Republican Rules of Reproduction and “Flipping the Script” on U.S. Health Care Reform

Abstract

Given the relatively conservative and marketized nature of U.S. health care reform, it remains unclear both why Republican resistance has been so intractable through much of the Affordable Care Act's (ACA's) tenure and why it has so suddenly receded into the background. This article seeks an explanatory mechanism to make sense of the ACA's changing historical fortunes, from enactment to the present. It argues that the Republican Party's “rules of reproduction,” a concept of historical sociology, best explains why the ACA met with such vociferous resistance and why that resistance has given way to surprising progress on coverage. It begins with a consideration of marketized U.S. health care, as well as the ACA's quest for expanded coverage—not structural rearrangement—as the basis for progressive change. Following this, I explore the “rules of reproduction” to explain Republican political actors’ relentless attacks on the law. The final section considers how the historically-contingent COVID-19 event has dovetailed with ACA entrenchment, effectively “flipping the script” on Republican rules, making anti-Obamacare maneuvers far less politically palatable. It is in this political space that reform advocates have been able to seize opportunity and broaden access.

Pessimism has long since been an understandable reaction to the prospects for health care reform in the United States. Entrenched structural inequality and powerful interests built into the U.S. politico–economic system have meant that predictions of “fair”—or even better—circumstances to come, particularly for low-income and/or racialized groups, are rarely vindicated. Social reform has moved in fits and starts for many, many decades, and the costs and outcomes for too many American citizens have been, to say the least, regrettable. As in other nations, the COVID-19 epidemic in the United States has certainly put the shortcomings of the health system on full display, subjecting it to an elevated level of scrutiny. But in the wake of the pandemic, one further trend has also been discernible: the expansion of health care coverage for millions of Americans since 2020. In 2022, the U.S. uninsurance rate quietly dipped to 8.0 percent, the lowest on record, re-establishing a secular trend in place since the enactment of the Affordable Care Act (ACA). ¹ This raises the prospect of a potential inflection point surrounding U.S. health care, where the foundation is being laid to close the coverage gap and bring on board the bulk of the uninsured population. It is difficult to determine whether this might, in turn, lead to equity-oriented re-regulation of health care delivery, but near-universal coverage would certainly elevate fairness as the next logical political discussion.

Literature on health care reform (including my own) has, quite rightly, emphasized both its shortcomings and its deep ties to capitalist profit imperatives.^2–6 Given the relatively conservative and marketized nature of this reform, it remains unclear both why Republican resistance to reform has been so intractable through much of the ACA's tenure, and why it has so suddenly receded into the background. This article seeks an explanatory mechanism to make sense of the ACA's changing historical fortunes, from enactment to the present. It argues that the Republican Party's “rules of reproduction,” a concept of historical sociology, best explains why the ACA met with such vociferous resistance, and why that resistance has given way to surprising progress on coverage. The “rules of reproduction” are a conceptual tool that help us make sense of actors’ behavior in face of structural conditions, especially when those conditions (in this case the market-friendly nature of health care reform) do not result in the outcomes we expect. Rules of reproduction compel behavior, because defying them can threaten actors’ ability to reproduce the conditions for their own existence. Between 2010 and 2018, intra-Republican rules related to recalcitrance on health care reform started as “innovative resistance” to Democrats political success but rapidly became obligatory, as adherence to anti-Obamacare rhetoric generalized across the membership and was endorsed by leadership. On pain of political backlash and potential extinction (most consequentially through the primary process), any logical Republican affinities to the marketized nature of the ACA were grossly outweighed by these rules. But while obstructionist rules continue to govern Republican actors’ behavior in a range of other spheres (e.g., gun control, immigration, “anti-woke” battles), they have run up against limits in the current historical context of health care reform.

To make this argument, the article begins with a consideration of the intractability of marketized health care structure in the United States, as well as the path down which the ACA has sought to address its unequal outcomes. This serves to demonstrate not only why expansion of coverage—not structural rearrangement—has formed the basis for progressive change, but also as the context in which to situate the prolonged and often confounding Republican resistance to the ACA. Following this, I trace these contentious politics and explore the “rules of reproduction” to explain Republican political actors’ relentless attacks on the law. This amounted to an unrelenting anti-ACA, obstructionist standpoint, misleadingly characterizing the reform as large-scale government intervention. The final section, however, also considers how the historically-contingent COVID-19 event has dovetailed with ACA policy entrenchment, effectively “flipping the script” on these rules, making anti-Obamacare maneuvers far less politically palatable. In this political space, reform advocates have seized opportunity and broadened access. This unprecedented closing of the coverage gap remains fragile, subject to political contestation, but step-by-step enlargement of existing health care mechanisms could, significantly, make future rounds of progressive change discernible on the horizon. ⁷

