Monday, March 26, 2012


I've been calling the health care reform bill passed in 2010 and being argued in the Supreme Court this week "ACA" because I've thought it was the most neutral term. Affordable Care Act or Patient Protection and Affordable Care Act both sound like propaganda to me...not even close to the worst bill name in that regard, but still. And ACA seemed even more neutral than PPACA, partially because to my ears it's even less associated with the underlying words.

Obamacare? Only one side of the debate was using it, for one thing. For another I don't like putting it all on the president; it's as much WaxmanPelosiKennedyDoddHarkinCare (just to name a few) as it is Obamacare; generally, I'm just not real happy about adding to the presidential emphasis in US political culture. A third issue: the bill isn't really one bill, and one thing; it's a combination of various proposals, with the exchanges/subsidies/mandate as perhaps the core element, but all sorts of other reforms and regulations as major initiatives within it. For whatever reason, "ACA" evokes that to me more than "Obamacare" does.

The first of these objections no longer exists, however, with the Obama campaign embracing "Obamacare." The second and third objections still stand (although the third one is awfully subjective to begin with). I'm still, however, very wary about the presidential focus, but at the same time I don't want to sound as if I'm being snobby or disconnected from the general discussion. What do you all think? 


  1. At my day job, we're going with ACA most of the time these days. It was clear that "the Patient Protection and Affordable Care Act as amended by the Health Care and Education Reconciliation Act of 2010" is a little wordy, and "PPACA-HCERA" was never going to work. In 2010 and early 2011, I thought "PPACA" (pronounced pee-pack-ah) was going to catch on, but since about mid-2011, it looks like "ACA" (pronounced long a-see-long a) is becoming the standard. "Obamacare" hasn't caught on here, as it feels like it has a political value judgement embedded in it, and we're supposed to be bloodless non-partisan technocrats.

  2. 'Obamacare' is what everyone calls it now, whereas hardly anyone knows what the ACA is, at least until you say 'health care bill' or some such.

    And yes, it adds to 'presidential emphasis,' but after all, no one asks historians to list the great Congresses. Madison and the rest must have known they were creating a demi-monarchical office. While not part of the Constitution, the fact that they provided a palace is very telling.

  3. I guarantee every single person who reads this blog (and every single person who reads any blog that links to this blog) will know what you are talking about when you say "ACA". So, no problem to continue using it.

  4. 'Obamacare' has pejorative value only for consumers of right-wing media, but I still don't care for it. First of all (and most importantly imo), it makes the measure sound like a new welfare program, when in fact it is mostly a regulatory regime. Secondly, there's the encoded hope that the measure doesn't long survive the Obama administration. After all, we don't call Social Security the Roosevelt Pension, or Medicare 'Lyndoncare', etc.

  5. I think that PPACA and ACA are descriptive: the bill does protect patients from illusory insurance, and it does make insurance affordable.

    I'm fine with Obamacare, though. The president put it on the table, he insisted on the key cost controls, and he threw his whole weight behind getting the bill passed when it faltered.

    It also occurs to me that the aural resonance, perilously or pleasingly depending on your perspective, evokes 'mamacare.' Hey, maybe there's a post in that. A short one...

  6. Obamacare when you WANT to attach a polemical or emotional emphasis, pro or con, including an attitude about the President. ACA especially on Twitter to save characters, but otherwise and more generally when you wish to discuss technical features of the bill in some historical or other "objective" framework - unless, of course, you're assessing the "debate over Obamacare" itself.

    In other words Obamacare will continue to refer to the notion of the state as symbolized in the pseudo-monarch, the real existing one, taking "care" of its citizen-subjects' medical needs. ACA will refer to the particular effort of 2009-10 to realize that idea legislatively.

