Barack Obama by Donkeyhotey.
Barack Obama by Donkeyhotey.

Robert A. Dahl died in February at the age of 98. For forty years he had been a professor of political science at Yale University and was often called the dean of American political science. An early — and seminal — work by Professor Dahl was Who Governs? written in 1961. In it, Dahl looked out from the ivy-covered towers of Yale at the City of New Haven. Who really runs this place? he wondered. How do they make decisions? How do we really govern a democratic society?

Dahl’s answer was “pluralism.” Real choices evolve from diverse forums, overlapping participants and multiple processes. But there is no single power structure, no narrowly defined path to the future.

The immediate debate among the political cognoscenti was with C. Wright Mills, whose 1956 book, The Power Elite, argued that a narrow group of movers and shakers, often with control over the economy, drives our political choices. Scholars after Dahl challenged the structured views of both men. In the decades that followed, political science moved on to quantitative analysis of human behavior, and the inclusion of economics and sociology. This network of different, but interconnected avenues of scholarship have since formed a virtual “string theory” defining the basic building blocks of politics and government.

The news of Dahl’s passing was personal for me. Dahl and his colleagues framed the political-science debate of my years in graduate school. The depth of Who Governs?, his subsequent work, and the blizzard of ideas, formulations, and theoretical frameworks from his colleagues, helped me understand that the demands of scholarly debate weren’t likely to be at the core of my future career either in the academy or in elected office. At best I would be a “political” scholar, or as it turned out, a scholarly politician, serving for 19 years in the New York State Assembly.

“Pluralism,” however, is what this series of essays has been describing all along. We are always in the immediate time of swirling debates and events, as the continuing saga of America’s evolving relationship with the Affordable Care Act plays out. That relationship evolved yet again in early March 2014, when the Conservative Political Action Conference (C-PAC) brought activists to its annual revival meeting in Washington, D.C. William F. Buckley, Jr., founder of The National Review and the American Conservative Union, the organizational sponsor of the event, would no doubt have marveled at the energy of the participants while, perhaps, raising the skeptical Buckley eyebrow at some of the content.

True to form, C-PAC this year was where conservatives gathered to bash ObamaCare. Demonstrating her enormous maturing as a professional entertainer (Take that, Tina Fey!), Sarah Palin took inspiration from Sen. Ted Cruz’s reading last fall on the Senate floor of Dr. Seuss’ Green Eggs and Ham during the lead-up to his self-destructing shutdown of the federal government.

In the Palin version it was voiced, “I do not like this Uncle Sam, I do not like his health care scam.”  This crowd loved this stuff. Almost every speaker, even Sen. Mitch McConnell’s cartoonish-rifle-aloft visual impersonation of Charlton Heston, included the obligatory ACA repeal lines.  But the real story of C-PAC 2014, is that time passes. There were other fights among the speakers. Where should conservatives go, or not go, on immigration reform? How should the movement approach the gender gap that kept them from the White House in 2012? Senator Cruz even took the opportunity to attack past party stalwarts McCain, Romney, and greatest-generation hero Bob Dole, for their lack of ideological purity. Sen. Marco Rubio sought the mantle of aggressive foreign policy leadership, while his rival, Sen. Rand Paul, advanced his libertarian conservatism but with  marked caution in defining the United States’ role abroad.

Even though opposition to ObamaCare remains the opening line in the mantra of orthodoxy among conservative activists, the battle over true belief has evolved to other issues.  We are no longer in the fall of 2010.

Yet, heading to the fall of 2014, events on the ground can’t be ignored in defining the Republican message. In the first vacant-seat election of the 2014 cycle, Republican David Jolly, a former lobbyist, was elected to the House of Representatives in a Florida Gulf Coast district. Jolly fills a seat held for forty years by Republican C.W. Bill Young, but which also gave President Obama majorities in the 2008 and 2012 election cycles. It is one of the few remaining true swing districts. While all special local elections are influenced by unique circumstances, with modest turnout often a powerful variable, media analysis framed its interpretation around Jolly’s unrelenting attack on the ACA against Democratic candidate Alex Sink’s support. The headline message said that a good Democratic candidate was defeated by a well-financed anti-ObamaCare attack. Political evolution is occurring, but the ACA is still red meat for Republicans in 2014.

