international analysis and commentary

Obamacare: popular program, unpopular president


Late-night talk show host Jimmy Kimmel made waves last year with a series of man-on-the-street interviews in which passersby were asked what they thought, alternatively, of “Obamacare” and “the Affordable Care Act” (ACA). All but one panned Obamacare and praised the ACA. The two, of course, are the same thing.

That tells you pretty much everything you need to know about the Obamacare debate:  The problem isn’t the “care” – it’s the “Obama.”

Polls show overwhelming support for virtually every component of the Act – prohibiting insurers from refusing to cover people with pre-existing conditions, allowing young Americans of working age to continue on their parents’ insurance, requiring all businesses with more than 50 employees to provide health coverage for their workers – except the (in)famous “individual mandate.

The mandate requires that every American possess some form of health insurance – if not employer- or government-provided, then purchased on the individual market – or else pay a penalty. This quickly became the centerpiece of Republican opposition to Obamacare – somewhat disingenuously: The notion of a private insurance “mandate” of some sort originated with conservatives themselves 20 years earlier as an alternative to government-run insurance. They believed that the private insurance market couldn’t survive a requirement to insure all Americans unless all Americans were under a reciprocal requirement to buy insurance; otherwise, anyone could simply skip paying for coverage until they needed it and then shift their bills to the insurance company. 

In any case, hostility toward the mandate became the core of the GOP attacks on President Barack Obama from the beginning. It nicely served the larger Republican message that the nation’s first black president was a dangerous radical bent on imposing an alien, dictatorial, socialist regime.

Obama didn’t help his own cause, though. Focusing on healthcare at the depths of the recession made the President appear aloof from the concerns of most people who at that point were more worried about losing their jobs and their homes. His decision to follow the massive 2009 stimulus package with a too-big-to-comprehend healthcare law simply played to the case Republicans wanted to build that Obama represented a dramatic turn toward Big Government. 

Even more fundamentally, however, most Americans aren’t concerned about the uninsured – they’re concerned about the costs of their own healthcare. Partial – though still large-scale – reform could have enacted virtually all the popular provisions of Obamacare, including the “exchanges” creating a competitive insurance marketplace for middle-class families, without raising the specter of the big-ticket Medicaid expansion to provide coverage for poorer Americans. That could have followed separately (and necessarily, once an individual mandate was enacted). 

All in all, however, Obamacare has achieved or is achieving all its aims. The ranks of the uninsured have fallen. The rise in insurance costs, while volatile, has slowed. More insurers are joining the “healthcare exchanges.” And, yet, Americans are overwhelmingly dissatisfied with it – and increasingly so.

At some point, something about Obamacare will have to change. One thing we know will change: the “Obama” part. He’s leaving in 2017. Maybe at that point, Republicans – as well as the people-on-the-street approached by Jimmy Kimmel – will be able to return to a rational discussion of the “care” part. Here’s what that might look like.

The vast majority of Obamacare’s provisions will remain popular and prove largely irreversible. The innovations that have occasioned the only real political opposition are: the individual mandate; the business mandate; the Medicaid expansion to cover the moderately poor; and the middle-class subsidies to buy insurance on the “exchanges.” Let’s take each in turn:

The individual mandate is actually unnecessary to its stated aims. Yes, patients have to be kept from “gaming” the system by paying for insurance only when they actually need it, but that can also be achieved by leaving people “free to choose” coverage or not – while imposing such steep penalties for opting out and then trying to cut back in line when convenient that no sane person would do so.

The alternative to mandating employer-provided coverage is to move completely away from an employer-based system. Conservatives have been advocating this more vocally in the past year or so, calling for a repeal of the employer tax deduction for healthcare expenses. This would subject patients to greater cost sensitivity, presumably lowering prices overall, but it would also double or triple insurance costs for the vast majority of families, currently subsidized by their employers. There’s a better alternative, however, to a state-of-nature approach making insurance even less affordable than the execrable situation we had pre-Obama: replace the employer tax credit with a credit for all health insurance, regardless of who provides it.

While the mandate has been the political bludgeon Republicans have used against Obama, their real objection is the Medicaid expansion, which ultimately means corporations and high-income Americans having to pay for poor people. A number of Republican governors have proposed various alternatives that involve utilizing private insurance rather than government-provided Medicaid. But why not go all the way and move all Medicaid recipients – new and existing – into private health plans? Government would simply provide a means-tested subsidy for private coverage – something Republicans advocated more than a decade ago… until centrist Democrats like Bill Bradley started to do so, too.

That would also integrate easily with the middle-class subsidies, creating a single, simple, universal but privately-based system of healthcare for all – and would end the injustices occasioned by the way the US Supreme Court rewrote the ACA: Modest-income families in states that rejected the Medicaid expansion are now left not only without government coverage but also without subsidies for private coverage limited to better-off­ families. Now, however, Republican governors who rejected federal funding for the Medicaid expansion are arguing that the middle-class subsidies shouldn’t be available in their states, either; a federal judge just ruled in their favor. If this ruling is upheld, the result could be two Americas, one where Obamacare continues to function as intended, and the other where, if you can’t afford health insurance, well, that’s too bad. 

Ultimately, then, it is possible to provide all Americans with better care, by building on the many Affordable Care Act provisions that most Americans support, and improving the rest. 

But, for now, it’s much simpler just to dump on Obama.