I write this in the last days of the run-up to the Supreme Court decision on the Affordable Care Act. If it comes down against the ACA in some important way, such as voiding the requirement that the uninsured must sign up for insurance or pay a penalty, that will be a major setback. If the ACA is upheld, that is hardly the end of the matter. There will still remain many possibilities for Congressional opponents to cripple it, and the loss of the presidency in the November election, as well as the possibility of a Congressional majority in the House and Senate, may doom it altogether.
Why all these troubles for the supporters of reform? There are many ways to answer that question, and many have tried, but I will start with two points. One of them is well described in a New York Times article yesterday on the comparative spending of supporters and opponents of the ACA. Of the $232 million spent on advertising on the ACA, only $700,000 has come from supporters and mainly from Department of Health and Human Services, whose ads are described as "bland." By contrast the ads of the opponents have run from the nasty to the vitriolic, scattering misinformation in all directions. One result of that imbalance as been a loss of public opinion support: the New York Times article cited a recent New York Times/CBS News poll that showed that “more than two-thirds hope the Court will overturn some or all of it."
My other point is the role of President Obama and the administration in trying to win over the public. On June 24, 2009, I was part of an audience invited to a White House town hall meeting. I was prepped by someone from ABC News, which broadcast the event, to ask Obama a question about rationing. I never had a chance to ask him anything. Every time Obama was asked a question he rambled on in the most
complex, wonkish, and ultimately boring way. I have no doubt others did not get to ask their prepared questions either. Diane Sawyer, one of the moderators, apologized to me afterwards, but I felt sorrier for her than for myself. I could only conclude that President Obama is a skilled talker but poor communicator, at least on complicated issues. I can't recall anything since then, on this or other issues, to change my judgment.
More generally, to be sure, there have been a number of other obstacles in making the case for the ACA. It is dreadfully complex and even its more cautious supporters are not sure it can deliver all the good things it sets out to do, particularly on the control of costs (I am a skeptic on that). By pushing some of the more decisive cost-control measures into the future, probably for political reasons, moreover, it delayed some of its most important features, notably the Independent Payment Advisor Board, not to fully take effect until 2018.
Less commented on, though I may well have missed it, is the weakness of the beneficiaries as a group to support and effectively help the ACA.The 50 million uninsured are not a cohesive advocacy group, with neither the organizational skills nor deep pockets of opponents. Thousands of parents no doubt welcome an important feature of the ACA, already in place: the insurance coverage of their
children to age 26. But they have not organized themselves to support it. The same can be said for those to be spared ceiling limits on insurance benefits.
The combination of a president weak in serving his own cause, the forces arrayed against him, and the failure to enlist beneficiaries of the ACA to help out paints a bleak picture. The hard-and-fast rule these days for pessimistic pundits is to end by mentioning some light at the end of the tunnel, to find a hopeful sign somewhere. I plan to observe that rule–once I see that light and find reasons for hope. I am searching.
Daniel Callahan is President Emeritus of The Hastings Center and author most recently of Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System (Princeton University Press). This fall, his memoir, In Search of the Good: A Life in Bioethics, will be published by The MIT Press and a collection of his essays, The Roots of Bioethics: Health, Progress, Technology, Death, will be published by Oxford University Press.