  7. I like ACA for your second reason. We should do what we can to de-fetishize the presidency.

  8. Those who don't closely follow politics are familiar with Obamacare but not ACA; avoid pointless jargon.

    t e whalen and other technocrats should embrace their partisanship. A growing government leads to more money and status for more technocrats. Since everyone is principally self-interested, technocrats should openly side with those who want to employ them.

  9. As a student of comparative presidentialism, I share the disdain for naming things after presidents. It is very common in Latin America to brand political factions after the president (or other politicians)--foxistas, uribistas, etc. I don't like it, in the context of any country's politics, because it de-emphasizes the institutional aspect and over-personalizes.

    I suspect the Obama campaign has started to embrace it because it assumes that, if the incumbent ends up being popular enough to be reelected, the policy, too, will become popular, because it is "his". But that still does not make it a good label.

  10. I've stated my opinion on this matter several times before on this blog, but the basic point is that "Obamacare" may have been coined as a pejorative expression, but that doesn't mean there's any reason it has to remain that way, and on those grounds, I have no qualms about using it myself. There are many terms that start out pejorative and later become neutral or even positive. I've already mentioned "the Big Bang." In the political realm, one example I read about recently was "muckraking."

    I realize the term is misleading in that it exaggerates Obama's role in the bill, but I really don't think that matters a whole lot. In the end, it's just a label, and it has whatever meaning people attach to it. I'm glad the Obama Administration has begun using the term; that's the surest way to deflate any negative connotations Republicans want to attach to it. As I've said, if Obama had been the one who coined the term "Obamacare," it would have sounded self-serving and egotistical, but having him embrace a term his opponents invented gives him all the cover he needs.

  11. I am still strongly inclined to go with "ACA", on the grounds that ... that's what it's called. I'm also not sure that it's fair to say that "the Obama campaign is embracing 'Obamacare'". AFAIK, Axelrod sent one email to that effect; not sure that counts as embracing the term forever.

    But then, I resisted calling the terrorist attacks "nine eleven" on the grounds that it was a shorthand for an event that ought not be described in shorthand. Obviously, no one else in the world felt that way, so... maybe my views on nomenclature aren't really that meaningful.

  12. imho, embracing "Obamacare" is an unforced error from liberals. I suspect that the derogation in the term is derived from an anticipated irony in the "care" part of Obamacare, which opponents expect will amount to "not a lot of care". The jury, as they say, is out.

    Its interesting, in this community and elsewhere, how much faith the left has that the pool of insured can be increased from 70% of Americans to 100%, with no decline in service and a decrease in cost. Perhaps, a chicken in every pot too. This cost decrease is mediated through some fired grunts at Humana, or perhaps fewer emerg vists from the uninsured.

    Surely the streamlining of Humana and ER triage are real effects; however, net of these helps, per capita HC spending in the US is going to have to drop by about a third. (This is necessary to provide 100% of the population HC services at less cost than what is currently provided 70% of the population).

    Does anyone believe that the ACA, from fewer HC employees or ER visits, can lead to a 1/3 decline in US per capita HC cost - without any decline in service? How is that even possible? Wouldn't Humana bank those efficiencies from their own interest, if it were that easy? And if we're really spending that much on uninsured ER visits, then big insurance/the polity is making a huge mistake by not extending insurance to those folks. A big self-interested mistake. Are big companies really that dumb?

    Long-winded way of saying there's a pretty good, logical, reason to believe that something will be sacrificed to get to full universal coverage. This doesn't make the ACA a bad thing; worst case, you can always argue its the lesser of two evils.

    But I think liberals need to be more wary of the "thing sacrificed" as what conservatives are referring to in the (sarcastic) "care" in "Obamacare". Liberals would be wise to run from the term, it seems to me.

    1. But that just seems to reiterate the linguistic fallacy I alluded to in my previous comment. Once a term becomes widely accepted, people generally don't go around dissecting its constituent parts. It just becomes a label for whatever it refers to, and whatever words it's made out of get ignored. I mentioned muckraking. Does anyone care about the originally insulting connotations of its literal meaning? You wouldn't think so listening to the way people use it now.

