Monday, August 6, 2012

The Future of "Obamacare" Again

Kevin Drum had an item yesterday about "Obamacare" -- the name of the program, not the program. He concludes:
[I]f ACA eventually becomes popular, then Obamacare will be a positive term. If it fails, then it will fade away. It's that simple.
I've written about this before: I still don't see it. There's no specific program associated with ACA which lends itself to being called "Obamacare." Or Affordable Care Act, for that matter. So a question for Drum: what exactly do you think will be called "Obamacare"? The exchanges? The entire health care system? The taxes on fancy private medical plans?

I think I'd say the opposite, actually. If Mitt Romney wins big and ACA is repealed, then Obamacare will be remembered, probably by that name, as a fiasco of one kind or another. If ACA survives and is implemented and basically works, then it will eventually lose its name...any name. The exchanges will be called whatever they're called, and the various other pieces of it may have names (so we'll have the IPAB), but most people and even most politicians won't associate that stuff with the ACA or Obamacare. No one will think to call Medicaid expansion anything; it'll just be how Medicaid is. No one will have a name for the subsidies, any more than we have a legislative name for the mortgage interest tax subsidy. We'll have serious mistakes, too: people won't remember what was ACA and what was previous policy and what was in subsequent legislation.

Mostly, a lot of what will happen, if ACA works, will be pretty invisible anyway. No one is going to realize that without "Obamacare" they would have been at risk for recission. Most people, especially after a few years, won't realize that they once would have been denied insurance because of pre-existing conditions, especially those whose "condition" was mild. The cost-saving stuff will also be pretty invisible, in most cases.

We'll still, of course, have political fights about health care, but I doubt that it will be in anyone's interest to characterize the future system, again assuming for now that ACA is fully implemented, as created by one law. As, of course, it won't be, anyway.


  1. So President Obama's name gets muddied by the "Obamacare" stigma if ACA fails but no credit by name if it succeeds.

  2. I agree that ordinary health consumers won't call Obamacare anything in particular -- it will just become the structure of the U.S. health-care system. But it's not clear to me that Drum is talking about health consumers; he's referencing recent public-policy discussions, and he may have in mind the term's positive or negative connotations in future such discussions. And for that purpose there will need to be some term for the landmark reform, just as we routinely refer to the legislation that ended Jim Crow as "the Civil Rights Act(s)" and the legislation that inaugurated modern air-quality controls as "the Clean Air Act." Truth be told, I've used those phrases in that way without knowing whether any specific feature was actually in the Act itself, or in some later amendment to it, or just in the general regulatory scheme or approach of which the Act is a founding element. Drum may be thinking that "Obamacare" will function similarly as useful shorthand in future policy debates. (Then again, I can't think of a parallel case of a person's name being permanently attached to a regulatory scheme.)

    1. P.S. I didn't make "structure" a hyperlink. Apparently this blog software is now auto-linking to ads.

    2. P.P.S. .....and then removing them! Huh.

    3. @Jeff: Actually, the links are done and undone by Obamacare.

    4. Thanks, Matt..... that will settle the question, then. We just need to wait and see whether the word "Obamacare" starts auto-linking to RNC or DNC sites.

    5. Late update: Apparently what I'm seeing is some ad-crapware that invades Firefox. Sorry, I mean some "web experience enhancement." Apologies to blogspot (which will probably now be hyperlinked and made into an ad).

  3. I remember seeming to notice that the number of people referring to is as "Obamacare" dropped off quite a bit after the SCOTUS ruling. It would be interesting to do some lexus or google trend-fu to see the % of news stories referring to it as the ACA, Obamacare, or simply HCR.

  4. You've probably noticed that the Obama campaign has been using "Obamacare" more frequently. Since the SCOTUS decision, it has been entirely foreseeable that the ACA would become less and less controversial since the controvery was not so much over the substance of the law, but rather the way it was passed. Now, of course, that controvery was utter crap since the ACA was passed entirely by the books (and no, I don't consider reconciliation to be breaking the rules). The law originated in Congress, went through hearings, was extensively scrutinized in the public sphere, passed both houses of Congress and was signed by the Prez. Just like "A Bill on Capitol Hill"!

    Now, if Obama is still leading in the polls by a five or so points in the fall, I think it would be a smart, bold move for him to heavily tout "Obamacare" as a signature accomplishment by him AND the Dems. It would put Romney in a brutal dilemma. On the one hand Romney could go off message and bog himself down in the health care debate (which many voters don't want to revisit) while also descending into the over-the-top, pissant criticisms of Obama that have made the Romney Campaign suck so very, very badly. But on the other side, conceding Obamacare as an accomplishment is a huge concession and would drive the Tea Party folks up a wall.