The Expansionary—Not Structural—Nature of Reform

What is the legacy of health care reform in the United States, and how has it sought to address challenges that have stymied access and provision? In rough terms, very large portions of the U.S. population lack or have been denied access for many decades. As the legislative process surrounding the ACA came to a head in 2009, nearly 50 million Americans found themselves without health care coverage. American health care was then—and is now—befuddled by two pronounced features: high cost and poor outcomes. Health spending in the United States is, by a long shot, the highest in the world, with a yearly per capita spending figure of $12,318. ⁸ Citizens in other Organisation for Economic Co-operation and Development countries spend far less on health, usually around half. More critically, the United States consistently places very low on quality outcomes relative to its advanced industrial counterparts. In an extensive study of 11 high-income countries by the Commonwealth Fund, both survey- and data-based, the United States ranks last on access, administrative efficiency, and actual health outcomes, including the highest infant mortality rate; the lowest life expectancy by age 60; and particularly poor showings for maternal mortality and avoidable mortality (pp. 4–9). ⁹ And the picture worsens considerably when we explore equity, where data shows ongoing racial disparities in access, affordability, and deleterious health conditions. ¹⁰ There have been wide discrepancies in terms of health care access across groups, where “Black and Latinx/Hispanic adults have historically reported much higher uninsured rates than white adults. This disparity reflects economic inequities, for these communities are less likely than white adults to receive coverage through their jobs, as well as immigration policies that can constrain coverage options for Latinx/Hispanic families in particular”. ¹¹ While implementation of the ACA has addressed some of these disparities, unequal access and disadvantage remain, and wider societal disparities on a broad range of issues (income, housing, community food access, etc.) magnify these health effects over time.

Structurally, change is difficult, given the prevalence of market-driven care and the use of individual “choice” as a political shield against solidaristic reform. The system of payment and provision remains a highly disarticulated, market-heavy patchwork, driven largely by corporate interests seeking to safeguard or expand their piece of the health-spending pie. Whether one accesses care through their employer, Medicare, or Medicaid, there is a high percentage (and growing) likelihood that it will be orchestrated by market actors. Government-funded health care alone involves hundreds of private insurance plans (payers), drawing revenues at the state and federal level, with a mandate to orchestrate care among networks of pre-arranged providers.^{4, 12, 13} The stakes here are not small: Medicare, Medicaid, and the Children's Health Insurance Plan (CHIP) cover around half of the total U.S. population, and these programs’ combined budgets amount to over $1.6 trillion.^{14, 15} Adding to this the even more lucrative private health care market (employer plans, individual plans, out-of-pocket payments) makes clear the motivation behind corporate actors’ determined fight against equity-oriented public regulation. Every reform attempt, historically, has witnessed vested corporate actors using any tools—from political influence to threats of “exit”—to secure existing revenue streams. From this standpoint, any major structural rearrangement of U.S. care (such as “Medicare for All,” a major expansion of fee-for-service Medicaid, or the establishment of a meaningful “public option”) are not on the near horizon.

This heavy corporate structural power partially explains the negotiating disposition of the Obama administration around the ACA. Labeled by John Geyman as the administration's “surrender in advance strategy,” enticements were doled out to the pharmaceutical, hospital, and insurance industries, in order to get all major health care players onside (p. 8). ³ Jacob Hacker and Paul Pierson have made clear that social programs gain political durability through societal entrenchment and that the ACA was:

…designed with enactment, not entrenchment, in mind. The strategy of the law's architects was to expand and improve coverage in ways that (a) would minimize obvious disruptions to existing coverage and (b) could attract the support or at least acquiescence of powerful stakeholders, such as health insurers and providers. Ironically, this strategy reflected the entrenchment of prior health care arrangements. Despite its many flaws, the U.S. health financing system provides reasonable protection to the majority of Americans, while obscuring the true incidence of its extraordinarily high costs. These high costs, in turn, support a formidable assortment of health industry players who profit handsomely from the system's many inefficiencies. The ACA was designed to bypass (read: buy off) these potential sources of opposition (p. 564). ¹⁶

Put simply, even with rising government intervention, deeply interwoven market arrangements make industry support politically vital, and this support is secured by aligning government expenditures with private revenue streams. Overall, direct and indirect government financing of health consumption expenditure has risen from 48 percent in 2008 to over 56 percent in 2021, but almost 80 percent of these government expenditures are being utilized in market or market-like payer–purchaser schemes. In fact, government expenditures will account for roughly 48 percent of all market-based health consumption expenditure in 2023 (pp. 6–11). ¹⁷ Moreover, a political culture of individual choice and market validation, reflected in the Obama administration's swift reassurance that Americans would not have to give up their existing health care packages, remained a formidable obstacle to structural reform. Political backlash would have been especially virulent from those benefiting the most from private care, as extensive tax exemptions favored—and still favor—expensive insurance plans for those with higher income in employer-based schemes. These schemes are usually touted as the core of the private delivery system, despite the fact that “middle- and upper-income Americans” relied on “an estimated $437 billion in tax-exempt subsidies for employer-based health insurance in 2019” (p. 627). ¹⁸ Given this context of public–private financing arrangements, any extrication and redeployment of government revenues toward a more robust public model would have, undoubtedly, become an organizational and political firestorm.