Meanwhile back at the ranch, at the White House literally, President Obama took his sign-up-for-health-care message to the online comedy show “Between Two Ferns” hosted by Zach Galifianakis. Description can’t do justice to the six-minute segment between the leader of the free world and the deadpan comedian, but within the banter, (What does it feel like to be the last black president?) Obama delivered his message to younger viewers. Go enroll in health coverage. You can do it online or over the phone. You can even go to an office to do it. Galifianakis played along by showing the President a weeks-old spider bite on his arm. You should get that looked at, says Obama! All of us may need medical attention, so sign up for health care.

By 6PM, the Between Two Ferns host website,, was the leading driver of traffic to and conservative pundits and politicians were ladling scorn on the President for “demeaning the office.” Clearly, his use of new media was working.

(Click here to buy a the latest issue of La Cuadra Magazine for your eBook reader, iPad, or other hand-held device.)

Across the country the ACA offers its own version of March Madness as the initial open enrollment period draws to a close at the end of the month. State by state, outreach teams use grassroots efforts to enroll those eligible for subsidized coverage or referral to the benefits of the Medicaid program. Built on the community-organizing lessons of the successful Obama campaigns, special attention is being paid to young adults, African-Americans and Latinos, a special target in states like California, Arizona and Florida. Media messaging, events with celebrities and administration officials, and the army of assisters employed by the federal and state insurance exchanges all combine to reinforce the President’s “sign up for health care” message.

By the end of February, enrollment had topped four million for private health insurance, millions more for Medicaid. While a projected end-of-March enrollment in the five million range will fall short of the original seven million that the Congressional Budget Office saw as a benchmark number, the administration will point to three consecutive months of one million new enrollments after the December surge of 1.8 million. Five million enrollees will have joined a program whose implementation was dead in the water on October 1, because of the technical failures of Added to these totals are some five to seven million young adults who remain on their parents’ family insurance policies as a result of an early ACA provision.

In addition, state-by-state efforts continue to advance the federally funded Medicaid eligibility expansion, mandated by the ACA but converted to state-by-state adoption by the Supreme Court. At last report, twenty-six jurisdictions, including the District of Columbia, had complied, twenty-five had not.

In early March, an important battle played out in the Arkansas legislature. Arkansas, with a Democratic governor, but Republican majorities in both its House and Senate, had negotiated an innovative Medicaid expansion with federal officials. Under its Health Improvement Plan, Arkansas could use Medicaid expansion dollars to allow beneficiaries to purchase coverage through a structured marketplace, a shift toward the right for those who see Medicaid as a governmental entitlement, but a nod toward practical compromise in the states resisting expansion. After initial agreement, the Arkansas legislature ran up against its own self-imposed requirement of 75 percent legislative approval for appropriations, the most demanding procedural standard among the states. Would an expansion from 2013 revert into the opposition column in 2014? After ten days of tense House votes, the super majority was achieved by the give and take of practical politics. Plurality prevailed over ideology. Arkansas stayed in the expansion column.

Active expansion politics continue under debate in Indiana, Missouri, New Hampshire, Pennsylvania, Utah and Virginia.  With Indiana most committed to maintaining its limited pre-existing program and Pennsylvania, at this writing, advancing the proposal that a work or work-seeking requirement be applied to Medicaid applicants, agreements between the states and Washington are far from assured. Nevertheless, state by state the argument that federal Medicaid support is good for our health system, good for our economy, and most powerfully brings our federal tax dollars back home, pushed forward against conservative ideological resistance.

By the end of the ACA’s march madness, it seems likely that the combination of young adults retaining family coverage, new market-place enrollees, and those in the Medicaid-expansion category will exceed fifteen million people, with some estimates as high as seventeen million. The political message to repeal the ACA may influence an electoral outcome, but there is now a “coverage on the ground” reality for any future Congress.

(Click here to buy a the latest issue of La Cuadra Magazine for your eBook reader, iPad, or other hand-held device.)