      Whatever positive or negative long-term consequences the health-care bill may have, I don't think it will make much of a difference what Democrats choose to call it--except that by embracing "Obamacare," they deflate one of the quickest and cheapest ways of insulting it.

    2. Kylopod, I see your point, and if there are no material service declines via the ACA, or any declines are otherwise opaque to the average consumer, there's a pretty good chance your assessment will be correct.

      Sake of argument, though, terms can also go the other way, i.e. away from neutral usage to something deleterious. Steven Pinker illustrates this via the progression of how Americans of African ancestry are described. We're at African-American today, which has no negative baggage, though it is the latest in a long line of terms that started out, Pinker argues, (relatively) innocuously but came to embody negative connotations, thus leading to their replacement.

      Obamacare isn't exactly the same thing, though if the legislation ends up letting down the average American, the term may acquire negative baggage, like those that preceded African-American. We have mostly left pre-African American terminology behind; the left will never be able to leave "Obama" behind. Thus the risk.

    3. Two points. First, the vocabulary of race and ethnicity gets special attention in our society in a way that other terminology doesn't. Except for those of with interest in history or etymology, most people use long-established terms like Social Security or gerrymandering without spending much time wondering about why they're called by those names. We just accept the labels as referring to what they refer to and be done with it. Indeed, the fact that English has so many phrases that don't make any literal sense (e.g. "head over heels") shows how indifferent most of us are to a breakdown of the expressions we use. Racial terms are an exception to that rule.

      Second, the rise of terms like "African American" in fact illustrates what I'm talking about: people put way too much stock in the power of language to affect the way we think. Take the move from "Oriental" to "Asian," which happened in the 1980s when I was a kid. Part of the purpose of this reform was to take people's mind off of race by adopting a neutral geographical term with none of the historical baggage that "Oriental" conjures up. But what's actually happened is that "Asian" has ceased to be a geographical term and is now a racial one. When most Americans talk about "Asians," they have in mind exactly what Americans from a generation ago had with the term "Oriental." The thinking hasn't changed; only the label has. Never was this clearer to me than when I watched a documentary about hate groups, and it showed a young skinhead bashing people he unhesitatingly called Asians. He seemed to have no sense that he was using a term that was created by multiculturalists to enhance racial sensitivity and that was once derided as politically correct. To him, it was as casual as saying "black," and while he might use more insulting terms at times, he doesn't think he has to.

      In any case, those language reforms were attempts to run away from earlier expressions that were deemed offensive or problematic, whereas the embrace of "Obamacare" by its creators and supporters is really the opposite effect. I do agree that if the law, after full implementation, turns out to be a disaster in the eyes of the public, the word "Obamacare" would get tainted by this occurrence, but if that happens, I'd say the choice by supporters to call it "Obamacare" would be the least of their concerns.

    4. Kylopod, your last two comments are very thoughtful additions, thanks for them. I agree with substantially everything in your last comment, though I arrive at a somewhat different conclusion wrt "Obamacare".

      Your points about racial terms acquiring negative baggage are substantially similar to Pinker's; a term like "colored" starts out with no particular negativity (beyond the general baggage African-Americans faced in America). Over time, "colored" comes specifically to mean something deleterious, and its replaced.

      And when its replaced, its pretty much gone. Now and then such earlier terms are still used in a derogatory manner, but as you note in the Asian example, people tend to leave the term behind with the negative connotation.

      In the case of Obamacare, its not clear whether the legislation will elicit hostility in a manner in any respect similar to the hostility that gets baked into previously-innocuous racial descriptors. But Obamacare might, and we'd surely agree that its supporters are counting on the fact that it certainly won't.