ACA reform, then, has been about the “buy-in” of U.S. citizens and not structural reform. Certainly, some significant regulatory changes were contained in the law, such as making illegal the refusal to insure based on “pre-existing conditions” or revoking coverage through “recission.” But no significant change was pursued that might interrupt profit channels for private payers and providers. Indeed, a health care market that is projected to grow at an annual rate of 5.4 percent to $6.2 trillion by 2028, roughly 20 percent of the U.S. gross domestic product, speaks directly to the reality that reform has been about reducing the uninsured population, not substantially controlling health care costs. ¹⁵ The bulk of this task is borne by two major pillars of the law: the individual insurance market and Medicaid expansion. While just over half of Americans gain their health care through employer-negotiated group insurance, those who do not (or who do not qualify for Medicaid or Medicare) had typically been priced out of purchasing individual coverage. The ACA directed states to set up individual insurance market exchanges (or allow the federal government to do it), with mandated affordable plans for individuals and families, with an eye to bringing this highly diversified group under the coverage umbrella. The “catch,” demanded by the insurance industry and inspired by a Republican template, was the so-called individual mandate: a progressive tax penalty for those who fail to secure a minimum level of coverage. At the same time, to address “affordability,” the legislation authorized progressively larger premium subsidies for those falling between 400 percent and 138 percent of the federal poverty level (FPL).

For those whose income fell below 138 percent, the ACA mandated non-categorical coverage under the Medicaid program. Medicaid coverage has always been plagued by a highly divergent and fraught politics of federalism, as well as the weak solidaristic and racist elements of U.S. political culture. The program's early association to welfare and disability assistance restricted its coverage, excluding able-bodied, childless adults, who were otherwise deemed “fit for work.” And even categorical eligibility was conventionally set by states at rather low income levels, with the average pre-ACA eligibility cutoff around 65 percent of FPL. To address this, the ACA legislated the expansion of Medicaid eligibility, based solely on income, to all individuals below 138 percent of FPL. This expansion population would be fully funded by the federal government, dropping to 90 percent federal funding two years after program adoption. Combined with subsidized (and mandated) individual insurance plans, this theoretically could have extended coverage across the entire U.S. population.

Confounding Resistance and the Rules of Reproduction

History, of course, need not proceed in ways consistent with the intended objectives of legislation, and this is especially true when there is partisan resistance. ACA reform evoked considerably bitter political resistance, though the ideological basis for this is anything but straightforward. In its expansionary designs, the ACA was modeled largely on Republican proposals, in existence since the 1980s, and especially on the already existent plan set up by Republican Massachusetts Governor Mitt Romney. ¹⁶ Generally, its expansion of market-based health care should have met with reasonable satisfaction on the right, as many Republican industrial donors (pharma, insurance) found new sources of revenue. Instead, these two pillars of reform were received—accurately or not—as a direct attack on core Republican values. At stake for critics was the centrality of individual choice, states’ rights, minimal government interference, and a general aversion to perceived “dependence” on public programs. On these counts, Tea Party gatherings virulently denounced the legislation, and Republican political leaders quickly sensed a rallying point of opposition. Republican attempts—largely symbolic—to defund or eradicate the ACA were prolific after 2010. Indeed, up until the Trump administration, there were 61 Republican-led attempts in the House aimed at partially or fully repealing the ACA. Legislative resistance was not, of course, the only field of political struggle, as numerous judicial cases culminated in the now infamous 2012 NFIB v. Sebelius Supreme Court ruling. To Republicans’ surprise, the individual mandate, around which much of the case hinged, was upheld. In a more surprising move, however, the court ruled that the Federal Government could not compel states to undertake Medicaid expansion. This resulted in only half of U.S. states initially adopting the expansion, a number which has since climbed to 40, plus D.C., as of early 2023.

