groups in the U.S. and has been a consistent presence within the health reform debate since President Harry Truman. The AMA lobbied against reform in Truman’s administration, and was a harsh adversary of President Lyndon B. Johnson’s Medicare years later. Today, the AMA remains one of the largest lobbying groups in the country. The organization acts as a major entrepreneur and broker in the arena of health policy often advocating against expansion of government-provided health care policy. It is not the only lobbying force influencing health care. The U.S. health industry lobby spent $4.7 billion between 1999 and 2018, focusing on both state and federal government. Many forces within larger coalitions jockey for supremacy.
In the Advocacy Coalition Framework, policy learning takes place in cycles that span years, coinciding with elections, movements and crises. The cycles of American health care policy explored in this article align with the presidents, senators, and other prominent policy entrepreneurs who exerted influence at the time, as their political agendas often reflected one of the contemporary advocacy coalitions. For example, Presidents Roosevelt, Truman and Johnson all broadly represented the New Deal and Great Society era of American policy, defined by an expansion of federal power and programs. Their influence changed what was acceptable to discuss during the political cycles they dominated, and may be part of the reason why Nixon felt comfortable proposing his own liberal reforms. While they were not the sole policy brokers or entrepreneurs for this group, they acted as institutional spearheads that advanced reform, tapping into or even changing the beliefs of their constituents in the process.
President Richard Nixon, like Johnson before him and Obama after, attempted to address health policy by expanding insurance coverage to more people. In his 1974 Comprehensive Health Insurance plan — the second of two failed health reform initiatives — he focused on expanding employer health insurance plans while opening Medicaid to anyone who didn’t qualify for insurance through their employer. Nixon’s plans for reform were more ambitious than what the Democrats passed in 2010. At the time, his proposal was a conservative response to single-payer health care plan advocated for by policy actors like Senator Edward Kennedy. Single-payer systems, like those found in many Western European nations, involve a single large public or semi-public insurance agency instead of a patchwork of private health care companies. Nixon’s answer to single-payer would remain a touchstone for later conservative policy entrepreneurs. For example, then-Governor of Massachusetts Mitt Romney passed a state health care plan that can trace its roots back to Nixon. It also shows how noticeable the shift in beliefs amongst advocacy coalitions has been in the last fifty years.
The modern American conservative coalitions did not emerge until after Nixon left the Oval Office and the influence of New Deal-era policy waned. Nixon was far from a liberal, but he was followed by a more reactionary conservative movement that struck back against the cultural and fiscal changes that defined the 1960’s and 1970’s. Barry Goldwater, Ronald Reagan, and the broad “Moral Majority” coalition, with contributions from the AMA and other lobbying powers, influenced a diverse range of interconnected policy positions from private school segregation to corporate deregulation. This shift formed the ideological roots of the Tea Party and the devoted pro-Trump right, both of which would play a key role in the fight over the ACA.
Battle of Beliefs: Right to Healthcare versus Freedom from Government
President Barack Obama inherited a long legacy of Democratic health care reform. President Franklin Roosevelt proposed a “Second Bill of Rights” which would extend to health care. Unfortunately, Roosevelt did not live long enough to enact reform after the end of World War II. President Harry Truman failed to make FDR’s aspirations a reality when he took office. Hoping to use political capital while he could, Lyndon Johnson ultimately expanded Social Security to include Medicare, achieving sprawling health care reform that would not be matched until Obama took office in 2008.
After riding a populist wave of support to the White House, the young President proposed a vision of change and consensus that contrasted against the ongoing quagmire of foreign war and the sudden economic recession of 2008. Years later, in 2013, Obama defended the ACA during a speech at Prince George Community College. “In the wealthiest nation on Earth, no one should go broke just because they get sick. In the United States, health care is not a privilege for the fortunate few, it is a right.”
Since the ACA came into effect in 2014, it succeeded in making insurance more accessible for millions of Americans. Those in marginalized and impoverished communities and the young who often go uninsured received the greatest benefits from the act. However, critics argue that it fell far short of making health care a universal right, citing the power it gave to insurance, pharmaceutical, and health care companies. The ACA is a large and complicated piece of legislation that required a monumental amount of political will to execute. Like Nixon’s proposals, the ACA left more left-leaning actors within the advocacy coalition landscape feeling unsatisfied, falling short of establishing even a public option — a public insurance agency that could compete against private insurers. One advocacy coalition won out, but their adversaries were not about to give up.
The discussion about health care being a human right is compelling, speaking to deep core and policy core beliefs about how an equitable society ought to be organized. The scholarly debate raged before and during Obama’s presidency, but beginning in earnest in the 2016 Presidential Race, the proposal for universal, single-payer healthcare grew in popularity as a solution to ensuring the right of health care be respected. Popular, if not controversial, policy entrepreneurs like Bernard Sanders of Vermont and Alexandria Ocasio-Cortez of New York have been vocal supporters of this approach, echoing the demands of Senator Kennedy during the Nixon administration.
