Has Medicaid expansion in states improved health outcomes?

In April 2013, four months after the Sandy Hook Elementary shooting killed twenty children, the US Senate voted on the Manchin-Toomey Act to expand background checks and to include gun-show and internet sales of firearms. Roughly nine in ten Americans, including a majority of gun owners, supported the bill—a figure that has held steady across more than a decade of polling. It fell short of the 60-vote threshold by six votes. This was not an outlier. On complex issues, representatives often fail to translate public consensus into reality. Research shows that legislators consistently vote in line with donor and interest group preferences over constituent opinion. Before the vote, the National Rifle Association (NRA) warned every senator it would “rate” their vote on its annual rating system, and a low NRA rating could cost senators their next primary. Consequently, the bill died 54-46, and the majority of Americans watched, powerless, as their consensus was overridden by self-interested representatives.

Liberal democracies need a method to bypass electoral incentives that run counter to public opinion. One already exists: Ireland faced the same stalemate on complex issues before it instituted a process called sortition. The beauty of sortition lies in its removal of the primary pressure that misaligns representatives’ interests from public interest: reelection. Much like jury duty, citizens are randomly drawn from the population. An independent body then stratifies the pool, so the final group mirrors the country by age, gender, geography, and income. The group meets over weeks or months, hearing from experts and the public, as well as debating frequently. At the end, it issues a recommendation that parliament may then put to a referendum or pass into law.