The greatest flaw in the Affordable Care Act is not structural, but cultural. In selling the law, President Obama made an unkeepable promise that we could keep the plans we like. When insurers began to cancel policies—in compliance with the government’s mandates—the Administration continued to assure the public that Obamacare could expand coverage without inflicting any costs on the insured. This was a fantasy. Until the administration frankly addresses the cost of covering the poor and uninsured, we are stuck with the same Obamacare paradox we started with: The American people are not interested in sacrificing their own coverage so that others will benefit. Because there was never true buy-in for healthcare reform, the law cannot accomplish its transformational goals.
Before the Affordable Care Act was enacted, Americans with insurance liked their plans. From 2001 and 2008, Gallup annually surveyed the insured on how they would rate the quality of their personal health care. Consistently, year after year, more than 80% of respondents rated it as good or excellent. A February 2007 poll by CBS News found that 85% of people were satisfied with the quality of their own health insurance. A September 2009 Quinnipiac University poll found that 88% of respondents were satisfied with their coverage. As I discuss in my new book, Unraveled: Obamacare, Religious Liberty, and Executive Power, people who had insurance overwhelmingly liked it.
Yet, despite the fact that Americans were happy with their own coverage, they also recognized that the health care system did not serve everyone equally. For example, 59% of the respondents in the CBS survey were very dissatisfied with the cost of insurance for the countryas a whole. Further, 90% said the U.S. health care system needed fundamental change. The CBS pollsters observed a contradiction: “Americans think the U.S. health care system needs major fixing, though they are generally satisfied with the quality (but not the cost) of their own health care.” During the July 2008 NetRoots Nation Conference, future Vox-founder Ezra Klein referred to this tension as a “paradox.” Roughly the same percentage of the insured wanted to keep their own coverage, but simultaneously improve everyone else’s care. You can’t do both.
The President’s promise that people can keep their plans was not only misleading, but created the wrong culture of how reform would work.
The like-your-plan-keep-your-plan pitch was not only disingenuous, but was also self-defeating. So long as people believe that their own coverage will not be disrupted—through higher premiums, smaller networks, larger deductibles—healthcare reform cannot succeed. If the United States is to in fact embrace health care as a “right,” beyond mere platitudes, the government must be frank about the immense sacrifice this entails. Unless that happens, the Affordable Care Act cannot survive the rational self-interest of people who still want to keep the plans they like.
Even worse, one of the few cost constraints in the ACA–the cadillac tax–was unceremoniously delayed. It will likely never go into effect.
The law will continue to limp along, until it can no longer stand.