This counterintuitive Republican recalcitrance on ACA reform has been critical in the ACA's fortunes and demands explanation as historical process. Here, we might turn to the thinking of Robert Brenner who, in understanding historical change, argues that we must be attuned to the specific “rules of reproduction” for actors across the social and political landscape. ¹⁹ These rules amount to the prevailing guidelines for significant social agents, insofar as they seek to preserve or enhance their existing status or life circumstance. In any given historical moment, rules of reproduction have a conditioning effect on behavior, “…because they are maintained or reproduced collectively, beyond the control of any individual, by political communities which are constituted for this very purpose,” and “actors cannot as a rule alter them, but must take them as given, as their framework of choice” (p. 58). ¹⁹ Political actors, then, also largely operate with rules of reproduction in mind and rarely act in ways that intentionally attempt transformative change. This helps us understand the continuity of action among actors across time, even when surrounding conditions indicate that they might (or should) act otherwise. However, if we take the rules of reproduction seriously, we must examine them with attention to historical specificity—that is, they cannot be understood as abstract historical laws. While not generally seeking dramatic change, actors’ adherence to the rules of reproduction should not be interpreted as ruling out the potential for change. In seeking to navigate these rules, particularly in moments of structural pressure, actors find creative and innovative ways to reproduce themselves that can, in the aggregate, shift or modify the ongoing terms of their social and political reproduction. While they may not be consciously seeking transformation, they are no doubt contributing to an evolving political community, with potential effects on the rules of reproduction, however subtle. Structural pressure, here, conditions behavior, but not absolutely, as Samuel Knafo and Benno Teschke have correctly pointed out: “Looming in this debate is [the] assumption…that structural constraints limit the margin of the possible and the scope for agency. While this seems at first glance like an unobjectionable claim, the problem is that historically we also know that changes often take place precisely when structural pressures build up…. So, while in the abstract, people have more freedom to change when there is little structural pressure, the reality is that they tend not to change unless forced to do so. People do not reinvent themselves because they have the luxury of doing things differently, they do so because they have to” (p. 266). ²⁰

In this sense, taking the rules of reproduction seriously requires that we navigate between historical contingency, political agency, and all of the conditioning effects of existing social structure. Political actors, while clearly impacted and shaped by market imperatives (in health care and elsewhere), do not respond mechanically to it. Instead, when necessary, they “attempt to contest, modify, circumvent and “escape” structural imperatives. In the process, innovation—or indeterminacy—is a constant possibility” (p. 254). ²⁰ Seen from this more critical standpoint, the rules of reproduction need to be carefully situated historically, where ostensibly “irrational” outcomes may be operating by their own—but no less consequential—social and political logic.

Republican attempts to degrade ACA reform by attrition can be associated to these rules, where the performative element of policy sabotage has been as much about competitive political displays to maintain political relevance as it is any actual disdain for the ACA. As the law was being negotiated, it is easy to forget how much structural pressure “Obamamania” had generated within Republican political circles. The emergence of Barack Obama, a young, extremely charismatic, and aspirational political figure, embodied both the changing electoral demographic and political imperatives of the post-Bush era. More than anything else, the threat of Democrats as a permanent governing coalition provoked the Tea Party reaction. Health care reform constituted an “innovative” terrain in which this reaction could be played out. Tea Party-cum-Freedom Caucus tactics squared poorly with prevailing norms surrounding bipartisan behavior (or its pretense), but they intensified, nonetheless, as a means to regain “relevance” on the national stage. Republican leadership also eventually adopted these strategies, making grievance politics a more integral part of Republican rules. From 2010 until 2016, the ACA became a performative target, where the law ostensibly embodied every reason to discard bipartisan behavior. In this way, obstruction was elevated over bipartisanship and, in the case of health care, with an almost zombie-like, intra-Republican adherence to the mantra of eradicating “Obamacare.” Even with constituents benefiting from expanding coverage, hardening values around the ACA came to threaten political extinction for those failing to display their anti-Obama credentials, most likely through an insurgent primary challenge. Obligatory anti-Obamacare political acts, with no viable end goal, probably reached their apogee when 2012 Republican presidential nominee Mitt Romney (upon whose Massachusetts health care law the ACA was based) reproduced Tea Party talking points against the law. The transparent hypocrisy of this move validated and reinforced Republican rules of reproduction, and ensuing symbolic and performative attacks in Congress over the next four years were unrelenting.

