THE STUMP MARCH 29, 2012
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Reid Cherlin, a former Obama White House spokesman whose portfolio included health care, had an interesting post up at GQ.com yesterday about why the Affordable Care Act is so damn hard to sell. The gist:
It would have been easy for Verrilli—or any of us—to explain single-payer health care. "Look," we could have said, "the government is paying for everyone to have coverage." End of story. But single-payer is not what our brilliant, world-leading political system gave us. What it gave us is essentially a halfsy—an extraordinarily confusing patchwork in which some novel legislative mechanisms are used to induce individuals, businesses, insurance companies, and states into doing things that add up to concrete good.
That was certainly part of the problem. But another part was that the law tries to do two big things at once: improve health insurance coverage for people who already have it, and bring coverage to people who don’t. Those two goals pull you in pretty different directions politically. Improving coverage implies a set of regulations (like ending rescissions and discrimination based on pre-existing conditions*) that are pretty popular. Expanding coverage implies spending a lot of money to pay for millions of new insurance customers.
Now, as a behind-the-scenes tactical matter, the bill’s two major objectives fit together pretty nicely. After all, the insurers' opposition to the new regulations would have been a lot more intense if they weren’t promised all those new customers. Likewise, the economics of health care also dictates taking on both projects at once: It’s hard to outlaw discrimination based on pre-existing conditions unless everyone has to have insurance, since otherwise people will wait till they’re sick before buying it, which would put insurance companies out of business.
But when it came to winning over public opinion, a lot of the people who have insurance were never convinced we had to spend a trillion dollars giving it to people who don’t.
Which brings me to the point of this post:
In principle, the way to deal with this problem would be to base the case for reform entirely on how it benefits the insured, while ignoring the ways it benefits the uninsured. To make people’s insurance more complete and secure, you’re introducing the aforementioned regulations. And to make it cheaper, you’re making the uninsured get coverage, so they won’t go to the emergency room when they get sick and drive up premiums for the rest of us.
Now, in practice, it was never that easy. As much as the administration tried to frame things this way, the conversation always seemed to drift back to covering the uninsured. The media and reform opponents just wouldn’t let that go. And liberals cared deeply about expanding coverage in its own right.
But the one place the administration could have imposed this narrative, I think, was the individual mandate. The administration could have framed the mandate as a measure that benefits people who have insurance, not one that persecutes those who don’t. The argument would be that the mandate is necessary because otherwise deadbeats won’t get covered and will drive up your insurance premiums, not because the president believes everyone should have insurance whether they want it or not. In effect, this would have cast the mandate as a conservative measure rather than a liberal one (which of course is how it was originally conceived, and how Mitt Romney once talked about it), and seems likely to have defused the Tea Party opposition that dogged it all the way to the Supreme Court. But except for a few feints in this direction, the administration never really invested in that argument. In retrospect, it was a costly mistake.
Follow me on twitter: @noamscheiber
*I realize that ending discrimination based on pre-existing conditions helps both people who currently have insurance (since they’ll no longer be denied coverage for a condition that predated their insurance, or charged more for that coverage) and people who don’t have it but want it (since it suddenly becomes possible or affordable to get insurance whereas it might not have beforehand).
16 comments
The bootstrap limiting principle: justify the mandate for individuals to purchase insurance with the mandate for insurers to cover pre-existing conditions. A rose by any other name. My solution: mandate coverage for pre-existing conditions and let the insurers figure it out how to avoid insurance fail; after all, there is no motivation greater than fear, in this case fear of survival for insurers. What's unstated is that that the primary motivation for "reform" wasn't dealing with pre-exising conditions, but providing another public benefit, insurance for the poor and nearly poor; the mandate was merely a means to an end: you can't mandate people to buy insurance if they can't afford it.
- rayward
March 29, 2012 at 6:30pm
First of all, I seem to recall that they made the argument, but that it was shouted down by the simpler message, "fear mandate." Second of all, I'm not sure it's a "costly mistake." Framing it this way would not have changed anything as far as the Supreme Court is concerned. And no amount of rational argument would have dissuaded the Tea Party types from challenging Obamacare in court. As for popular opinion going forward, Obama remains free to make this argument in his re-election bid or otherwise. If there was a costly mistake, it may end up being the mandate itself, or, at least, the way it was described and implemented. This is stupid. The constitutionality of the ACA shouldn't turn on the sales pitch or pure technicalities that make zero difference to anyone. But, given that some courts and justices are giving such stupid arguments great deference, perhaps they should have had the Act phase in a universal health care tax against which credits would be offered if you bought coverage, and which would be engineered to have precisely the same effect as the tax penalty actually provided. Don't call it "a mandate." Call it a credit or tax break or incentive or nudge. That's all it is anyway. Perhaps then Kennedy would not have seen it as a fundamntal shift in the relationship between the federal government and the individual citizen.