If we accept that “pluralism” is the vehicle for real decisions, there are multiple dimensions to the current status of the ACA.  Republicans still cluster around their ideology of opposition.  The repeal message rings true to the conservative faithful and will, no doubt, make red districts and red states an even darker crimson in the fall of 2014. The Obama Administration is driven not by ideology, but by demographics. Outreach to African-Americans, to Latinos, and especially to younger voters continues the power of the Obama style, and more importantly appeals to voters who will find real benefit from the law.

At another level of analysis, we may be experiencing a political age in which Republican conservatives find success in off-year-elections where an older, whiter electorate turns out to vote, but that Democrats, empowered by the gains of the ACA, prosper in the broader and larger turnout of the presidential cycles. What Republican strategists feared most from the ACA was that Obama’s health-care expansion would contribute to a longer term realignment of the Democratic Party with the nation’s future diversity. Their fears may turn out to be well founded.

Beyond the political debate and initial enrollment activities, where possible, administration officials have sought to delay potential ACA controversies in the business community. The requirement that larger employers be penalized for not providing coverage, delayed initially from 2014 to 2015, has again been extended to 2016. Additionally, citing the initial enrollment chaos of the federal exchange, the Administration has extended permission for policies to be renewed that were initially disallowed under new minimum benefit rules. While reluctant to engage in an immediate debate around the definition of full-time employment, clarifications have also been issued to units of government to avoid penalties against school-based or emergency-service workers who typically work limited hours. Don’t pick new fights, is a clear implementation message from the White House.

(Click here to buy a the latest issue of La Cuadra Magazine for your eBook reader, iPad, or other hand-held device.)

Perhaps the most major “policy” development in the first months of 2014 has come from three Republican senators who, without fanfare, introduced legislation which could qualify as the long-awaited alternative to the ACA, should a future Congress begin the historically typical process of amending and adjusting  a piece of major social legislation. In late January, on the day before the President’s State of the Union Address, Richard M. Burr (R-NC), Tom Coburn (R-OK) and Orrin Hatch (R-UT) introduced what could be considered a substantive Republican alternative to the ACA. True to the rhetoric of their party, the bill repeals virtually all of ObamaCare, save the changes to Medicare such as the elimination of the doughnut hole in Medicare-Part-D. We are not changing the Medicare provisions, said the Senators, understanding that Democrats were ready to pounce.

Beyond the “repeal” and Medicare provision, however, the bill goes well beyond earlier minimalist Republican alternatives. It finances insurance expansion by proposing a tax credit to allow lower income people to purchase coverage. Included in the detail is a provision by which individuals could be automatically enrolled in the coverage, subject to a personal decision to opt out of enrollment. With this approach, the sponsors argue for the potential of their plan to achieve broad insurance pools without “mandating” individual purchase of insurance. They address the pre-existing-condition challenge by a one-time open-enrollment period, precluding higher rates, as long as the person then stays insured through employers or the individual market. This system would encourage personal responsibility and limit the need for more governmental regulation, say the sponsors. The bill continues the young adult inclusion in family policies, albeit with a state opt out. It would continue to support state-based high-risk pools. Medicaid would be allowed to continue by allocating funds to states on a formula basis determined by a per-capita allocation, arguing that flexibility on program design and administration, including the option of purchasing private coverage as in Arkansas, would support greater efficiency.

The bill contains one piece of poison to Republican rhetoric. To pay for its provisions, the bill proposes that the tax exclusion for employer-provided health benefits be capped at 65 percent of an average plan. In the end, employees would pay higher taxes for an existing benefit. This would be responsible cost sharing to the sponsors, but it is also an easy line of attack for opponents. Overall, it’s a responsible balance say the Senators.

One independent observer remarked that “It checks all the boxes of ObamaCare.” It may do less than the ACA, provision by provision, but it enters the next generation of health policy debate with alternatives which go far beyond the simple politics of repeal. The real message of the bill may be that it’s time to move on. The reality of early 2014 may be that when Barack Obama leaves the White House on January 20, 2017, the process of amending and improving his signature achievement will already have begun.

Professor Dahl would be pleased.

Jim Tallon is the President of the United Hospital Fund, a health policy think tank in New York City. He served previously as Majority Leader of the New York State Assembly. Political cartoon by DonkeyHotey.

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