Andrea Campbell is a brilliant political scientist at the Massachusetts Institute of Technology. She is also the author of a wonderful book: How Policies Make Citizens. That work focuses on how the design of certain policies–she gives the case for Social Security and Medicare–make organized interests out of otherwise ordinary citizens. In essence, the elderly were once the least politically active group in America. Then, once the government started providing them sizable benefits, they suddenly became the most politically active group in America, because they wanted to make sure the benefits kept coming their way. This might explain how the wealthy manage to keep getting favorable tax breaks that make them ever wealthier.
Of course, not all policies make citizens, even if they provide people with benefits. For example, welfare recipients get government benefits, but this doesn’t make them more politically active. In fact, the stigma of welfare may actually demoralize them, making them less politically active than they would otherwise be.
In a recent article in the Journal of Health Politics, Policy and Law, Campbell revisits this issue of citizen-making policies through what she calls “policy feedbacks.” In the article she asserts that “the design of public policies influences the attitudes and political behaviors of both target populations and other members of the public.” A few things are at issue: 1. The size of benefits. 2. How programs are administered. 3. How benefits are earned (or not).
In general, a program that provides sizable benefits, is administered in a consumer-oriented manner, and where the benefits are perceived as being earned or deserved is likely to create passionate citizens. Such is the case with Medicare, for example. On the other hand, a program with small benefits, administered in ways that generate stigma, and where the benefits are widely perceived as a hand-out to the undeserving are unlikely to create passionate citizens. Such is the case with welfare. Not surprisingly, politicians are more sensitive to the interests of passionate citizens, since they actually vote and make campaign contributions.
The visibility of government benefits is also important. The government provides most of us with benefits, but it does so in the form of tax deductions and tax credits, which don’t feel the same as the government sending us a check every month. That level of invisibility leads us to the incorrect belief that we pay taxes and get nothing in return. For example, people are aware that they have Medicare coverage, but they don’t think of it as a government program, which is why seniors protested ObamaCare with signs instructing the government to “keep its hands off my Medicare!”
Campbell concludes that faced with ObamaCare “Seniors…thought they were being robbed of benefits they had already paid for. It is difficult to reform a health care system in which those with national health insurance believe they have earned it and resent its extension to those they believe have not earned it, particularly when they believe that those new benefits will be carved out of their own.” Therein lies the challenge: With each new policy, the ability of the government to introduce subsequent policies may be limited in important ways. It is important to think through these unintended consequences before it’s too late.
Brad Wright, PhD
Shirie Leng, MD
Nicole F. Roberts
Wright on Health 