Many in the health policy world worried when President Obama made only passing reference to health care in his State of the Union Address -- only two mentions of the words “health care” and one each for “Medicaid” and “Medicare.” While there may be a number of reasons that Obama chose not to highlight one of his most important legislative accomplishments, much of his speech effectively reaffirmed the ground on which it was adopted and painted a picture of the Democrats’ vision for the country going forward.
The latest Kaiser Family Foundation tracking poll found that Americans remain divided in their opinions of the Affordable Care Act: 44 percent have an unfavorable view, while 37 percent have a favorable view of the law. As some have suggested, health care reform is simply not an issue that is going to get voters excited. The law has passed and there is little that Obama or Congressional Democrats can do at this point to strongly shift public opinion.
In fact, defending the law in public may draw even more negative responses and help to legitimize repeal efforts. Public opinion is unlikely to change significantly until the Supreme Court hears various challenges to its constitutionality in March, considering that 59 percent of Americans believe political and personal ideologies of the justices will impact the final ruling on the individual mandate. In the meantime, the president has chosen to stick to the less controversial provisions that regulate insurers, saying during the State of the Union, “I will not go back to the days when health insurance companies had unchecked power to cancel your policy, deny you coverage, or charge women differently from men.”
Given the public unease and uncertain fate of the law, one can understand why President Obama chose not to more directly discuss the merits of his expansive reform efforts, but this is not to suggest that he has abandoned the cause of health care reform. One of Michelle Obama’s guests at the address was Adam Rapp, who was diagnosed with cancer at the age of 23. Because of the Affordable Care Act, Adam was able to stay on his parents’ health insurance policy and receive treatment; he is now cancer-free. Such a subtle approach to promoting the law is likely more politically viable than confronting it head-on.
Despite the relative absence of health care in his remarks, the president cited many of the values embedded in the health care law: progress, collective responsibility, justice, and fairness. He touted the merits of basic research and innovation that “could lead to new treatments that kill cancer cells but leave healthy ones untouched.” Although much of this is rooted in economic prosperity and global competitiveness, it also connects with the notion of creating a more efficient health care system of the highest quality possible.
One cannot ignore Obama’s central theme of addressing economic equality in the United States, including his proposal that individuals making more than $1 million a year should not pay less than 30 percent in taxes. As he said, “We can either settle for a country where a shrinking number of people do really well . . . Or we can restore an economy where everyone gets a fair shot, everyone does their fair share, and everyone plays by the same set of rules.”
While this is an explicitly economic argument about fair distribution of wealth and ensuring all Americans can prosper, it also implies support for collective responsibility for the health and well-being of all individuals. The health care law is founded on the idea of expanding high quality and affordable health care to upwards of 30 million Americans, while also creating incentives for individuals to improve their personal health. Reform means that fewer Americans will go into bankruptcy because of health care bills, overall health status will improve, and individuals will be better equipped to participate in the economic engines of the economy. These should be compelling arguments for individuals concerned about our country’s economic future and those concerned about ensuring fairness and justice in the provision of our nation’s resources.
There is certainly more work to be done, given that health care costs still consume upwards of 17 percent of our gross domestic product. While Obama gave little time to directly confronting the deficit, he did say that he is “prepared to make more reforms that rein in the long-term costs of Medicare and Medicaid . . . so long as those programs remain a guarantee of security for seniors.” As William Galston said at a Brookings Institution event the morning after the speech, it appears as though Obama “opens the door, but in no way walks into the room [on grand deficit bargaining].” Health care costs and the role of entitlement programs in the deficit will likely reemerge as a significant issue as the presidential race heats up this summer.
The competing vision between Democrats and Republicans for how to reform Medicare was on display at a State of the Union Congressional debrief sponsored by National Journal and The Atlantic. Whereas Paul Ryan [R-WI] insisted that there is “growing bipartisan support” for structural changes in Medicare, such as premium support and block-grants, John Dingell [D-MI] stressed that these reforms will not work because they shift costs onto individuals and states in ways that they cannot handle. These tensions may only intensify in the coming months and result in a complete overhaul of Medicare and Medicaid if the Republican nominee wins the election in November.
As Obama said on Tuesday night, “The state of our union is getting stronger,” but we are in a process of rebuilding which will involve “a renewal of American values.” Cultivating a nation of collective responsibility, equality of opportunity, and fairness will require recognition that the government has a role to play in that process, particularly when it comes to health care. Even though the president failed to mention the promises of the Affordable Care Act, our nation’s economic prosperity depends on the health of our workforce and efficiency of our health care system
Ross White is the public policy associate at The Hastings Center and a graduate student in philosophy and social policy at George Washington University. Follow him on Twitter @rossswhite.