WASHINGTON (AP) — It sounded so simple. Too simple, it turns out.
President Barack Obama’s early efforts to boil down the intricate that eventually became the Patient Protection and Affordable Care Act (PPACA) so Americans could understand it are coming back to haunt him, leaving a trail of caveats and provisos in place of the pithy claims he once used to sell the law.
In the summer of 2009, Obama laid out his health care agenda in a 55-minute speech to the American Medical Association. It was, his former speech writer Jon Favreau recalls, “one of the longest speeches he ever gave.”
Fine as an initial policy speech, Favreau thought, but not a communications strategy.
“My lesson from that was, well, he can’t be giving a speech this long and complicated every time he talks about health care,” Favreau said.
Indeed, a good sales pitch must be brief, compelling, accurate. But when it comes to a complex product like health insurance, brevity and persuasiveness can take a toll on precision.
For example, Obama had promised, “If you like your health care plan, you’ll be able to keep your health care plan, period.”
Instead of a period, the statement required an asterisk. It turned out, yes, some plans would be taken away as an indirect result of the law’s tougher standards.
The enrollment experience, Obama said, would be simple: Hop online and comparison-shop “the same way you’d shop for a plane ticket on Kayak or a TV on Amazon.”
Instead, as the entire country now knows, October was a website disaster.
Then there was the cost. “Through the marketplaces,” Obama said, “you can get health insurance for what may be the equivalent of your cell phone bill or your cable bill, and that’s a good deal.”
A good deal, indeed — for those who qualify for federal subsidies to offset the cost. But not for all.
By last week, the president had inserted a new, though little-noticed line to his health care speech: “There’s a fraction of Americans with higher incomes who will pay more on the front end for better insurance with better benefits and protections.”
Then on Monday, speaking to supporters of the law, he added a clarification: “If you have or had one of these plans before the Affordable Care Act came into law and you really like that plan, what we said was you could keep it if it hasn’t changed since the law was passed.”
Favreau said Obama’s message got caught between two promises — to not disrupt those who already had health care and to provide better more comprehensive coverage.
“To the extent that the two promises collide, that’s what we’re dealing with now,” he said.
David Cutler, a Harvard economist who advised Obama on health care during the 2008 campaign, warned the White House in a 2010 memo that the administration was not properly prepared to implement the new law. One result, Cutler said Monday, was that new premium rates under the law’s insurance marketplaces were not ready before insurance companies sent some customers notices that their current policies did not meet new federal standards and were being terminated.
“That means that many people who will do better — better coverage, lower price — cannot know that,” Cutler said in an email exchange with The Associated Press.
It may be that Obama and his allies in Congress overlearned the lessons of 1994, when President Bill Clinton’s push to overhaul health care collapsed. Many Democrats walked away convinced they had fallen victim to a colossal effort to scare Americans out of supporting it, illustrated by the “Harry and Louise” television ads that showed a typical couple at their kitchen table, lamenting how a health plan they’d liked had been yanked out from under them, replaced with bad choices and higher prices.
Jonathan Gruber, who played a central role in crafting PPACA, said the moral of that story was that most Americans are happy with their health care and are resistant to change. So rather than cast Obama’s effort as ripping up the health care system and starting from scratch, Gruber said, the administration emphasized that most Americans wouldn’t be affected.
“The view was, ‘Look, we’ve got to get this across the finish line.’ To do that, you have to explain to people in a way that they understand,” Gruber, an economist at the Massachusetts Institute of Technology, said. “You present the facts in a way that’s ultimately not 100 percent accurate for every person, but tries to get across the gist of what you’re trying to do.”
To be sure, Republicans set out to lambast and undermine the law from the beginning. Democrats claim a deliberate campaign to misinform the public about the law made explaining it clearly that much harder. The law’s critics argued it would hurt small businesses and kill jobs, drive up costs, lead to rationing and put health care decisions in the hands of politically-motivated bureaucrats.
Each of those allegations could be easily captured in a sound bite. So Obama fought back by being equally straight-to-the-point.
“You have to pay attention to what your opponents are saying, and do what you can to correct the record,” said Nick Papas, the White House’s spokesman for health care for the first three years after the law passed. “The Republicans in Washington were lying to people and leaving tens of millions of Americans with the impression they were going to lose their health insurance, that this was going to be an apocalyptic development for the American health care system.”
Such differing interpretations of the same set of facts is reflected in polling that suggests the public doesn’t quite know what to think about the law more than three years after Obama signed it. Although the figures have ebbed and flowed, Americans remain relatively split, with 38 percent viewing the law favorably and 44 percent viewing it unfavorably, according to the Kaiser Family Foundation’s monthly tracking poll.
Anna Greenberg, a Democratic pollster who has studied public opinion on health care, said what’s been missing from the White House’s message is how completely dysfunctional the health insurance system was before “Obamacare.”
“You need to have a coherent framework for why we’re doing it that allows you to get through the glitches that were inevitable,” Greenberg said. “We never really explained to people why we’re doing this.”