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.
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*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).