Simulating Representation: Elite Mobilization and Political Power in Health Care Reform

The debate and the outcome in the Obama Administration's drive to enact national health care reform illustrate the conditional nature of democratic governance in the United States, a blend of partisan policy maximization and elite mobilization strategies that exploit core public policy preferences. The public's core policy preferences have, for some time, favored expanding access to health insurance, regulating private insurers to ensure reliable coverage, and increasing certain taxes to pay for these programs. Yet the intensely divisive debate over reform generated several notable gaps between proposed policies and public opinion for two reasons.First, Democratic policymakers and their supporters pushed for certain specific means for pursuing these broad policy goals—namely, mandates on individuals to obtain health insurance coverage and the imposition of an excise tax on high-end health insurance plans—that the public opposed. Second, core public support for reform flipped into majority opposition in reaction to carefully crafted messages aimed at frightening Americans and especially by partisan polarization that cued Republican voters into opposition while they unnerved independents. The result suggests a critical change in American democracy, originating in transformations at the elite level and involving, specifically, increased incentives to attempt to move the public in the direction of policy goals favored by elites policies and to rally their partisan base, rather than to respond to public wishes.