People Like Health Reform When They Learn What It Does

My family visited West Virginia this Thanksgiving.

While there, I spoke to some community audiences about the Affordable Care Act, building on the book Lawrence Jacobs and I recently published, Health Care Reform and American Politics: What Everyone Needs to Know.

While I enjoy talking to non-academic audiences, I was nervous. Health reform has been pilloried, nonstop, as a “government takeover” that would harm the economy and destroy individual freedom for patients and doctors. Would audiences be unfriendly? Would the Medicare recipients at an old folks’ home believe in “death panels” and denounce reform? Would the crowd at the Charleston library include Tea Partiers convinced the law is socialist?

None of these fears came to pass. People were polite, engaged, and asked a lot of questions. I came to know an earlier hunch with more certainty: Americans are anxious about health reform. They know the law matters, but Affordable Care seems huge, complex, and mysterious. When people learn more about the specifics, they feel better, becoming more interested in how to carry through the law’s implementation effectively.

How can a nation spend more than a year debating, and yet have people essentially knowing less about a major piece of legislation than ever before? We should ask which features of our media and national politics produce this outcome. Intensely partisan efforts to caricature reforms that threaten windfall profits explain a lot, but the law’s supporters bear responsibility, too. They have been timid and tongue-tied.

So, in my talk, I outlined the “guts” of Affordable Care. They’re three big, very popular things:

1. expansions of public programs (Medicaid and Medicare) and public subsidies (credits) to enable those who haven’t been able to afford health insurance to get it in the future;
2. the creation of state-level “exchanges” or markets where people can shop for health plans, finding out what they cost and provide;
3. and the establishment of rules preventing private insurance companies from denying, limiting, or rescinding coverage to people with illnesses or problematic health conditions.

These are the biggies—common sense moves to make health insurance affordable and available and to prod insurance companies to behave better. No socialism. No death panels. No threat to freedom or the market. There are a lot of other provisions (including additional subsidies for Medicare prescription drugs and rules to let young adults stay on parents’ insurance plans until age 26), but much of what is debated endlessly on TV and on blogs simply isn’t central to this law.

Moreover, the core provisions will mostly be fleshed out over time by each state. There’s no one-size-fits-all “ObamaCare.” Citizen groups, health care providers, and businesses will have room to help shape Affordable Care to fit their needs. Some states may set up very market-oriented systems, with government playing a mild referee role. Others may choose strong “public option” or single-payer systems, with government doing more to offer choices.

When I explained these basics, audiences were pleasantly surprised, wondering why they hadn’t heard this from the media or politicians before. Even the controversial “individual mandate” (that everyone needs to buy some kind of insurance) doesn’t sound so awful, once they learn the details. This rule, I explained, is like car insurance, preventing people from shifting the costs of their illnesses to others. Further, it doesn’t go into effect until after new credits are in place to help people afford a plan.

Academics are interested in the big picture, of course. From that point of view, Affordable Care, if it can be implemented between now and 2014, is one of the most equality-promoting pieces of social legislation ever enacted in the U.S. It promises to extend subsidized health coverage to lower-income Americans. It should encourage experiments in health care delivery to control costs and enhance quality. Faithfully implemented, it’ll reduce the federal deficit. It’s paid for with taxes on the very wealthy and on businesses in the health care marketplace.

Affordable Care, in short, is highly redistributive—and that’s why there’s a furious, ongoing political campaign against it. Conservatives, Tea Partiers, the Republican Party, and major business lobbies are all trying to disrupt the law. They know that its concrete provisions—which, despite resistance, Jacobs and I fully believe will be carried through—will be embraced by average Americans.

Still, public ignorance helps those who would undo this law before it becomes a full reality. Health reform supporters must inform themselves, explain the basics to every audience they can reach, and work with fellow citizens to push forward implementation in each state. The more Americans learn about Affordable Care’s specifics, the better the reforms will do.