Obamacare’s Long Hard Slog — And the Alternatives

by Sheri Rivlin and Allan Rivlin on December 6, 2013

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The problems with the launch of the Affordable Care Act have always been far less severe than Republicans have been saying but quite a lot worse than many Democrats fully realize.  This has never been just about a bad website, and it is not going to be all better as soon as the glitches are fixed.  The truth is, had there been a perfect website and first month roll-out, the uphill campaign to make this law popular would nonetheless still be going on for years – and there are structural reasons for this that could be understood from the polling before the law was passed.   As the nation reached near consensus that there was a problem, there was never any such agreement on the specific solution. 

In speaking about Iraq before the US invasion in 2002 General Colin Powell was famous for quoting the pottery store rule, “you break it, you buy it” but the American health care system was already broken and President Obama and the Democrats bought it anyway — as a fixer-upper.  There was a lot to fix and the Affordable Care Act when fully implemented will mean millions of people who could not get care under the old system will be able to get care now, but (and this is a big “but”) countless frustrations of the old health care system will continue in Obamacare — and at least some if not all Republicans can be counted on to harp on every frustration now that the Democrats own the US health care system.

Under the old system people saw price increases or cancellation letters all the time, but now those are Obamacare cancellations and price increases.  People had disputes with their insurance providers or were denied medicines or procedures they believed they needed — now these can be spun as disputes under Obamacare.  And in the old system people could be denied coverage if they had a pre-existing condition, get charged a higher rate just for being female, or see their coverage disappear or bump into spending caps when people really need it due to illness.  These elements of the old system have changed for the better. 

For most of these issues there were large numbers of people involved — tens of thousands or perhaps millions – but this represented a small proportion of the U.S. population.  Remember, the majority of Americans liked their current health care arrangements before Obama began reforming the system.  And this is why President Obama said so often that people who liked their plans, and their doctor, would be able to keep them.

It was always a political oversimplification, belied by policy complexity, to suggest that with reform everyone wins or at least nobody loses when it is the nature of insurance that there are winners and losers.  We all are paying for something we hope we do not need very much. 

In this sense it is not surprising that health care reform was both undersold and oversold as it was being debated and passed into law and subsequently.  In 2009 and 2010 the focus was less on public approval than it was on securing a majority of votes in the House of Representatives and first 60 senators, and eventually 50 to get the legislation over the finish line.  Since passage there has never been a majority of the public in favor of the reform law, and support has slipped since the rollout.  But it is also true that there has never been a majority supporting repeal, and this too is unlikely to change before the 2014 election. 

All of this suggests a debate over Obamacare that will go on for years, even if voters wish it ended years ago, and the politicians would just work together to create jobs and solve other problems.  The Democrats versus Republicans discussion is basically a stalemate that will benefit neither side, in a long hard slog that we predict the Democrats eventually win, some five to ten years from now as the law becomes established in the mind of the public as a provider of health care security. 

An alternative for Obama and the Democrats would be to more readily admit the problems with the ACA and more generously engage Republicans in efforts to improve the law.  President Obama has made statements inviting Republican ideas on many occasions and returned to the theme in his event on Tuesday when he said, “I’ve always said I will work with anybody to implement and improve this law effectively.  If you’ve got good ideas, bring them to me.  Let’s go.”  But the tone can often sound like taunting Republicans over their lack of substantive ideas, and their inability to specify what the second half of their “repeal and replace” mantra would entail.  This may be deserved but it is also self-defeating. 

Do not be surprised if the tone changes in time for the State of the Union address.  To the degree that Obama can humbly and credibly invite Republicans to really join in a policy discussion to improve rather than scrap the Affordable Care Act he could share both the credit and the blame for health care reform.  Democrats would no longer own every negative experience with the vastly complicated health care system. 

Democrats really have everything to gain from depoliticizing health care, admitting the law is not perfect, and calling on leaders regardless of party to offer ideas that strengthen the law.  The truth is, the law is here to stay and nothing that weakens it has a chance of moving forward.  But rather than talking points and heated rhetoric — it is time, and getting the details right, and a few legislative fixes that are needed for the new health exchanges to be successful and ultimately popular .

The last thing the public wants is more partisan fighting over health care when what they really want is cooperation to get the economy working for ordinary middle class families, and to solve some of the other problems that have been waiting for the health care wars to subside.  So the best strategy for Democrats, and Republicans too, would be to pass a job creating infrastructure bill and comprehensive immigration reform and raising the minimum wage.   

 

 

 

  • Paperback Ruyter

    Great analysis. For the most part the GOP has focused on attacking the ACA while Democrats defend it, although Obama has had to make some alterations and concessions already out of necessity more than by choice. There does seem to be a quiet faction within both parties that is willing to make changes while keeping the overall structure of the plan intact, but the extremes will have to soften their positions first before we make much headway. That doesn’t seem too likely in today’s political environment.

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