The Affordable Care Act is radical

Free University of Berlin

In the meantime the name has become established - whether it is a permanent abuse or a symbol of historical success remains to be seen. Obamacare is by no means the radical, “socialist” reform that it has been decried as in America's conservative circles. The private insurance companies, which were able to prevent Bill Clinton's attempt at reform in 1994, were given a seat at the negotiating table from the start and the law brought them to millions of new customers. The single payer option preferred by the party left, i.e. a state insurance system into which every taxpayer pays, was not even introduced into the negotiations. The American private insurance system will not be fundamentally changed, the existing state health programs - such as Medicare for retirees, Medicaid for welfare recipients, S-CHIP for children from low-income families - will not be expanded significantly. On the contrary: the financial crisis and the need to finance health care reforms threaten them with cuts, especially in view of the current US budget crisis.

46 million Americans have no health insurance

Why was reform necessary? Around 46 million people in the US live without health insurance, and millions more are dramatically underinsured. In addition, many people fear for their insurance coverage, especially if they lose or change their job. For-profit insurance companies have a higher administrative streak than state systems, and many of their employees are only occupied with dismissing claims from insured parties or terminating their contracts when the costs become too high due to serious or chronic illnesses of the customers. Health care costs were the number one driver of personal bankruptcies in the US prior to the mortgage crisis.

With the reform law, the government is now trying to insure an additional 30 million citizens. The law contains an "individual mandate," an obligation to purchase private health insurance for nearly all Americans who are not otherwise insured. Citizens from lower and middle income groups are entitled to state subsidies, and so-called health care exchanges are to be established in the individual states so that group insurance is also possible for the self-employed, the unemployed or employees of smaller companies. Without such group insurance, which most Americans have access to through their employers, the policies are much more expensive and often contain so many deductibles and exclusions that they only really come into effect in the event of a disaster, such as serious illness or accidents.

Insurance companies throw patients out

The reform also restricts the ability of insurers to reject people with existing illnesses or not to insure these “preexisting conditions”. The strategy of insurance companies of throwing expensive patients out of insurance because of formal errors is also made more difficult. The impartial Congressional Budget Office has calculated that the reform will reduce the budget deficit by $ 138 billion over the next ten years.

In the face of this rather tame reform, which is also closely modeled on that of the former Republican governor of Massachusetts and current presidential candidate Mitt Romney, did the hateful political rifts come about? This began in 2009, when the members of parliament and senators were exposed to severe hostility in their constituencies, where there was talk of allegedly planned “death commissions” to decide who would still be treated in old age? Was the reform responsible for defeating the Democrats in the 2010 congressional election? Although the Senate could be held, Obama's party lost across the board. In the House of Representatives, 63 Democratic MPs lost their seats to Republicans; the change of power was the biggest turnaround since 1948. In addition, there are now six fewer Democratic governors and six fewer senators.

A number of conservative politicians and journalists claim that health care reforms were instrumental in the catastrophic election result. However, this thesis does not stand up to closer analysis. Indeed, the reasons for the Democrats' defeat are many and - as they say in statistical data analysis - “overdetermined”. The unpopular health care reform undoubtedly contributed to the ruling party's poor popularity ratings, but the poor economic situation and high unemployment were likely to have played a decisive role. Because in a recession, the public mood is directed against the president, his politics and his party. For example, Reagan's Republicans lost the congressional election in the 1982 recession. As Jonathan Chait of politics magazine New Republic argues, the Democrats would definitely have lost public support in the recession, regardless of their policies.

Good chances for health reform

The health reform as such wasn't even particularly unpopular right before the election. In a poll conducted by the polling institute Pew Research Center on October 10, 2010, 38 percent of those questioned were in favor of health care reform - and 45 percent against. A survey by the television station ABC and the daily Washington Post on October 3, 2010 even showed that 47 percent of those surveyed were in favor and 48 percent were against. On August 30, 2010, the Gallup Institute asked 1,021 citizens which of the two parties they believe to have specific policy content. Democrats got 44 percent of the vote in health policy and Republicans only 43 percent - this was the only policy area where citizens polled trusted Democrats more than Republicans.