The political reality shifted radically at the end of 2016, with Donald Trump's electoral victory and full Republican control of Congress (only the second such instance during the postwar era), but Republican rules of reproduction around health care did not. Importantly, it is one thing to mobilize symbolic political action in the absence of full legislative or executive power, and entirely another to handle the full reins of government. Republican rules and symbolic anti-Obamacare performance were placed on a collision course with Americans’ actual health care coverage. Legislative acts like the ACA take time to develop political and social resilience, which emerges only with sustained implementation and palpable societal effects. Jacob Hacker and Paul Pierson have suggested that the ACA has, with time, undergone a process of entrenchment, whereby:

…individuals and groups become invested in particular programs and thus gain increased incentive to defend them (and often increased capacity as well, due to the resources that policies bestow on them). The concept of entrenchment is grounded in the idea of policy feedback, the observation that policies and programs, once enacted, can reshape politics in fundamental ways. Some policy provisions give rise to strong support constituencies and make cutbacks highly visible, while others do not. These constituencies usually include program beneficiaries, of course. But they can also include third-party providers (e.g., doctors and hospitals) and others aided indirectly by social programs (pp. 554–555). ¹⁶

ACA entrenchment, then, can reshape the political landscape, exert structural pressure, and form the basis for an alteration of the terms by which the rules of reproduction proceed. But there is, of course, no automatic equation between growing entrenchment of a social policy and the rules of reproduction surrounding it. The latter can fail to keep up and even contradict the political reality of entrenchment. While these rules must eventually adapt, they can continue to condition behavior in ways that appear confounding.

During the first half of Trump administration, hard-charging Republican attempts to upend the ACA exemplified the continuing strength of rules of reproduction surrounding the ACA, even in the face of growing entrenchment. From the America Health Care Act to the Graham–Cassidy repeal bill, party in-fighting over both the extent of the ACA's dismantlement, as well as any mechanisms to replace it, exposed a political minefield. These legislative efforts generated active resistance from powerful industrial sectors, including insurance, pharmaceuticals, and hospitals. Their trade organizations warned that Republican efforts would not only destabilize health care coverage for medium and low-income recipients, but that it would “potentially allow government-controlled, single-payer health care to grow”. ²¹ Even with this corporate pushback, as well as public opinion polls clearly against the law's dismantlement, continuing Republican political action resulted in multiple rounds of legislative embarrassment. Having failed to repeal the law, Republican tactics shifted toward the elimination of the much-reviled individual mandate. Again, the health industry reacted, warning of “serious consequences if Congress simply repeals the mandate while leaving the insurance reforms in place: millions more will be uninsured or face higher premiums, challenging their ability to access the care they need”. ²² In the end, however, even the powerful insurance lobby could not prevail over political rules of reproduction, and the individual mandate fell victim to the very legislative instrument that gave it life, budget reconciliation, with Republicans utilizing tax reform to “zero out” the mandate's penalty, making its effect null and void.

Beyond Republican Congressional maneuvers, the administration also continued aggressive attacks on the law, setting its sights especially on Medicaid expansion, again acting deeply against the grain of public opinion, which is highly supportive of the program. ²³ The Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma made clear that Section 1115 Medicaid waivers would be welcomed that included previously discouraged reform measures, such as beneficiary premiums and work requirements. This brought applications from 22 states for waivers that required work or work-equivalent status among beneficiaries, 13 of which were approved prior to the 2020 Presidential election. ²⁴ The desired effect here was to make Medicaid criteria more difficult in expansionary and non-expansionary states alike. As such, Republican-led states that had already long embraced expansion, such as Ohio and Kentucky, now requested more restrictive waivers. Much of this, ultimately, would be reversed and shut down by the Biden administration, but this avenue of “counter-reform” remains a strong area of vulnerability for health care enrollment among low-income Americans.

The lemming-like behavior of Congressional actors and the permissive behavior of CMS officials demonstrate the strength with which the performative rules of reproduction hold fast. Republican willingness to sacrifice much of the 115^th congressional term at the altar of anti-Obamacare tactics demonstrates the strength with which these rules were operating in relation to health care. Even “mandarins” of a technical bureaucracy could not prevent the demonstration of conservative credentials by a political appointee (Seema Verma), which went far beyond any necessity of office. Ultimately, however, it could not remain an inverse relationship between the rules of reproduction and ACA entrenchment. While rules around obstructionism and performative displays of harshness have hardly relented across an array of issue-areas for Republicans, the terrain of health care, as the next section makes clear, has generated unexpected political realities and trapped Republicans in their own logic.

A Perfect Storm? Seizing Opportunities, Raising Expectations

While rules of reproduction are integral to historical process, they can also be interrupted by historical contingency, a strong dose of which was administered by both the 2018 midterm elections and, not long after, the COVID-19 pandemic. In the former, Republicans experienced clear electoral punishment, losing 41 seats and the majority in the House of Representatives, while gaining only two seats in the Senate, despite a terrible electoral map for the Democrats. This was popularly interpreted as a function of the political fiasco surrounding Republicans’ ACA repeal attempts, with voter turnout the highest since 1914, and exit polls registering health care as the primary issue of concern among voters.^{25, 26} Here, we see an initial layer of structural pressure accumulating for Republican actors, whose ill-fitting rules of reproduction seemed to be undermining the viability of the ACA, potentially to the detriment of millions of beneficiaries.

