Change the Discourse, Don’t Change the Bill

“Repeal and replace Obamacare” was a rallying cry for Republican challengers on the campaign trail this fall. Now that Republicans have regained Governorships and Congressional districts across the country, the battle to save the health care law swings into full force. At least in rhetoric, Republicans want to raze the health care law and start over with some “market based” alternative.

Sam Brownback, the new Governor of Kansas said that the new law was “an abomination,” Tennessee’s new Governor Bill Haslam said that the law was an “intolerable expansion” of federal power and a “reminder of the incredible arrogance of Washington.” But how Republicans plan to advance their repeal agenda, and how Democrats can parry the blow are both hugely uncertain.

Let me start with a simple observation. The health reform bill does not poll well with the public, but for voters, the main issue was overwhelmingly the economy. Moreover, for every five people that want to repeal the law, two are happy with the law as it is, and three say that they wish the law was actually strengthened and expanded. The split is largely partisan. If Republicans want to appear engaged on the economy and focused on bipartisan solutions, then they risk alienating half the electorate with a costly health care standoff.

If they do take on the fight, the Republican offensive can come on two fronts. In Congress, Republicans say that they plan to use their control over agencies such as the Internal Revenue Service to strip the capacity to oversee key provisions of the legislation such as the tax penalties to uninsured individuals. Republicans can also make a spectacle by dragging the HHS Secretary Kathleen Sibelius or CMS head Don Berwick into hearings (my suggestion — you don’t want to mess with Don).

Second, the new crop of Republican governors can undermine the state-level component of health reform by joining in the lawsuits already under way. They can also halt and actively undermine efforts to build health insurance exchanges. Many state Governors have the power to appoint insurance commissioners, key figures in the implementation of the exchanges. Again, this comes with a risk. The legislation allows the federal government to run state exchanges where the states opt out of implementation.

Whether these tactics could actually succeed is very difficult to know, because they require a fairly detailed understanding of the legislative infrastructure behind the bill. The larger point is that Democrats have an opportunity to sway public support back toward the reforms. Everyone knows Democrats don’t message, but I have three ideas for how Democrats could start talking about the bill to a confused and anxious public:

Regulation, Competition, and Choice Go Together The number one rhetorical soundbite for conservatives is that government bureaucrats are going to come between individuals and their doctors. Democrats need to counter this message more effectively, but a technocratic discussion of health care pricing and insurance markets is not going to keep anyone awake.

Democrats have tried to get the public riled up about greedy insurance companies, but I can’t imagine this tactic will succeed forever. Instead, Democrats need some better metaphors to explain why regulation promotes better competition. The internet and mobile phones may provide some (imperfect) analogies. We could talk about the insurance regulatory framework as a platform on which all competitors must meet certain compatibility standards. The insurance exchange is an impartial aggregator of information that helps to rate the content of different insurance plans.

Real People are Already Getting Real Benefits Every time the Republicans talk about repealing the legislation, Democrats need to be able to parade in front of the media people that had lost their insurance because of health conditions that they developed, and who can no longer be denied care. The same goes for young people under 26 years old who are now coverable by their parents’ health insurance, low-income children that are covered because of the CHIP expansions, and working parents.

The Sum is More than the Parts This is mainly a cautionary note for Democrats. There is a strong temptation to seek a compromise on the legislation that preserves only the popular provisions while getting rid of those that the public dislikes such as the individual mandate. It is important to convey that it simply is impossible to construct a comprehensive approach to coverage that doesn’t in some way prevent adverse selection (healthy people opting out of the pool). To make the health reform bill work, we need to create large and diverse risk pools. In a forthcoming post, Paul will pick up the ethical arguments on insurance pools. I think we should talk about these issues in terms of social responsibility, but I also think that there’s a way to communicate to the public that cost-savings can only be realized once markets are consolidated and insurers are no longer encouraged to expend resources on gaming the risk pool.

Like Medicare in 1965, the Affordable Care Act will have plenty of bumps getting started. If Democrats can keep ground for a couple more years, and the coverage pools start to build, more people will get covered, and the legislation will start becoming more firmly established. Now is the time to build the trenches and take up positions.




About Brendan Saloner

I am a postdoctoral fellow at the University of Pennsylvania in the Robert Wood Johnson Health and Society Scholars Program. I completed a PhD in health policy at Harvard in 2012. My current research focuses on children's health, public programs, racial/ethnic disparities, and mental health. I am also interested in justice and health care.
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2 Responses to Change the Discourse, Don’t Change the Bill

  1. Pingback: Is health insurance like a television? (or, What is the point of health insurance?–Part 2) | Inequalities

  2. Pingback: Highlights so far… | Inequalities

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