As a journalist and a health advocate, I have a professional interest in health care reform. But as the Supreme Court upheld the Affordable Care Act this week, I had a personal interest as well. Last fall, after three decades as a salaried employee with health benefits, I became a self-employed consultant with none. And this spring, after 56 years of perfect health, I learned that cancer had invaded my colon and my liver. Fortunately, my wife has an employer-sponsored plan that covers my treatment, but without health care reform, my treatment would hinge on her job status. Any change in her employment could have landed me in front of a death panel—not a fictional one manned by bureaucrats who ration our health care, but a real one made up of insurance companies that couldn't or wouldn't cover people with known health problems.
Many Americans live closer to the edge than I do, and each of them has a stake in this this week's ruling. As the Institute of Medicine declared in a 2009 report, the continuing decline in access to health care is causing "illness, suffering, and even death" among children and adults in this country. Yet polls consistently show that more Americans oppose the Affordable Care Act than support it—not because they've evaluated and rejected it but because they don't understand it. There are plenty of reasons for that confusion; the law is complicated, opponents have misrepresented it, and the news media have focused on the politics rather than the substance. But as the bill's chief architect and advocate, President Barack Obama bears equal blame for the tepid public response. Contrary to his persistent illusion, bold reforms don't survive on merit alone. They have to be sold—and this one has scarcely been marketed.
As signed into law two years ago, the Affordable Care Act holds tangible advantages for most Americans. By 2014, it will create new health care options for 30 million people who now lack coverage, while improving quality and lowering costs for those who are insured. The act has already secured coverage for 3 million young adults by enabling them to stay on their parents' plans through age 25. Millions more children and adults will have new gateways to health care in 2014, thanks to new tax credits and an overdue revision of Medicaid's eligibility rules. The new law also bars insurers from discriminating against people with "pre-existing conditions"—a group that includes roughly half of the non-elderly population—and freed 105 million policyholders from the lifetime caps on essential benefits. Before that rule took effect, some 20,000 patients were being dropped by their insurers every year, often while receiving critical care. The expansion of access may sound costly, and it is. But by bringing healthy people into the insurance pool, and improving the quality of care, it will save the average American household nearly $1,600 a year by 2019, according to an analysis by Families USA. And the nonpartisan Congressional Budget Office estimates that the act will shave $130 billion off the federal deficit by 2020.
When asked, people tend to favor specific reforms such as barring discrimination against those with pre-existing conditions. Yet surprisingly few associate these reforms with the Affordable Care Act. In January 2010, just before Obama signed the act into law, the Pew Research Center quizzed a national sample of adults on its basic provisions. Only 39 percent knew it would protect people with pre-existing health conditions. Only 33 percent knew it would help them switch jobs without losing their insurance. And just one in five (21 percent) realized it could reduce their out-of-pocket health care costs. Obama acknowledged his own failure to communicate at the time, saying, "I take my share of the blame for not explaining [the act] more clearly to the American people." But two years and countless news cycles later, the public has yet to be rallied to its own defense. In recent polls conducted by the Pew Research Center, the Kaiser Family Foundation and AP-GfK, opponents of the act still outnumber supporters by 5 to 14 percentage points. And with House Speaker John Boehner (not to mention presidential hopeful Mitt Romney) still promising to repeal health care reform, public opinion still matters.
How could a leader with Obamas rhetorical talents fall so flat on such a critical issue? The failure stems partly from his misplaced faith in the decency of his adversaries. As the Affordable Care Act was taking shape in 2009, Obama's progressive base clamored for a single-payer system that would cover all Americans. The President ditched that idea, along with a more modest "public option" that would give people an alternative to the private insurance market. Instead he adopted a longstanding Republican idea: the so-called individual mandate. To expand the health system's financial base without swelling the public sector, the mandate simply requires everyone to get some form of insurance. "Many [states] require anybody driving a car to have liability insurance," the conservative Heritage Foundation argued in a seminal 1989 pitch for the idea. "But neither the federal government nor any state requires all households to protect themselves from the potentially catastrophic costs of a serious accident or illness. Under the Heritage plan, there would be such a requirement."
As passed by Congress and enacted two years ago, the Affordable Care Act included that requirement. But instead of lining up behind their own idea, Republican lawmakers set about demonizing it as a government attack on consumer freedom. Meanwhile, attorneys in conservative states filed a barrage of lawsuits challenging its constitutionality. It was the President's moment to rally the country with a story about basic human needs and his determination to see them fulfilled. But the man who won the presidency by winning our hearts held back, assuming that reason would prevail, and his opponents gladly supplied a new story line. Instead of a narrative about the desperate struggles of ordinary Americans, the public got one about Barack Obama as a radical ideologue scheming to force his views on a freedom-loving country.
The White House has learned from the experience and is speaking out belatedly on the benefits of the health care reform. Now that the court has upheld the health care reform law, the President and his allies have a new chance to forge a national consensus—not through government pronouncements but through the kind of mass mobilization that swept him into office four years ago. No one did more to defeat the Clinton administration's 1993 health care proposal than "Harry and Louise," the fictional suburban couple victimized by government bureaucrats in television skits produced by the insurance industry. By 2008, the actors in those ads had seen enough to switch sides and produce a new set of spots urging the next president, Democrat or Republican, to place health care reform at the top of his agenda. ("Lisa's husband just found out he has cancer," Louise confides to Harry this time. "He just joined a startup and he can't afford a plan.")
Obama heeded the call during his first year in office, but his allies have been outspent three-to-one by opponents since the Affordable Care Act took effect in 2009. This spring, his Health and Human Services department selected a PR firm to produce educational materials about the act, as the law itself requires. But the face of health care reform is still that of a demonized politician—Barack Obama himself—not that of a family bankrupted by medical bills or a child denied asthma treatment because the condition predates her insurance policy. Finally this spring, Obama's election web site has started profiling people whose stories show in raw, personal terms what's at stake for the country. If the president can use this week's court ruling to reassert his own gifts as a storyteller—and his supporters can spark the kind of social-media uprising that helped elect him—health care reform may yet have a chance. His success, and our well-being, now depend on it.
Geoffrey Cowley has worked as a senior editor at Newsweek, an associate commissioner at the New York City Health Department and a media director at the Planned Parenthood Federation of America. He is now an independent journalist and public health consultant.