This structural pressure on Republican actors was further magnified by the COVID-19 pandemic, a moment of public crisis in which public officials would, conceivably, be expected to act in ways that forcefully address social needs. But while officials in the Trump organization could not ignore the necessity for action, this was expressed far more through blame avoidance than positive political action. Leadership, instead, came from Democratic legislation, with the Families First Coronavirus Response Act responding to both the public health crisis and the surging reality of job loss in the U.S. economy. Under this legislation, CMS increased the federal matching rate (FMAP) distributed to states for Medicaid programs by 6.2 percent with clear conditions: States could not change eligibility criteria or disenroll beneficiaries during the declared public health emergency. This “continuous coverage” over the course of three years has been the basis for a surge in Medicaid enrollment. By August 2022, federal data revealed an increase in enrollment by over 30 percent. ²⁷ Combined with CHIP, these two programs currently provide health care access for over 90 million Americans or roughly 27 percent of the U.S. population. Reinforcing this, the America Rescue Plan Act of 2021, a COVID-19 stimulus package, enhanced and extended existing federal subsidies for the individual insurance market. This advanced premium tax credit (immediately applicable on health care premiums) temporarily raised the zero-premium threshold from 100 to 150 percent of FPL, and enhanced subsidies all the way up to and beyond 400 percent FPL. ²⁸ This has made the ACA insurance market exchanges more attractive to U.S. citizens, evidenced by the growth in plan enrollments, surging from 11.5 million in 2020 to 14.5 million in 2022.

There is no guarantee that these gains can be solidified—they can be subject not only to the struggle of national-level politics, but also the highly varied and friction-filled field of federalism, where socioeconomic and racial inequalities have historically been frustrated. On the other hand, the current expansionary trend in U.S. health coverage may, indeed, qualify as a significant historical conjuncture. Consider the virulent, seemingly insurmountable opposition to the individual mandate. When Republicans used tax legislation to zero out this mandate, there was, contrary to administration desires, no radical drop-off or collapse in enrollments. In other words, on balance, citizens valued the benefits emanating from a publicly supported program (here, insurance subsidies) more than any principled stand they might take against the ACA. The seemingly bottomless political resentment and ideological fervor, into which Republican political figures had regularly tapped for years, faded.^{29, 30} This has been, ultimately, reflected not only in the stability of the exchanges but also changing opinion polls—whatever people thought of the ACA in its emergent form, they do not wish to lose its real implemented form, which positively affects their lives.^{31, 32} There are, in other words, clear signs of popular entrenchment of the ACA, which could have only grown through the expanding health care rolls evidenced during COVID-19.

The lingering question, then, relates to the connection between the COVID-19's historically contingent effects, popular entrenchment, and the evolving political rules of reproduction. Historical events are certainly significant, but far more significant is the reaction of Republican political figures under the pressure that these events bring about. What are we to make, for instance, of significant Republican political figures’ unwillingness to let the ACA fall in 2017? Were they already altering their behavior, specifically on health care, in the face of policy entrenchment? And what are we to conclude from the party's seeming readiness to put aside attempts to bring down the ACA as a whole, even while they prosecute a series of meaningless, largely symbolic fights in the 118^th Congress? ³³ Could it be the case that, at least in relation to health care access, we are witnessing a significant politico–cultural inflection point, whereby health care on reasonable and manageable terms is being recognized as a settled expectation of U.S. citizens? It does not seem out of the realm of possibility that coverage resulting from the ACA is currently transitioning into a kind of “third rail” politics, typically associated with Social Security.

These may be overly bold and ill-advised historical assertions, particularly in relation to a topic as politically sensitive as health care. But Sanford Schram has suggested that discerning historical change is often difficult in the current context of American public policy, where so many policy objectives continue to be imbricated with the “common sense” of either market operations or market logic. ⁷ We might do well, however, to view historical change through the lens of what he terms “radical incrementalism,” where small changes instigated and cemented over time lay the groundwork for more progressive change down the line. He is careful to warn that it is important to differentiate between alterations that merely bolster the status quo and those that will lead to long-term, beneficial change. Certainly, the ACA, with its endorsement of private insurance forms, has garnered a reputation on the left as the former rather than the latter. But here Schram offers up the possibility that “…over time as it comes to include more of the uninsured in the U.S. health-care system it will lay the groundwork for a transformation to a more equitable and efficient system” (pp. 187–188). ⁷

