The main social policy problem in the U.S. healthcare sector is the lack of universal health coverage, defined as the ability of everyone to have access to health services when in need (equity), of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship (World Health Organization, 2018). Universal coverage achievement is judged in binary terms, it is either universal or not (Beland et.al, 2016).
PPACA History
In 2010, the Patient Protection and Affordable Care Act (PPACA) was signed by President Obama after a narrow, party-line Democratic vote. This legislation aimed at medically insuring 95% of the eligible US population, at an estimated cost of $940 billion. The law provided numerous rights and protections that increased health coverage and in general made it more affordable (Beland, Rocco, & Waddan, 2016).
Both political parties in the US viewed this reform as one of the most crucial pieces of social legislation in several decades (Sade, 2012), and without doubt the largest health care reform in the US since Medicare and Medicaid (Beland, Rocco, & Waddan, 2016). However, it has two main technical shortcomings. The first is 3-5 million people losing their employment-based health insurance, as many businesses found it more cost-effective to pay the penalty and let their employees purchase insurance plans individually. Secondly, the rise of premiums for those not covered by Medicaid by an average of 25%.
The absence of universal health coverage is a controversial problem. Academics have argued that this absence stems from cultural preferences, national values and American exceptionalism (Ladd, 1994). This essay illuminates three salient political reasons that account for this problem.
Political Hindrance to Successful Implementation
The first factor impeding the successful implementation of PPACA is partisan competition. Given the highly competitive two-party system in U.S. democracy, most decisions that politicians make are affected by the political and economic interests of narrow constituents in the states they govern rather than the actual healthcare needs of citizens. As Beland (2016) highlights, the decision to reject Medicaid expansion under the PPACA was highly partisan. Republican governors have turned it down, with a few notable exceptions, such as Ohio governor John Kasich’s Medicaid expansion policy (Zak, 2016). Republicans view the PPACA as increasing taxes and government control over people’s lives. Opponents of Medicaid and PPACA also argue that Medicaid will “crowd out” market-based insurance for working adults. Consequently, expanding Medicaid will attract many previously uninsured wage earners, thereby increasing citizens’ dependency on the public sector (Olson, 2015). Democrats prefer a robust national role teamed up with an enlarged private market presence. Thus, they support increasingly expansive Medicaid policies. Clearly, partisan politics trumps actual citizen needs.
The second factor is institutional fragmentation. Beland (2016) defines it as the fragmentation of the process for policy enactment and implementation amidst numerous veto points at which opponents of reform can mobilize against particular initiatives. An example of institutional fragmentation of the policy implementation and policy making process is when four of the Republican governors Medicaid expansion supporters found themselves challenged by their Republican-controlled legislatures: Arizona, Florida, Michigan, and Ohio. Institutional fragmentation is exacerbated by the separation of powers within the American constitutional system (Powell, Dalton, & Strom, 2015).
The healthcare problem is political. It requires a substantial degree of legitimation capacity to override opposition to proposed initiatives to ensure greater coverage for health expenditures. One example is Kentucky Governor Steven Beshear’s executive action after rejection of Medicaid expansion by the House. He was in a position to issue an executive action, usually unpopular with the electorate, only because of his consistent and high approval ratings, following his easy electoral win in 2011. (Sullivan & Blake, 2014).
The third factor is policy packages. Reforms similar to PPACA are characterized by their intricacy, hence why the concept of “triple aim” gained attention in the years leading up to the health reform; this concept asserted that advancements in cost, quality and access need to be tackled together (Berwick, Nolan, & Whittington, 2008). While coverage extension was attractive to liberal supporters of healthcare reform, the proposal was packaged with more controversial service delivery reforms which divided the liberal base (Lane, 2009).
The US still lacks universal health coverage, owing to three factors. High partisanship and electoral competitiveness, which prompted a higher than expected resistance from the Republican party. Institutional fragmentation, which makes the implementation of a Union wide reform highly problematic, given the big number of actors involved. Intricacy, which led to divisions between and within interest groups. Also, multiple amendments to the bill prevented the implementation of any version of the PPACA proposed. Nevertheless, it still managed to provide greater health coverage to the low-income population (Beland, Rocco, & Waddan, 2016).