- JakeH
March 29, 2012 at 6:45pm
What choice do you have, other than Federal intervention, when a powerful industry pretty much controls the lives of individual Americans? Except of course for those with government insurance policies, like, the Supreme Court justices. The rest of us are up for grabs.
- Sophia
March 29, 2012 at 6:58pm
jakeh nails it with this: perhaps they should have had the Act phase in a universal health care tax against which credits would be offered if you bought coverage, and which would be engineered to have precisely the same effect as the tax penalty actually provided. This is precisely what I argued for over 2 years ago but people like Cohn, etc. ignored the dangers of the mandate. Their hubris might lead to ruin. And for those who say that maybe Nelson or Lieberman would not have accepted a tax, well I can not believe if Obama's Presidency had been on the line they would have been so willing to buck it. As it is it seems there is a great chance that the whole bill would be tossed out, and worse the existence of Medicaid funding itself will then be called into account if the Medicaid expansion is thrown out as well. As far as I am concerned it would have been better to have only small reforms, like expanding Chip then have the Roberts court begin to unravel our society.
- blackton
March 29, 2012 at 7:43pm
I can see how an older person benefits from the mandate, but how does the younger person benefit while they are young? I think the case is top to bottom politics as usual. People voted, Congress passed it, and all of a sudden it's this terrible thing. Compare. We went into Iraq for stupid reasons and the invasion was poorly executed. Nobody ever apologized or got fired and it was very expensive. There was no outrage like there was about health care reform because we had to respect the troops. But it's okay to care little about the people who would benefit from the ACA
- Nusholtz
March 29, 2012 at 8:17pm
"How Obama Could Have Avoided His Mandate Quagmire" Huh? You mean this Supreme Court quagmire? As my fellow posters have already asked, how would modifying the political sales pitch have influenced either the likelihood that Obama-hating Republican state attorneys general would file suit against the ACA or that Obama-hating Republican Supreme Court justices would vote to overturn it? At most you could hypothesize that a different emphasis could have shifted public support slightly in the ACA's favor, but I find the idea that tweaking the rhetoric could have increased popular support to the point that Tea Bagging AsG would have demurred to sue to be implausible in the extreme.
- AaronW
March 29, 2012 at 8:20pm
The likelihood of it getting overturned would be much smaller if ACA were actually popular. The administration was concentrated on the mechanics of getting it through Congress, and the hope that if it were "bipartisan" then the public would sign on. When the GOP dropped the pretense of playing along, that strategy of winning public approval failed and the administration had no Plan B. The result was the toxic town hall meetings in the summer of 2009, and poor poll numbers for ACA, which continue to this day and give the swing votes in the Supremes the political cover they need to strike it down (if they really want to.) Whether the ACA is too complicated to explain (the matter of the previous MacGillis post) or not isn't really the point, as not much effort was made by democrats to whip up support for it among the general populace, and the demonizations and misperceptions went unquestioned in the daily news cycle for way too long. This was made worse by the public squabbling of the conservative democrats about what they would or would not support in the final bill, discussions which should have taken place behind closed doors. The Supremes would have a tougher time overturning a law which at least had the approval of a large majority of the people it is meant to help.
- stanalama
March 29, 2012 at 8:34pm
I tend to agree with stanalama in the sense that it wasn't the White House so much as the utterly mealy-mouthed dancing around the project by conservative Democrats that made this difficult. There was no sense on the D congressional side that this was a major achievement that one could legitimately go to market with in the knowledge that it benefited more people as well as introducing some efficiency into the system that would lead to better financial management and thus survival of the system. They let the "government hands off my medicare" slogan grow legs instead of confronting it. They seemed to embody a kind of politics that said "I was elected because people didn't really think of me as a Democrat -- if I support this, they'll know!"
