The botched roll-out of government health insurance exchanges has trained a harsh spotlight on the Affordable Care Act. While the health law’s impact on the economy remains sharply disputed, Richard B. Saltman argues that politically motivated implementation decisions – from disruptions of existing insurance coverage to special treatment for labor unions and favored industries – have deepened a legitimacy crisis for government in general. He writes that as levels of citizen trust in government reach an all-time low, the ability of either party to make policy is diminished

Saltman, Richard B.

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blogs.lse.ac.ukhttp://blogs.lse.ac.uk/usappblog/2014/02/24/the-implementation-of-the-affordable-care-act-has-undermined-public-trust-in-government/Credit: The White HouseThe implementation of the Affordable Care Act has underminedpublic trust in governmentThe botched roll-out of government health insurance exchanges has trained a harsh spotlight onthe Affordable Care Act. While the health law’s impact on the economy remains sharply disputed,Richard B. Saltman argues that politically motivated implementation decisions – from disruptionsof existing insurance coverage to special treatment for labor unions and favored industries – havedeepened a legitimacy crisis for government in general. He writes that as levels of citizen trust ingovernment reach an all-time low, the ability of either party to make policy is diminished.Political scientists like to stress the role of popular legitimacy in the design of good public policy ina well-ordered democracy. Unless a program has broad public support, they suggest, it will be tough to implementand sustain.  The lifespan of public policy that isn’t seen as meeting the needs of the broad majority of the citizenscan be expected to be, paraphrasing Hobbes, “nasty, brutish and short.” If governments insist on keeping in placepolicies that citizens don’t see as legitimate, political leaders then have to resort to increasing levels of coercion tomaintain compliance, and the risk of corruption grows as various powerful groups try to buy their way out. Asgovernmental behavior in the questioned area deteriorates, popular trust in government in general declines andspreads from bad policies to good. If left unaddressed, the ability of the country’s elected leadership to governdeclines precipitously, with the country’s population becoming increasingly distrustful of all political powerregardless of which party or leader is in power.This quick gloss on the core importance of legitimacy in a democracy could be referring, unfortunately, to anyrecent morning news report in the United States about the problems of the 2010 Affordable Care Act. With this bill,the Obama Administration chose to pursue not just a solution for the 15% of the US population who lacked regularhealth insurance, but decided at the same time to impose the country’s first official national health policy, directlyaffecting insurance coverage, costs, and quality of care for the other 85% of the citizenry who already hadinsurance. Moreover, they set out to transform medical insurance and clinical care in a country which is three-time-zones and a continent wide (excluding Alaska and Hawaii, which are further away still), with a population of315 million people, nearly 75% of the entire 28 country European Union.The results were exactly whatcould have been (and in somequarters were) expected. Withoutgoing through the entire litany onthe insurance side, the now-functioning insurance exchangesare said by the White House tohave produced a small expansionpercentage-wise of the Medicaidwelfare program—e.g. poorcitizens signing up for free care—and a small increase in coverage(perhaps 10%) of those non-poorwho lack insurance at some timeduring the calendar year.Conversely, however, the 60% ofthe population who already hadprivate health insurance havebeen thrown into substantial sometimes extreme disruption in their insurance costs, coverage, and providers. Inparticular, those citizens in the private individual market who buy their own insurance themselves (some 15 millionAmericans) found themselves upended both financially and clinically, with policies cancelled outright, initialdeductibles on new policies jumping as high as $12,000 a year for a family of four, and long-time treatingphysicians being excluded from authorized treating networks.On the employment side, small and mid-sized employers (who provide over 70% of all jobs in the US economy)responded to the higher costs and greater uncertainty of the Affordable Care Act’s myriad mandates andrequirements by reducing their exposure. Since the Affordable Care Act required employers with over 50 full-timeworkers to provide health insurance, small businesses—badly damaged by the post-2008 contraction in theeconomy, increased taxes, and worried about their own economic survival—and also county and municipal governments responded by a) stopping most hiring, b) reducing or keeping employment below 50 workers,  and c)dropping the hours of existing workers back to a maximum of 29 hours a week  (the Affordable Care Act stipulated30 hours/week as full-time). As one direct result, millions of unemployed hourly workers cannot find work and nowhave dropped out of the workforce entirely, flattering the official but increasingly misleading unemployment rate.The response of the Obama Administration to these structural problems has been to improvise and delay. Nearlyevery day now brings a new, major change in health policy, many of them likely illegal under the terms of thefederal law that the Obama Administration itself jammed through Congress. Client groups of the administration(labor unions, particular industries like technology) have beaten a path to the White House seeking specialdispensation through waivers and special caveats, and, depending on their contributions to Democratic Partyfundraising, often getting them approved. The White House, of course, insists that these emergency measuresare perfectly normal parts of the implementation process.In essence, then, in its zeal to provide formal health insurance to the 45 million legal and illegal residents wholacked it, the sitting administration has jeopardized and, in millions of cases, put at risk the existing insurance of160 million other Americans. Further, as part of this process, the administration has turned health