May 1, 2018

Affordable Care Act Provisions that Went Beyond Healthcare ‘unseen by the public eye,’ Professor Says

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The staple of Barack Obama’s 2008 election platform was healthcare reform. However, soon after the Patient Protection and Affordable Care Act was signed into law, a majority of the American public supported its repeal. What happened?

A landmark piece of legislation, many argue that the ACA brought the U.S. substantially closer to having a comprehensive healthcare system, an objective already accomplished by most high-income countries and one placed on many agendas since the Truman administration.

Yet, as Prof. Suzanne Mettler, government, notes in her book, The Submerged State: How Invisible Government Policies Undermine American Democracy, the ACA’s accomplishments went largely unnoticed by the American public, and despite the successful expansion of health insurance coverage to millions of Americans, Democrats in Congress suffered great losses in the 2010 midterm elections following the ACA’s enactment.

Among many achievements, such as expanding Medicaid and providing insurance to more Americans, the ACA improved coverage for people with preexisting conditions and it allowed people under age 26 to be covered by their parents’ insurance plans.

As Mettler indicates in her book, in the month following the ACA’s enactment, over 50 percent of the public said they were “confused” about the act’s provisions, and months later over 60 percent said they supported its repeal. There was a widespread uncertainty about what the ACA entailed and how—if at all—it would benefit Americans.

While the explanation for this paradox rests in part with political partisanship and opinions about the state of the economy, it also stems from a phenomenon which Mettler describes as the “submerged state.”

According to Mettler, the submerged states describes the subset of policies that function through invisible avenues like the federal tax system or subsidies to private institutions, often benefiting the public without the public noticing. Thus, submerged policies, like the home-mortgage-interest deduction, are largely unseen by the public eye, while policies like food stamps, which more directly channel benefits, are more visible.

“The submerged state permits people to not acknowledge government’s role in their lives. It’s easier to be anti-government if you don’t realize [that] the things that have benefitted you and your family members and your community are government benefits,” Mettler said.

Mettler cited a national poll from 2008 in which participants were asked whether or not they had “ever used a government social program.” Over 40 percent of respondents said “no,” but when presented with an array of specific federal policies and asked whether they had ever benefited from at least one, over 90 percent said “yes.”

As Mettler had predicted, submerged policies were predominantly among those policies whose beneficiaries had responded to not ever using a federal social program.

As a result, Mettler argued that the submerged state ended up undercutting American democracy by promoting misinformed, passive, and anti-government sentiment among the public. When Americans receive submerged benefits, they aren’t likely to understand the policy’s content or impact and they detect almost no action or attention coming from their government.

To describe the relation between the submerged state and the ACA, Mettler notes that submergence contributes to the broad, misinformed notion that healthcare policy is created through market institutions. Since Americans generally don’t perceive healthcare as functioning within the government’s purview, government intervention and initiation of reform efforts are unexpected and often unwelcome, denounced as a “government takeover.”

Moreover, as Mettler explained in her book, Obama’s particular vision for healthcare reform “required transformation of the Submerged State in order to be accomplished.”

Obama was required to rework the anatomy of the submerged state, changing deep-rooted and often invisible policies and precedents in order to establish new provisions, many of which, like the “channeling [of] millions of new customers toward insurance companies for coverage,” were also invisible, Mettler wrote.

Further, because selective interests were deeply invested in the submerged state, the Obama administration couldn’t simply ignore them. It had to accommodate them in order to achieve reform.

Mettler talked about the involvement of selective interests in the policy process leading up to the ACA.
“Every time for decades that change has been proposed in these policy areas, [selective interest] groups double down and they protect the existing system. And Obama was up against that,” Mettler said.

The Obama administration’s dealing with selective interests was noticed by the public, and as a result, the administration landed its reform efforts a reputation for favoring moneyed interests and excluding the American people.

What the public often perceived, then, was not only a disregard for ordinary Americans, but also an amalgam of unclear or unseen objectives functioning within a policy domain not thought appropriate for government involvement in the first place.

Mettler believes that heightened awareness of the submerged state would generate more favorable circumstances, not only in regards to healthcare, but in regards to all social policy.

“One of the things that I hope people take away [from this research],” Mettler said, “is that in fact nearly everyone in the United States, nearly all of us, are beneficiaries of government social benefits.”

Mettler talked about how the structure of social benefits in the U.S. deviates from that of other developed countries.

The key difference is that in the U.S. the array of social benefits are “more upwardly redistributed. We give more benefits to higher income people,” said Mettler. However we do so in a submerged manner that seems to erase any trace of government involvement. As a result, “people think of these as earned benefits, and they think of them as coming through the private sector.”

In order for the submerged state to be reconfigured, Mettler suggested the need for more transparent and meaningful communication between the American people and the government and more policies that challenge submergence.

“We like to think of social benefits as just for those other people, particularly low-income people,” Mettler said. “But in fact, the welfare state, once you include these [submerged] policies, is actually just as large as it is in other comparable, affluent nations.”