The advocacy coalitions opposed to liberal or left-leaning reform don’t say health care is an exclusive privilege instead of a right. They found success framing the debate around more accessible positions that appeal to freedom from government overreach, tapping a deep core value. During the runup to the PPACA’s passage, Republican lawmakers evoked freedom and choice when arguing against the bill. 2008 Vice Presidential candidate Sarah Palin was the first to use the powerful term “death panel” in the debate over health care expansion. Posting on her Facebook page, Palin wrote, “The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s ‘death panel’ so his bureaucrats can decide, based on a subjective judgement of their ‘level of productivity in society,’ whether they are worth health care. Such a system is downright evil.” The morbid, dystopian image Palin conjured is a perfect distillation of a successful strategy. Her comment also embodies how quickly the devil shift — the view that the other side is acting out of extreme malice — can be weaponized in the battle over policy. Accusations of the ACA being “socialized medicine” saturated the conversation, evoking the argument made decades earlier by the AMA and its allies. The ACA is portrayed as a direct, malicious assault against the fundamental values of the conservative voter, even if the bill in question matched those floated by Nixon and Romney.
The narrative Palin popularized continued well after Obama left office in January of 2017. The brunt of Republican healthcare legislation focused on demolishing the controversial individual mandate, which required Americans to purchase health insurance plans or pay a fine. Through legislation, the Republican Congress reduced the individual mandate penalty to $0, while the pending California v. Texas case set to be heard by the Supreme Court questions the entire ACA’s constitutionality. Reframing the narrative from a right to health care to freedom from government tyranny helped appeal to a deep core belief in a decent proportion of the electorate, paving the way for Republicans to dismantle Obama’s program.
Despite this campaign, popular support for the ACA remains high. According to a Morning Consult poll in September 2020, 62% of all voters supported the ACA. That support broke down dramatically along party lines, with 85% of Democrats, 59% of Independents, and 36% of Republicans respectively. At least to some extent, conservative advocacy coalitions were successful at refocusing the public debate from rights to liberties. An earlier poll published by the same organization suggested that nearly a third of Americans either thought that the ACA and Obamacare were different or didn’t know if they were the same.
External and Internal Health Crises
At least for the moment, a return to a Nixonian compromise seems unlikely. Actors in rival advocacy coalitions often resist learning from one another unless they are forced to react to crises from within or without the policy-making system, and the battle over health care is no different. While rival liberal and conservative coalitions have been learning from each other to better influence policy, there doesn’t seem to be enough motivation to bridge the ideological gap in earnest. However, if the status quo becomes an unbearable hurting stalemate for enough of these policy brokers and entrepreneurs, this will change.
The grounds for cross-coalition learning exists within broad partisan blocks and extends outwards to independent political actors, meaning policy learning and adoption between coalitions is possible. The discussion over Medicare for All during the 2020 Democratic Presidential Primary demonstrated this dynamic. A loose coalition, composed of grassroots leftist organizations and progressive lawmakers, worked to popularize single-payer health insurance within the Democratic party, competing against the establishment bulwark that produced the ACA and the conservative coalitions. A recent poll from the Kaiser Family Foundation shows the effects — four in five self-identified Democrats support Medicare for All to some extent and over half of independents view it favorably. However, a 64% majority of Republicans strongly oppose it.
Internally, there is plenty of crisis to prompt policy reform. Rising health care costs are crushing many Americans, forcing some to delay care or ration medication. From the 1980s until today, U.S. health care spending per capita reliably rose to approximately double what wealthy countries like Germany, France, and Canada pay. To some, this fact alone may be enough to urge decisionmakers to replicate whatever services these other countries have in place, giving rise to the increasing popularity of a single-payer system. However, rising costs alone may not be enough to force reform if coalitions do not seize the opportunity.
Throughout 2020, the COVID-19 pandemic brought the United States health care system to the brink. Judging by daily infection rates at the time of writing, the virus shows no signs of slowing down. A once-in-a-century pandemic qualifies as a profound external shock. Death panels haunt the American consciousness once again, albeit in the form of reverse triage caused by limited resources and a pandemic. Voices on the left and right debate whether a single-payer universal health insurance would be an adequate response in a world ravaged by a pandemic. While the shock wrought by COVID-19 it could forge new coalitions, it could also intensify the competition along current partisan lines and deepen existing divides.
The new presidential administration in 2021 will make an impact on future health care reform, but to what extent their version of reform will succeeds depends on how they capitalize on the previously-mentioned crises and appeal to the beliefs that bind coalitions together. Incumbent Donald Trump campaigned on demolishing the ACA and replacing it in 2016, and his administration managed to hack away at the program via the individual mandate. However, a comprehensive Trump-era alternative has yet to materialize, and it’s unlikely it will resemble anything Republicans proposed a few decades ago. Meanwhile, President-Elect Joseph Biden declined to adopt the more radical Medicare for All position of other Democrats. However, he ran on defending and expanding the ACA, continuing the legacy of the president he served alongside. However, a Republican Senate will continue to level accusations of government tyranny if Biden advances liberal reforms, and may have enough power to halt policy altogether, because deep-seated beliefs do not easily die.
Lessons
Through its framework of beliefs, ACF explains how American health care policy shifted from New Deal aspirations to a bitter battle over pre-existing conditions and Medicaid expansion. Arguably, the conservative ideological campaign against health care reform succeeded, even as impressive inroads were made by Democratic administrations. In the past sixty years, a broad conservative advocacy coalition dragged the debate rightward to a place where liberal policy entrepreneurs felt comfortable pitching a watered-down Nixonian health care policy, when a generation earlier, they argued for a single-payer system. This shift wouldn’t be possible without appeals to quasi-religious deep core beliefs. Though an emergent left is attempting to strike back at this ideological shift, their strategy must strike at deep core belief in a similar fashion in order to be successful. Any competing appeal to belief doesn’t need to convince a majority of Americans; after all, the conservative message never needed to convert a supermajority. A successful message only needs to influence enough people within coalitions to pull levers of power in a new direction.
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