  5. Your point may be correct as far as the general public is concerned, but there will always be people who remember the bill, or who read about it in history books, and there will always be people aware of which policies were initiated by the bill. Those people will need a name for the bill, and I suspect "Obamacare" is more likely to stick, and to be retained in the history books, than "the Affordable Care Act." Therefore, whether the policies arising from the bill are commonly viewed as a success or failure will very probably have an impact on whether "Obamacare" goes down in history as a positive or negative term.

  6. I suspect most readers of this blog have some version of large group health insurance, with costs reimbursed in an HMO structure. If readers are of a certain age (and pay attention), they probably recall a time when their health costs were reimbursed using a "fee-for-service" model; further, most probably have a vague sense that, net of technological improvements, "fee-for-service" was preferable to the more restrictive HMO model.

    Fee-for-service was better for many consumers to the extent that more fees were being disbursed for more services, as the HMO is a means to control costs by restricting access. Professor Bernstein, along with about a million others, has frequently reminded us that the great budget challenge of the coming years is the explosion of health care costs, from which we can infer that further efforts to control costs by more restricted access are in our collective future.

    So Joe the Corporate Plumber, assuming he's of a certain age, will likely perceive the following: fee-for-service >> HMO >> the next generation of health care.

    Joe the Corporate Plumber may not be conscious enough to articulate the negatives in going from fee-for-service to HMO; fortunately, the Republicans have provided Joe with a convenient descriptive frame, "Obamacare", within which to think of that next generation of health care.

    Curiously, our President, his vanity duly stroked, is only too happy to oblige. Aside from the obvious benefit to those with pre-existing conditions or near their lifetime caps, there may not be much more to this story than that.

  7. I forgot to add those currently locked out of the insurance market as obvious beneficiaries of the ACA/next generation of American health care.

    I also should add how startling it is that folks still speculate that the ACA/next generation of American health care might be wildly popular beyond the obvious benefits to classes such as those with pre-existing conditions and others locked out of the current market. Its as if the shift to HMOs was unpopular because people don't like acronyms, and not rather because HMO is a corporatespeak euphemism for HRO, or "Healthcare Restriction Organization".

    Do we not all see the ballooning future cost of healthcare, threatening the very solvency of the country? Do we not all see the way those costs are going to be managed, relative to today? Do we not sense that the changes to come will make the shift to HMOs seem like child's play in comparison?

    And you're cool with binding the name of your transformational President to that process?

    1. CSH, that's a great analysis of the downside of calling health reform "Obamacare." Basically, what you're suggesting is that the beneficiaries of the reform, unlike (say) African-Americans during the Civil Rights Movement, are mostly not a group conscious of their oppression yet, and therefore primed to celebrate their liberation from it and enshrine this in the canon of Great Events in American history. They've assumed that not having health care was just a natural circumstance, not the result of really screwy public policies. Jim Crow was by comparison a fat target.

      Here, though, is what I think might offset the effect you're positing. At ground level, the transition to next-generation health insurance will be gradual, not a Big Bang where people are suddenly herded through a door marked "Obamacare." On that, JB is right: What people actually interact with will be various features of the new system with their own particular names. At least as importantly, what pushes them out of the previous system will be a local decision, like their employer deciding to drop health coverage. Or they'll change jobs, and the HR person at the new job, instead of saying "Here are our health plans," will hand out a pamphlet explaining how to arrange a plan through the state's exchange. I doubt that the net effect of such local events will be a lot of grumbling about how Obamacare ruined everything; lots of people either won't understand what just happened or will be grateful that in a world where decent health plans were becoming scarce, there's some government office with a web site and all where they can sign up for a plan.

      If I'm right about that, then the main continuing use of "Obamacare" as a term will be in public-policy debates, and there, you'll at least have one side vigorously arguing (it now seems) that the alternative to moderately rationed care through universally available insurance was increasingly rationed care through very selectively available insurance. Medium-term, I think that's a winning argument. (Long-term it will be irrelevant, because Obamacare will give way to next-next-generation HCR.)

    2. Jeff, those are good points, in particular the one about Obamacare having a different meaning for every individual. Something else that's germane which I didn't add above:

      If memory serves, opposition to the widespread move to HMOs from fee-for-service was framed using the typical scare tactics, you know, coming between you and your doctor, wait periods and all the rest. (A bit of truth to all of it, as always). The riff-raff wasn't opposed to HMOs philosophically; they just didn't like HMOs because they amounted to less health care.

