New Book Examines ‘Dysfunctional Politics’ of Affordable Care Act

Greg Shaw's latest book offers suggestions on how to improve dialogue as our society grapples with issues surrounding health care costs, quality and access.

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 Barack] Obama.”

Greg Shaw

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.