The failure to explain health reform

The public doesn’t understand it. Whose fault is that?

If the Supreme Court rules the health reform law or its central feature—the individual mandate requiring people to have health insurance—is unconstitutional, much of the public won’t shed a tear. The Affordable Care Act remains about as unpopular as it was two years ago when the president signed it into law. In April 2010, one month after passage, 46 percent liked the new law while 40 percent did not. Kaiser Family Foundation’s latest tracking poll shows that in May only 37 percent of the public had a favorable view of the law; 44 percent viewed it unfavorably. Over the months in between those numbers have seesawed back and forth, with neither supporters nor opponents able to claim a clear majority.

What is not measured in those pro and con numbers, though, is how poorly the law is understood. As the Affordable Care Act continued its long bloody march through the legislative process, then-Speaker of the House Nancy Pelosi declared, “We have to pass the bill so that you can find out what is in it, away from the fog of the controversy”—an admission from the get-go that the American public knew little about a bill that was about to land on the president’s desk and in whose name it was passed. The controversy over it continues, yet large numbers of people—even those who might benefit from it—still know little about health reform. In Omaha a few weeks ago, for one of my CJR Town Halls, I talked to Heather Brown, a 38-year-old nurse who has no insurance, can’t afford to buy it, and, under Obamacare, would probably qualify for subsidies to help defray the premium. What did she know about the law? “Very little,” she admitted. “There’s just so much crap being spoken from both sides, it’s hard to know what’s the truth. You just stop listening.”

And in March, Kaiser’s tracking poll also found that familiarity with the law’s provisions “erodes as time passes.” Kaiser found that the proportion of Americans who are familiar with the provisions in the health reform law has dropped in the months following its passage. For example, in April 2010, 75 percent recognized that the law provided for subsidies to help people buy insurance. In March 2012 only 56 percent did.

Why is the law so poorly understood?

The Republican strategy to demagogue the Affordable Care Act has certainly taken its toll on clarity. As the Pew Center’s Project for Excellence in Journalism showed in a study released this week, the enemies of the Act are winning the communications war. And they seem to have the help of the media.

Pew’s research found that coverage of the health reform law “largely disappeared” as a news subject as it wound its way to the Supreme Court after passage.

When it was a major story, however, most of the coverage focused on the politics of the bill rather than the substance of the legislation. And the language and framing of the issue favored by the bill’s Republican critics was far more prevalent in the news coverage than the language and framing favored by Democrats supporting the bill.
Still, ferocious messaging by the Act’s political enemies is just part of the story. The president and his allies have been doing a poor job of explaining it. A few weeks ago New York Times columnist Tom Friedman wrote:
Barack Obama is a great orator, but he is the worst president I’ve ever seen when it comes to explaining his achievements, putting them in context, connecting with people on a gut level through repetition and thereby defining how the public views an issue.

Not only the president, but other Democrats and the advocacy coalition that helped shepherd the bill through Congress have not been not talking about the heart of the Affordable Care Act—the individual mandate—and how it operates, and why they think it is necessary for health reform to work.

And media, meanwhile, too often take their lead from the politicians. If President Obama wasn’t explaining the mandate, the press wasn’t about to either. The press has been doing a poor job of telling their audiences how the Affordable Care Act would affect all of them, for good or ill. During the peak of debate in 2009 and 2010, CJR observed that there was a dearth of stories about the individual mandate—and repeatedly urged the press to ask questions about its rationale and how it would supposedly work. Such comprehensive stories were rare—and remain rare now. As a result, when the public hears about the mandate, it tends to hear about it from the perspective of those who oppose it, rather than getting neutral explanations.

The upshot? The public had a vague sense that it was wrong for insurance companies to deny coverage to sick people, but explanations of why the law was necessary to stop that practice flew over a lot of heads, if they few at all. To many, the idea of a mandate—with penalties for failing to buy insurance—made no sense. In another CJR Town Hall, a worker at a Pennsylvania Walmart told me, “If you can’t afford healthcare, how are you going to afford the penalties? Why punish them?” The president—and therefore the press—failed to address the “why” in terms people could understand.

Meanwhile, a third factor is at work: Our health insurance system is changing under our feet, and those changes make it more difficult for proponents to explain the Act, and they make it easier for its enemies to blame Obamacare for marketplace shifts, even though most of the Act has yet to take effect.

When he did try to explain his health reform law, the president’s language and what ordinary people were experiencing were not in synch. For example: Several times Americans heard Obama tell them if they liked the coverage they had, they could keep it. But today’s reality is that they can’t keep what they had, and they know it.

The health insurance market was changing in 2009 and 2010 even as the president pitched his plan. Employers had started giving their workers insurance coverage with sky-high deductibles and high coinsurance, in an effort to make them pay more for the cost of their care. In Omaha, a young woman explained to me that to keep the premiums low, her employer had increased the amount of the family deductible from $5,000 to $10,000. That means she has to pay $10,000 toward medical expenses before the insurer pays a dime. “Obamacare is making an impact on insurance policies,” she said. “He’s driving the price up.”

Meanwhile others—like Robert Smale, an assistant professor of Latin American history at the University of Missouri, whom I spoke with back in the summer of 2010—know they are losing the good coverage they have. Smale’s university had informed employees that the level of their insurance benefits was too high. “Our coverage is too good, according to health reform,” he said. The Affordable Care Act indeed discourages so-called Cadillac plans that offer high-cost, comprehensive benefits, as a cost-control measure. The theory is that if insurance covers less, people will use fewer medical services, and the price of care will drop.

There are exceptions, but there has been little reporting on these continuing big shifts in the health insurance market. The public knows they don’t have the same coverage they had a few years ago, and that reality may show up in their responses to pollsters.

In March, as the Affordable Care Act approached its second birthday, the administration began a new sales job for the law, touting its more popular provisions. Still, there was no discussion on why the mandate was necessary.

The Hill reported that while the president was not mentioning healthcare in his public appearances, administration officials were busy making the case for Obamacare by releasing “a deluge of positive reports, press releases and blog posts.” One example was a report timed to coincide with National Nurses Week that highlighted what the law is doing to help cure nursing shortages. The National Journal reported in mid-March that the “HHS Health Message of the Day” reminded voters that drug coverage in the Act had saved some 5 million seniors and disabled people $3.2 billion, by filling the “donut hole” omission in coverage that was part of an earlier prescription drug law. The press picked up on some of this PR and offered up stories, especially ones about young adults continuing coverage under their parents’ insurance.

Positive response from the public could arrive in 2014, when the uninsured will start getting government help paying for their coverage—the heart of the law.That assumes, of course, the mandate survives.

Even so, how much the subsidies would be, and who actually would get them, is not clear—given a not-so-secret assault on the funding mechanisms in the law from employers, insurers, and manufacturers of medical devices. They are waging fierce campaigns in Congress to rid themselves of taxes imposed by the Affordable Care Act to help pay for those subsidies. If Congress repeals the taxes, what will that do to the subsidies they were to help finance? If there is less money for subsidies, will Congress scale back who will be eligible for them? And how much will those still eligible get? Those are important questions overlooked by a press still waiting for its cues from the president.

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman. Tags: , , , ,