- ironyroad
March 29, 2012 at 8:47pm
"The Supremes would have a tougher time overturning a law which at least had the approval of a large majority of the people it is meant to help." Very good point, Stamalana. Obama could have sold the ACA much better by concentrating on a few key benefitss and in a coordinated, persistent way hammering home the message himself and through surrogates. Insurance companies can no longer pin pre-existing conditions on people. More young kids will survive. The non-insured won't get to rip-off the insured for free coverage. Perhaps putting these and a few other points better than I can, but keeping it simple and highlighting human interest stories to put faces to these facts. Instead, no one understands it, so the Republicans could undermine it through posturing and slogans.
- Thunderroad
March 29, 2012 at 8:48pm
A few other problems/observations: people are deeply afraid of anything "socialist," except Medicare of course, which somehow isn't "socialist." Regardless, single payer OR Obamacare = "socialism" and you'd have a fight on your hands selling it. We've been brainwashed on this issue for decades. So either way you get "socialized medicine," which means two things: Loss Of Freedom and Giving My Money To Those Other People, both of which are toxic especially in today's pseudo-libertarian, TP atmosphere that's also biased against the non-rich. Maybe of greater importance is the fact that the insurance insurance is mega-powerful. Otherwise why didn't Obama go straight for single-payer? It makes more sense. It would have avoided altogether the constitutional issues and it would have been easy to point out, hey, Medicare works, right? Even if it is "socialist." And even if the insurance companies do have REAL death panels, it is how they make a profit.
- Sophia
March 29, 2012 at 9:58pm
But, single-payer would have been a non-starter. It puts the uppercase S in socialism as far as conservatives go.
- Tgossard
March 29, 2012 at 11:59pm
Frankly, I don't believe any of this. The simpler Obama might have made the bill would only have painted bullseyes for the radical right and insurance industry to aim at. In the end the same old argument, "America has the best healthcare system in the world, so why should we tinker with it in any way." For the greater part Americans can be made to believe this despite all the evidence against it. Perhaps a few marginal concessions might have been won, but what would be the point of that?
- Tgossard
March 30, 2012 at 12:07am
I agree with Stan, Irony, and Thunderroad. The administration has been deeply incompetent or uninterested in persistently making clear the benefit of this and other policies. It's ridiculous, and it's political malpractice, and it may well result in the ACA being struck down. Conservative congressional Dems were also deeply counterproductive (as well as cowardly and selfish regarding their own careers, not that it appears to have worked out well for them, what with Nelson, Bayh, etc forced into retirement anyway) in the way they publicly hectored against and negotiated with the bill.
- Curran1
March 30, 2012 at 1:09am
I find the argument that somehow the Tea Party would not have been very vociferous in their opposition to the ACA ridiculous. Largely, the Tea Party is the creation of extreme right wing groups that have been re-packaged as 'Tea Party' grass roots groups. I don't see anyway they would have been appeased if more arguments had been made regarding how it helps the currently insured. Also, regarding the popularity of the current law, this is the conundrum of all health care reform efforts - the 75% of people who are insured are concerned about the potential impact to their insurance from trying to cover the remaining 25%. While the 75% generally feel supportive of getting the uninsured covered, this support weakens when specific proposals come to fruition andare seen as threats to the cost or coverage or availability of current insurance schemes.
- RobertW
March 30, 2012 at 10:34am
If only LBJ had handled the sales job on the Civil Rights Act better, the South would still be Democratic, Rush Limbaugh and other assorted racists and gasbags wouldn't exist, Jesse Helms would have succeeded Thurgood Marshall on the Supreme Court and been the most liberal Justice of the modern era, and we'd be talking about how Trayvon Martin chased down a suspicious-looking white guy roaming around a gated community and asked him to leave, only to find to his embarrassment that the white guy lived in the community too. Of course, in this racism-free utopia (curse you, LBJ and MLK!) Martin wouldn't have had a gun because people wouldn't go around armed and dangerous because of irrational fear of the other, and the "community" wouldn't have been gated, so both Martin and white guy would still be alive, probably having a beer and laughing about the misunderstanding. And Lincoln somehow merits Rushmore, despite all the unfinished business he left behind. Strange.
- GeoffG
March 30, 2012 at 10:56am
Of course, Geoff--this is the best of all possible worlds; how silly of me to forget. It's clearly impossible that alternate choices could have made things come out substantively better on this issue. What naifs are those who suggest it.
- Curran1
March 30, 2012 at 3:43pm