      What if Obamacare does end up adopting negative connotations, either because a) cost savings didn't materialize or b) savings materialized at an unacceptable decline in service to the current landed HC gentry in the US? The race-related example would tend to suggest that proponents of Obamacare would move on to a neutral term - particularly because, whatever its eventual flaws, something like Obamacare will always be with us, as it is almost certainly preferable (from a societal perspective, if not necessarily for everyone in the landed US HC gentry) to the alternative.

      In conclusion, it seems to me that there is a big difference in leaving behind the negative baggage of a term like 'colored' and a term like 'Obamacare'. We can leave 'colored' behind because it doesn't resonate much today beyond cringeworthy quotes from old movies.

      But Obamacare? Half the term is a very important early-21st century politician. How does one leave such a thing behind, if one wishes to?

    5. First, a self-conscious clarification: the parenthetical I inserted (beyond the general baggage African-Americans faced in America) after the comment you italicized ('colored' starts out with no particular negativity) was meant to reflect that the term was hardly an honorific; as you note, it imposed whatever generally negative feelings the white majority culture had toward blacks. We'd agree, I think, that such terms nevertheless 'get worse' with time.

      Bringing us back to our discussion: will Obamacare's equity deteriorate with time? Well, the legislation would first have to disappoint a significant portion of the population, itself a moot point. Suppose it does. While I agree that Obama's legacy is tied to the ACA, regardless of what its called, I do wonder, as an example, how many virulent opponents of the entitlement state think FDR when they spit and say "social security". The connection is not hidden, of course, but words have power: I bet the percentage that top-of-mind associate FDR with hated entitlement legislation is smaller than we might imagine. Suppose instead of "social security", common parlance referred to it as "Social Security Presented by FDR". Might FDR's equity follow the legislation more in that second case?

      I think so, again because words have power. Once Obama's name is permanently on Obamacare, for all of the reasons you cite, it ain't coming off. Still thinking that's unnecessarily risky from an equity perspective.

    6. Guys, I'm pretty sure that if Obamacare goes into effect and has anything like the staying power of Social Security or Medicare, it won't still be called Obamacare well into the future. It's not a single program like those are, it's a complicated set of regulatory and delivery reforms. People won't interact with "Obamacare"; they'll interact with the various specific agencies involved, particularly the insurance exchanges. "Obamacare" will simply become the American health-care system, or a large part of it. The term might still turn up occasionally in histories of how that system came into existence, but since there won't be an "Obamacare Adminstration" sending people checks, ordinary citizens will mostly forget about it.

      To fit this to your racial-terms analogy, the term "Obamacare" will go the way of terms like "quadroon" and "octoroon" -- it will fall into disuse because it names something that there's no need to name.

      (Having said that, I think the Dems missed a chance by not calling the ACA "Americare" or something of that kind. But, missing good political opportunities is what Dems do.)

  13. Unlike foreign policy projects - the Monroe Doctrine, the Marshall Plan - the ACA involves a domestic program with which Americans will (presumably) interact for decades and which the government itself (though not necessarily its officers) will not continue to refer to as Obamacare in almost any circumstance. Better to adopt and spread the name for which the program is most likely to be known.

  14. Actually, most of it won't be visible to most people. The exchanges will be visible...AFAIK, the states (at least those that move ahead and establish them) will be able to name them, while the federal one will presumably have some sort of name -- don't know whether it will have whatever name or acronym it had in the bill, or if HHS has the freedom to name it. At any rate, the exchanges will have names, although only a relatively small group will use them, at least in the short run.

    Anyway, (and not to cut off the discussion, but just to check back in), thanks all for fascinating comments and all, but I'm going to wind up with Matthew Shugart -- I'm going to stick with ACA for now.

    1. Read Frank's and JB's comments after posting mine above. Right, the overall design of the system (="Obamacare") will not be what most people interact with and won't be visible to them. The mistake is calling Obamacare a "domestic program" -- it's not, in the sense that Medicare and Social Security are programs with specific bureaus, budgetary line-items, headquarters with addresses in DC, etc.


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