If recent incrementalism around health coverage during COVID-19 has intensified entrenchment, it has also surely resulted in altered the rules of reproduction on both sides of the partisan divide. It is noteworthy that any Republican proposals are now effectively trapped by the same logic that has, for years, underwritten their own rules of reproduction. Their contestation of the ACA has included a long and steady drumbeat that insists on Democrats wanting to “take away” Americans’ private health plans. This strategy worked well in opposition over the years, forcing the Obama administration, for instance, into defensive claims that Americans “can keep the plans they already have.” An emergent problem for Republicans is that expansion of Medicaid has taken place almost entirely through private plans and managed care, and insurance exchange expansion is obviously based on the same model. States’ strategies around Medicaid have intentionally obscured their governmental foundations and even intentionally blended them deeply into commercialized insurance markets. ³⁴ Any effort by Republicans to constrain or reduce these ACA programs will, quite literally, be “taking away” Americans’ individual (marketized) health plans. Moreover, heavily reduced or zeroed-out premiums will be a powerful political lever for Democratic political actors moving forward. Who, after all, wants to be the Republican political figure who unleashed substantial premium hikes on millions of low- and middle-income Americans? It was both predictable and unsurprising, then, that President Biden could aggressively call to make health insurance subsidies permanent in his 2023 State of the Union address. ³⁵ While continuing obstructionism and performative extremism on a host of other issues (debt ceiling, gun reform, immigration, congressional “investigations,” etc.), changing circumstances and the trap of their own anti-governmental logic have occasioned changes in Republican rules of reproduction specifically on health care.

For their own part, Democrats have long been criticized for their willingness to reinforce status quo inequality, merely tinkering at the edges of a grossly marketized health care system and unwilling to challenge sectoral interests. However, as the ACA has grown in popularity and Republican rules have become more constrictive, Democrats have actively challenged this status quo, albeit intermittently, with public calls for single-payer care, public options, or “Medicare for All.” This may have shifted, however subtly, the rules of reproduction even for centrist Democrats, who now seem willing, en masse, to press for incremental advantage in ways that seemed improbable less than a decade ago.

Democrats are certainly aware that the combined effect of Medicaid and insurance subsidies represents a historically limited opportunity. With the official end of the public health emergency in April 2023, CMS will begin a phased reduction of the 6.25 percent FMAP injection for state Medicaid programs by year's end, inviting a massive, state-by-state “redetermination” process assessing enrollee eligibility. Normally a yearly process, this post-COVID-19 round could witness enrollment losses between 5 and 14 million enrollees. ³⁶ This would be, by far, the largest one-time loss of coverage in U.S. history. Recognizing this, Democrats are focused on staving off its worst effects. The Consolidated Appropriations Act of 2023 enables the Federal Government to create more stable guide paths through this process. This includes the availability of transition FMAP funds through 2023, with an eye to slowing redetermination down. These funds have been made contingent on states following federal requirements, including extensive and categorical data reporting to CMS and, by 2024, that all children under the age of 19 in Medicaid or CHIP receive 12 months of continuous eligibility. This is augmented by the reinforcement of a program to provide FMAP funds for those states guaranteeing 12 months continuous eligibility for postpartum coverage (30 states have so far opted in). In a national landscape where almost half of all births are covered by Medicaid or CHIP, this latter program is no small matter, affecting not only coverage but also a series of critical health outcomes, not the least of which is maternal mortality.

Beyond these more targeted attempts to keep the nation from veering off the “Medicaid cliff,” Democrats are building into legislation ongoing fiscal incentives to bring into the fold more citizens who are caught in the coverage gap. Part of the America Rescue Plan Act 2021 enabled the CMS to offer non-expansion states, should they opt to accept the 90 percent FMAP for Medicaid expansion (moving their criteria to 138% of FPL), an additional 5 percent FMAP for two years, applied to their much larger (and more expensive) traditional Medicaid program. This would not only nullify state costs on Medicaid expansion for two years but will create a revenue windfall, where “new federal funds under the 5 percentage point bump are more than two times larger than new state expansion costs”. ³⁷ Recently, this incentive was too good for majority GOP legislators in North Carolina to resist, initiating Medicaid expansion that will result “in what is essentially a $1.8 billion check to be spent at the North Carolina General Assembly's discretion”. ³⁸ Even in the politically conservative southern regions, this potential fiscal injection makes it increasingly difficult for state administrations to keep turning down Medicaid expansion. At the individual level, the push to close the coverage gap has been furthered in the Inflation Reduction Act of 2022, where a provision extends the previously mentioned insurance exchange subsidy enhancements for an additional three years, through FY2025. This extends highly attractive subsidies that have occasioned surging enrollments, heads off likely premium increases as the public health emergency ends, and creates an alternative for those losing coverage through redetermination. ³⁹ All combined, Democrats have seized on the moment in which Republican recalcitrance on health care is no longer a default position, potentially effecting changed expectations throughout U.S. political culture: that health care will not only be attainable, but it will be affordable.