      A big difference between then and now is that the populace is probably somewhat more educated now about the health care landscape, including the cost of care, and the cost of no coverage. Still, the scare tactics are always crude proxies for the same thing: we don't want less health care services.

      The future, the "next" generation of health care, will amount to less health care services. Different people will call different parts of that future landscape Obamacare, but you could argue that its in the Democrats' interest that no one call any of it Obamacare.

    3. Not sure who is still reading this thread, but I just caught up on it...

      I guess I'd say a couple of things. One is that I'm beginning, from Drum, with the assumption that ACA "works". That's not well defined at all, but I think at least part of it is that some costs are squeezed out of the system without pain to consumers. From where? Mostly bureaucracy, at hospitals and insurance companies (which, remember, now have to devote more of premiums to benefits); or, another way to look at it, money to people throughout the provider chain. There does seem to be a ton of waste and inefficiency, and they're trying to do something about that -- which isn't costless, because "waste" doesn't just disappear, even fraud doesn't just disappear, someone pockets it.

      Will they succeed? Above my pay grade, but experts are optimistic that they can succeed some. Will the rest come through stuff that patients will notice and hate? Could be, but I really do disagree with CSH about whether it's out of the question for it to work without that.

    4. Jonathan, thanks for the comment, fwiw I agree with the argument that the ACA will generate cost savings from squeezing out inefficiencies; I also (mostly) agree with you elsewhere that our budget challenge, going forward, is a health care cost challenge. At a 60,000-foot level, it seems reasonably clear that the changes required to solve that health care cost challenge are much greater than what the ACA and its descendents will achieve naturally. As always, the devil is in the details.

      There's another sense in which the HMO shift is instructive: I'm no expert, but my understanding is that the unsustainability of the fee-for-service model (patient just asks and the insurer pays) was addressed, with reasonable fairness, by the move to HMOs. In this sense, HMOs were arguably 'better' than the alternative future with a fee-for-service model. In being 'better', HMOs took stuff away from consumers, and from what I recall, people focused more on the stuff taken away than how preferable HMOs were to the alternative.

      The solution to the coming massive health care cost challenge is going to involve, among other things, a lot more taking stuff away. Whatever its many other merits, the shift to HMOs probably tells you that a party should keep its iconic brands as far away from 'taking lots of stuff away' as possible.

    5. Of course, part of why Dems are prepared to use the term "Obamacare" is that they're finally figuring out that health reform IS their iconic brand, and hence needs a "brand name." Even if Dems had invented one of their own, instead of appropriating and re-purposing their opponents', they'd be risking its future unpopularity for all these same reasons. But I don't think that opting-out of the branding altogether, as they were doing before, was helping them, and that seems to be, for better or worse, their own current calculation too.

      As to taking stuff away, I think the big fight ultimately might not be over what consumers get out of the system, but what providers get -- especially doctors' salaries (and the requirement that MD's oversee and get a cut of everything), but also support personnel who make high-five-figure incomes with associates' degrees and the like. I don't know that any of this even registers as "waste," but really, if I guy is making $700,000 a year mostly (say) setting fractures, and you'd have no shortage of equally skilled people willing to do it for a "mere" $200K, aren't we basically looking at a half-million or so of "waste"? And yeah, I know the AMA and the other gatekeepers here are politically powerful, but ultimately the people and the taxpayers are more powerful. Political history could almost be defined as the history of how the power of once-powerful groups was finally broken.

    6. Excellent analysis; something omitted from my comment above is the following, easily-observable fact: yes, everyone hated HMOs 30 years ago when the switch from fee-for-service was underway, but today people are mostly happy with their HMO, with very few remembering what they're missing vs. the old fee-for-service model. In this regard, the future is likely to be similar to the past.

      Further, IIRC the medical establishment was a loud opponent of the HMO revolution, as the negotiated $50 fee to see your GP was an unfortunate, from the physician's perspective, result of such changes. They've been handled before, they can be handled again.

      All that said I'm still not sold on the name. It will take time for whatever declines in service associated with necessary cost savings to become the new normal. It will happen, as it did with the HMOs, but it will take time. Bringing Obama into that process arguably makes the journey more difficult, in addition to placing a "kick me" sign on the Democrats' collective backs.

    7. You may well be right, CSH; one thing the HMO revolution didn't have was (a) a political party with obvious ownership of it, and (b) Rush Limbaugh and his ilk screaming daily about how any threat to your health insurance (or health) is the direct fault of that party or president. So this should be interesting! (Insert reference to ancient Chinese curse here.) ;-)


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