New Book Examines ‘Dysfunctional Politics’ of Affordable Care Act
May 29, 2017
BLOOMINGTON, Ill.— A new book on the Affordable Care Act brings new understanding
of lawmakers’ motivations in crafting the legislation and provides suggestions on
how to improve dialogue as our society grapples with issues surrounding health care
costs, quality and access.
Illinois Wesleyan University professor and chair of political science Greg Shaw is the author of The Dysfunctional Politics of the Affordable Care Act(Praeger, 2017). While the book helps to explain why politicians approached the issue
of health care policy the way they did, Shaw said he was determined “not to engage
in too much Monday-morning quarterbacking.” The book includes insight as to why congressional
Democrats designed the Affordable Care Act (ACA) of 2010 the way they did, clarifies
some of the consequences of the act’s features, and examines why Republicans have
fought the implementation of the law so fiercely. Yet a significant portion of the
book is devoted to suggestions for doing a better job moving forward.
Shaw said that in an important sense, the ACA represented “an elaborate exercise in
building on the known.” A 2006 Massachusetts law was especially important, Shaw said,
in bringing together three elements: 1) insurance regulations to protect consumers;
2) an individual mandate to obtain insurance; and 3) government subsidies to help
people pay those premiums. Shaw said the ACA’s provisions represented a consensus
of sorts among health policy thinkers in the mid- to late-2000s.
Democrats, however, failed to recognize just how unpopular the individual mandate
would be, and they also failed to anticipate how controversial the Medicaid expansion
would be in most GOP-controlled states, Shaw said.
On the other side of the aisle, most GOP members of Congress and policy thinkers were
slow to realize how the rise of the Tea Party and its libertarian tendencies would
foster hatred of the individual mandate, Shaw said. “Public opinion polls during 2008
and 2009 show that rank and file Republicans shifted away from the mandate before
congressional leadership finally did,” said Shaw. “Beyond this principled resistance,
GOP officials in Congress and the states were also driven in large measure by partisan
motivations. Opposing Obamacare came to be part and parcel of opposing [then President
Shaw noted Republicans’ grudging acceptance of at least two of the three elements
of the ACA is clearly visible today. The bill passing the U.S. House of Representatives
on May 4 includes tax credits to help people buy insurance and also maintains the
consumer protections of the ACA, Shaw said. That bill drops the individual mandate,
but it retains a vestige of it— individuals who allow their insurance to lapse will
experience potentially steep price increases.
The book also includes details on what the American public knows — and doesn’t know
— about the Affordable Care Act of 2010. Shaw tracked public knowledge of the provisions
of the ACA over a five-year period, and found, among other factors, overall knowledge
did not improve between 2010 and 2015.
“Our political institutions and processes did not foster public learning on a very
important piece of health care legislation,” said Shaw, noting the ACA is the most
significant piece of health legislation since Medicare and Medicaid were created more
than 50 years ago.
Shaw offers several suggestions to “get to an information environment that includes
fewer falsehoods.” He notes Democrats would have helped themselves by doing a better
job of explaining the ACA to the public. In addition, he notes “we need better journalism
that focuses more on policy substance and less on the horse race of who’s up and who’s
down at the moment. As people get information from highly partisan and ideological
sources, they’re not hearing anything like the whole story.” And Shaw notes our entire
society should advance far beyond the point where “politicians don’t get so much electoral
traction when they demonize government.”
He notes in the book that considerable evidence shows “the public can make good collective
decisions when provided with a reasonable amount of substantially correct information
about the problems it faces and the policy choices it makes.”
This is Shaw’s second book on health care. His first, The Healthcare Debate, was published in 2010 and looks at the evolution of Medicare and Medicaid and the
rise and fall of the Clinton health care plan. He is also the author of The Welfare Debate (Greenwood Press, 2007). His writings on American social policy have appeared in
Political Research Quarterly, Political Science Quarterly, and other venues, including Public Opinion Quarterly, where he served on the editorial team. Shaw earned a doctorate in political science
from Columbia University and joined the faculty at Illinois Wesleyan in 1998.