There must be one proviso to this evaluation: Republicans will not merely cede political ground, particularly at the state level. Space considerations here rule out a more fulsome discussion of state-level health care politics, but undoubtedly much will hinge on the redetermination process through 2023. Some states, for instance, have already demonstrated a poor track record on redetermination, ⁴⁰ and this round will occur potentially in quantities four to five times greater than any previous round. ⁴¹ To the extent that Republican actors—particularly in non-expansion states with highly restrictive Medicaid eligibility—can withstand the political backlash of large-scale disenrollment, the conjunctural progress made in the last three years will face erosion. However, this may not be so straightforward, as it will require “strategies designed to diffuse or occlude responsibility…, such as oversized bipartisan majorities; procedural strategies that limit the degree to which voters can identify cuts with particular politicians; and policy strategies that spread costs in the future or hide their magnitude through other means” (p. 554). ¹⁶ The pure magnitude and targeted nature of redetermination will put it under state- and national-level scrutiny, making a political strategy of “blame avoidance” a particularly difficult endeavor.

Equally as concerning, any change to a Republican administration in Washington will almost certainly re-invite 1115 waiver proposals from states that wish to tighten Medicaid criteria. Work requirements, premiums, and/or health savings schemes included in these waivers either provide the pretext for disenrollment or actively discourage enrollment. Finally, ongoing anti-immigrant rhetoric combines powerfully with a longstanding federal five-year ban on immigrant enrollment in federally funded social programs. The rate of uninsured among non-elderly Hispanic is now the highest in the country, and while this is in no small part centered around cost, it must also be connected to administrative confusion and political fear related to eligibility for federal programs. ⁴² Ultimately, if there is a basis for optimism in closing the health care gap, there is certainly no automatic passage to that scenario. All politics, including those around health care, are about struggle. And particularly at the state level, where the rubber so often meets the road in policy, Republicans appear in no way prepared to cede terrain.

Conclusion

The 2020 and 2022 elections were notable, in part because of what did not happen. Republicans, in the main, dropped their concerted pronouncements on “scrapping Obamacare.” Indeed, then-Minority Leader Kevin McCarthy's 2022 “Commitment to America” plan was purposefully vague on questions of health care, suggesting only that it would “personalize care” and “lower prices through transparency, choice, and competition”. ⁴³ The “task force” ostensibly put in charge of health care concerns has opined that it will focus on “unlocking a new, revolutionary wave of health care price transparency” and “give businesses and employees more flexibility, including through association health plans and Health Savings Accounts, to offer or purchase, respectively, the most affordable health insurance policy that best meets employees’ needs”. ⁴⁴ While there is some hint of reform here, there is no mention of the ACA, Medicare, Medicaid, or insurance exchange plans. This is, no doubt, by design, as it appears to now be built into the Republican rules of reproduction that full-frontal attacks on existing coverage arrangements are no longer de rigueur.

That the ACA ever did anything other than feed and expand fully marketized forms of purchase and provision in health care is, of course, preposterous. Both parties have largely endorsed existing arrangements in the health domain, and the system's structural intractability for the foreseeable future is largely assured. But the altered political rules of reproduction at the national, especially Congressional, level have “flipped the script” on health care, at least in coverage terms. Denunciations of Democrat-led government intervention in health care, advanced successfully by Republican political figures for nearly a decade, were once creative forms of resistance but now constitute a political liability—perceived as “taking away” increasingly attractive personal insurance arrangements. Evolving rules of reproduction explain how the grandeur of Republicans’ opposition to the ACA has been grossly whittled down, summarized by one Republican strategist as now merely seeking “…to alleviate friction points that Americans experience as they interact with the health care system”. ⁴⁵

The significance of this shift in rules should not be underestimated. If coverage losses around the redetermination process can be held to a minimum, we may indeed be witnessing a moment of radical incrementalism, where a critical mass of citizens, holding dear to coverage that is accessible and even affordable, generate the political capital necessary not only to close the coverage gap in non-expansion states but bring in those who willingly “opt out” of coverage. The more who have accessible and more affordable coverage, the more who will be loath to give it up. And the still sizable part of the population that currently opts out of coverage—either perforce or as a “choice”—will have terms before them that make attaining coverage less of a financial sacrifice. Originally seen as an imposition on the individual, the mandated obligation to attain coverage may find new political oxygen. After all, in an actuarial sense, the cumulative effect of millions opting out of risk pools is to raise the premium prices for everybody else. This potential doorway to regulate universal or near-universal coverage would signal a leap from the virulent ACA politics of “individual liberty” to a more settled politics of societal fairness—an incremental outcome, but a radical one, indeed.