What has undoubtedly harmed the Democrats, however, is the aggressiveness and volume with which the Tea Party movement in particular attacked the reform, financed by free-market entrepreneurs and spurred on by conservative media, especially Fox News Channel. Glenn Beck, presenter of the Glenn Beck Show at Fox, even became a symbol of the Tea Party movement through his comments and organizational work. He has to go by the end of the year, but one can hardly hope that the polarized and polarizing American media will find their way back to professional journalism.

Why did Obama's health care reform allow such a determined, sometimes hateful opposition? Statistician and publicist Nate Silver writes in his Five Thirty Eight blog on the New York Times website that health care reform was relatively popular in election year 2008 - popular enough that Barack Obama could be elected with his reform promise. In the spring of 2009, a few months after the election, around 40 percent of the population were in favor of the reform, 25 percent against, and 35 percent undecided. When the law was passed in March 2010, around 40 percent were still in favor of the reform, but by then 50 percent were against it; the remaining ten percent were undecided. Almost all previously undecided voters who now expressed an opinion had decided against the reform. How did this happen?

Obama at times without a talent for communication

On the one hand, the White House had a poor communication strategy - the president had already given the impression several times that he had lost his communication talent, which was impressive during the election campaign. Communication and strategy were largely left to the leadership of the Democrats in the House of Representatives, who in any case never enjoyed high approval ratings. On the other hand, the course of events reconstructed by Nate Silver shows that the traditionally state-skeptical American population was being overwhelmed: In October 2008, under President George W. Bush, an aid package worth 800 billion dollars was passed to avert an economic catastrophe for the American economy. The Democrats approved by a large majority. In February 2009, the Obama administration passed another $ 800 billion injection of funds, with almost unreserved support from the Democrats in Congress. But the number of unemployed rose by 3.7 million in the period from February to July 2009, and thus even more than economists had expected - an economic catastrophe.

At first glance, the rescue and economic stimulus packages seemed ineffective. How much worse it would have been without her could not be shown or even proven. Then there was the ever-increasing debt that led to an unprecedented financial crisis in the USA in the summer of 2011. In this situation, according to Silver, the health care reform, again at about $ 800 billion in medium-term costs, could barely gain broad popular approval. Silver argues that the Americans have perceived a pattern of irresponsible government spending and penalized the state accordingly.

Maybe there was really nothing to gain for the Obama Democrats, maybe the Supreme Court, as the highest court in the United States, will ultimately uphold one of the ongoing lawsuits against health care reform: In fact, the obligation to buy a privately offered product is at the same time insufficient regulation of the providers, at least questionable. Or the Republicans manage to simply “dry out” the reform. Because in order to be able to carry it out as planned, many more budget decisions still have to be made - for example with regard to the health care exchanges that are important for their success and are to be set up by the individual states.

Paranoid traits in the tea party movement

Perhaps many states will find ways to get out of reform altogether, not through better single-payer systems like Vermont, but, for example, by allowing governors to take time to implement it until the Republicans in Congress and the White House do Repeal the law. For all of these defeats, the Democrats are likely to blame the unreasonable, uncompromising populists of the Tea Party movement. Indeed, their anti-establishment stance has the “paranoid” traits observed by the American historian Richard Hofstadter.

Ultimately, however, the Democrats must also ask themselves why they did not develop a comprehensive new vision for the USA, why the crisis was not used to redefine the regulatory role of the state in an economy and society that have been increasingly liberalized and deregulated over decades. The American people, including the Tea Party movement, are more than ready to take a critical look at banks and mutual funds; at the moment the anger at Wall Street is taking place in the "Occupy" movement in many places.

It is their own connections to Wall Street and the American business world that ultimately prevent the Democrats from leaving the discursive terrain of Republican economic and social policy and challenging their hegemony. Obama talked about a lot with his compatriots, and his eloquent speech on racism rightly paid tribute to him. But he never talked about taxes in principle, mostly only in connection with tax cuts; only the very rich have so far been exempt from it.

When it came to health, too, Obama remained strangely unconvinced. Instead of taking up the support that was initially available in the population and resolutely formulating a vision, he left the details to the unprincipled and undignified haggling of the Congress. In his 1919 essay “Politics as a Profession”, Max Weber made a distinction between ethics of conviction and ethics of responsibility. The latter is based on actual results and their practical consequences. The former, on the other hand, according to principles, regardless of the consequences. The truly great politician combines both ethics, Weber said. Obama could use a dash of ethics, and not just in defending his health care reform.