reform into akind of perverse Middle East bazaar, in which the President grants indulgences from his own signature law tofavored supplicants, often based on their prior political contributions to his election.There remains, of course, a segment of the population who still believe that both this particular expansion of healthinsurance and the implementation of this new national health policy is a moral imperative. These supportersinclude the senior leadership of the Democratic Party (re-styled as “progressives”) which controls the US Senateand many state democratic party organizations, many lower income uninsured (many younger uninsured are notimpressed), large segments of the Obama-compliant mainstream media, and—tellingly—almost the entire publichealth and health policy establishment in US universities and think tanks. Thus far, these groups have maintainedtheir conviction in the moral correctness of universal health insurance even as the financial and constitutionalconsequences of current policy accumulate around their feet.It has not helped that President Obama, for three years, in every speech, has said “If you like your insurance plan,if you like your doctor, you can keep them.”  Especially when documentation from inside the Department of Healthand Human Services only recently surfaced  showing that the President knew in 2010 that most people would notbe able to keep their health insurance, and that  most citizens would be forced into “compliant” (read narrowed)networks of doctors and hospitals. Indeed, in a decidedly peculiar live television interview with Fox News’  BillO’Reilly on Sunday February 2, given as part of the pre-game warm-up to the Super Bowl football game (100million viewers), President Obama begrudgingly admitted when pressed that he had in fact not told the truth aboutthis issue.The broader political context in the country has, not surprisingly, exhibited other, equally questionable forms offederal government behavior. These include the National Security Administration (NSA) monitoring of all Americanemails and telephone calls (despite explicit prohibition in the federal Patriot Act passed after 9/11) and the inactionand deflection of responsibility for the terrorist assault and murder of the US Ambassador to Libya in Benghazi on9/11 in 2012. Most important, the Internal Revenue Service has been hijacked for Democratic Party politicalpurposes in a manner that not even President Richard Nixon contemplated (Nixon used the IRS to attack politicalenemies personally, while the targets in the ongoing assaults are political associations participating in state andCredit: Andrew Aliferis (Creative Commons: BY-ND 2.0)national elections, thereby fundamentally perverting the democratic process itself).Drawing the inevitableconclusion, increasing numbersof the electorate no longer trustnot just the ObamaAdministration, but – exactly aspolitical scientists have theorized– they no longer trustgovernment. A Gallup poll of trustin government showed “an all-time low” in September 2013,with only 49% of respondentssaying that they had a great dealor fair amount of confidence, “2%below the previous low of 51%.” AJanuary 2014 poll of 6000college educated adults,conducted annually for arespected private foundation,showed that the percentage ofthose who “trusted government”had fallen to 37% from 53% in 2013 – a fall of 16% in one year. The rapid rate of decline was particularlyworrisome.What happens next is hard to predict. Financially, the Act is unaffordable in a country that already has piled up$17 trillion or more than 100% of GDP in federal debt (much more if one includes state and local governments),which already has the highest business tax rate in the developed world (35%), and which has unfunded pensionand healthcare liabilities that now approach 7 times annual GDP. At the same time that nearly every Europeancountry is cutting back social expenditures, however, the Obama health care program continues to blithely spendon.  In 2012, the Congressional Budget Office (conservatively) estimated taxpayer costs of $2 trillion more innational debt would be required to pay for the Affordable Care Act’s first 10 years of operation.Politically, however, the fate of the Obama Administration is too deeply intertwined to extricate either itself or thecountry from the 2010 Act, and the opposition Republican Party is too feckless to be able to offer a crediblealternative either politically or in terms of health reform. Thus the average American has little alternative but tohunker down as best they can, and future measures of trust and legitimacy will in all probability continue to fall.Thus we come to what is, for President Obama, Democratic Party progressives, mainstream mediacommentators, and academic health policy elites alike, a thoroughly counter-intuitive outcome. The DemocraticParty had expected that expanding publicly subsidized health insurance to millions of Americans would help builda “new coalition of Democrats,” like Franklin Roosevelt’s New Deal legislation famously did during the Depressionyears of the 1930s.History, however, does not appear to be repeating itself. Instead, even as millions are signing up for coverage, theAffordable Care Act is in practice further eroding the legitimacy of government for a substantial proportion of theAmerican electorate. Far from getting a new electoral coalition, then, the Obama Administration may only bestoring up tinder for a far less pleasant political reckoning.Please read our comments policy before commenting.  Note:  This article gives the views of the authors, and not the position of USApp– American Politics and Policy, norof the London School of Economics.Shortened URL for this post: http://bit.ly/1fNcsI3 _________________________________About the authorRichard B. Saltman – Emory UniversityProfessor Richard B. Saltman is Professor of Health Policy and Management at the RollinsSchool of Public Health of Emory University in Atlanta, Georgia. His research focuses on thebehavior of European health care systems, particularly in the Nordic Region. He has published 20books and 130 articles and book chapters on a wide variety of health policy topics, particularly onthe structure and behavior of European health care systems.CC BY-NC-ND 3.0 2014 LSE USAPP

The implementation of the Affordable Care Act has undermined public trust in government

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