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Supporters of the Affordable Care Act (ACA) are in a tough position. Now that Donald Trump has become president, the threat of a Senate filibuster will be the only thing keeping Republicans from being able to do whatever they want—or at least whatever they can agree to amongst themselves—from repealing Obamacare to privatizing Medicare and blocking granting Medicaid. Republicans can actually make significant health policy changes without having to worry about the filibuster, such as by using regulation to alter climate change policy at the Environmental Protection Agency or the Congressional reconciliation process to repeal the major coverage provisions, like the individual mandate, exchanges, and Medicaid expansion. I suspect Congress will punt on some of the toughest ACA questions, passing major decisions on to the states. Once again, states would then become a primary battleground in the fight over health reform.
Supporters of the ACA should look to an uncomfortable place for ideas on how to respond: the Tea Party. In fact, the January 21 Women’s March in Washington, DC, and in cities around the world is a great parallel for how the Tea Party was launched. The first rallies were in February 2009, shortly after a new president took office, and large numbers of people were worried about the economy and about being marginalized by the new administration. In the wake of this month’s marches, many people are asking what they do now that they are home.
Look to the Tea Party.
The Tea Party was amazingly effective at influencing policy outcomes in states around the country, in many cases beating an unprecedented coalition of the historically most powerful interest groups in health, such as insurers, hospitals, doctors, small businesses, and consumer advocates. I have interviewed more than 200 policymakers about these fights, including many Tea Party activists. I have learned at least seven lessons from this research that supporters of the ACA should consider as they try to save the act.
Tea Party activists (as opposed to politicians who co-opted the movement) were almost always regular citizens with virtually no experience in government. They were not even political junkies who paid disproportionately close attention to policymaking. They were grandmas and grandpas who were deeply concerned with the direction they saw their country heading. They were not polished, but if anything, this enhanced the sincerity of their message. They did not wait for invitations to get involved or formally join an organization. They self-mobilized. If you really disagree with Paul Ryan or worry about what Donald Trump will do, then you need to get involved.
Where should you begin? By personally connecting with your elected officials. Politicians care deeply about reelection and so generally make themselves accessible to constituents. Tea Partiers did not just write letters and disagree on social media, they called and made staff members listen to them. They showed up at district coffee hours and vented to their representatives. They dropped by their legislators’ office. They went to town hall meetings and spoke up. This Vox article does a great job of summarizing tips from a former Congressional staffer on the best ways to get your representative’s attention.
I did not always agree with Tea Party activists I interviewed, but I was almost always impressed by their commitment. I regularly came away feeling that our political discourse and policy outcomes would be very different if more Americans across the political spectrum showed the same level of interest and dedication. One of the most important ways to fight for the rights of vulnerable populations is to make sure politicians see the people behind the arguments. Immigrants, LGBT youth, and recently insured Americans need to put their stories out there and personally introduce themselves to their leaders. The daily reality of work and family obligations means it will be harder to get involved than it is for retirees, but these voices need to be heard.
Go to marches. Attend town hall meetings held by your member of Congress. Call or email your state leaders. Speak up on social media. Engage with local government. Run for office. Last week, I collected enough signatures to get on the ballot for a position in my town. I realize that participating in the governing of a small town in the liberal state of Massachusetts won’t change national policy, but it is my way of stepping up and getting involved and it will add up if enough people do the same.
The Tea Party first gained prominence through its large rallies around tax day in 2009, but activists had the most influence by inserting themselves in the minutiae of the policymaking process. For example, one leader in Michigan wrote on her blog that “Attendance at a Committee Meeting is more effective than large rallies” (the emphasis is in the original). In my forthcoming book Exchange Politics: Opposing Obamacare in Battleground States, I chart the spike in the number of Tea Partiers that attended committee hearings about an exchange in the subsequent months and the effect this had on the outcome. Many of them testified against an exchange, but even the mere presence of groups as small as 10 people has the ability to dramatically change the dynamic. Legislators are chronically worried that a spike in attention is just the tip of the iceberg signaling that many more will mobilize if they vote the wrong way.
Regular people wanting to affect policy outcomes should make a point of understanding how Congress and their state legislatures work. Figure out how to follow the process and show up at key moments.
There is no such a thing as “the” Tea Party. It is actually a decentralized collection of local movements. This is an advantage in many ways, but creates a power vacuum. National and state-level organizations played an important role as the de facto leaders in many states. Sometimes these were conservative think tanks and sometimes they were dark money groups funded by the Koch brothers, Charles and David, wealthy contributors to conservative and libertarian causes and campaigns. They did not have power in a hierarchical sense, but they were instrumental in educating regular citizens on the policymaking process and explaining policy debates in simple terms. They alerted people through social media and blogs about key hearings or legislative votes. If a grassroots movement defending the ACA and blocking Trump is to succeed, these types of organizations will need to step up.
The Tea Party movement is driven by fairly simple ideology. I was often jealous of an interviewee’s ability to boil any complex argument to two words: freedom and liberty. Did the policy in question enhance or jeopardize freedom? They were not interested in talking about the risks of adverse selection; an insurance mandate is bad because it restricts liberty. Just about anything that increases the role of government should be resisted because it infringes on freedoms.
We have to appreciate that better evidence is not enough to win policy arguments; we have to tap into and frame these ideas in terms of core American values. There is no reason that supporters of the ACA and those who disagree with Donald Trump can’t take back ownership of words like freedom and liberty. Policies that would limit immigrant rights or restrict access to health care should be framed in these terms. People are not free if life, liberty, and the pursuit of happiness are not options.
Priority number one should be changing how congressional districts are drawn. As I wrote right before the election, the shape of our maps dramatically affects everything about our politics. Balancing our districts won’t guarantee that Democrats will win a majority, or even more seats—but that is not the point. The goal is to move our arguments to the center, where the incentive is to compromise and solve problems rather than stay on the extremes, where the incentive is to fight and resist compromise.
There are a number of risks to encouraging grassroots activism of this sort on the left. For one, I am a firm believer that population health goals transcend partisan politics. Public health needs a stronger stomach for politics and should focus more on building more bridges than getting in the mud. The Tea Party stoked an unhealthy us vs. them mentality that culminated with the ugly 2016 election cycle. What I am imagining would have the opposite effect, hopefully. We should reject political discourse that is personal and mean. I am intrigued by Van Jones’ call for a #LoveArmy to reach out with “respect to the Trump voters who don’t subscribe to everything he has ever said.” As Jones puts it, “The problem is not the abundance of people with bad intentions; it’s the superabundance of people with good intentions who don’t know what to do yet.”
If you are one of these people, I suggest you get involved, personally meet your elected officials, learn the policy process, and advocate for redistricting reform.
David K. Jones is a School of Public Health assistant professor of health law, policy, and management. He is editor-in-chief of Public Health Post. An earlier version of this POV ran on Public Health Post on December 13, 2016.
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