Thursday, September 19, 2013

Using the Term "Obamacare" to Refer to PPACA Just Furthers Public Confusion and Misunderstanding

For a while now, I've wanted to write a rant on the problematic embrace by the "centrist" and liberal media of the right-wing nickname "Obamacare" for the Patient Protection and Affordable Care Act. The universal use of the term is a sign of journalistic and intellectual laziness, a preference for convenience at the expense of clarity.

Some liberals and Democrats say they want to use the term in order to re-claim or re-appropriate it. Obama himself has even playfully alluded to this idea, noting how he likes the implication that he "cares." Re-appropriation, however, often ends up as little more than singing to the choir.

I want to address several ways in which the use of the term concedes the terms of debate to Republicans or just continues (or exacerbates) public confusion.

Amplifying Partisan Bias

Although the term "Obamacare" was first used by a health care lobbyist in 2007, its etymological origins lie within Republican messaging. Republicans used the term "HillaryCare" pejoratively to refer to the Health Security Act of 1993, the legislation crafted by the Clintons and their advisers. The term "HillaryCare" intensified the partisanship through which individuals viewed the legislation because it ensured that one's views of the Clintons shaped one's views of the proposal itself. The media adopted the term out of laziness and a desire to simplify rather than inform.

In 2007, amidst the presidential primaries, Mitt Romney was the first politician to use the term "Obamacare" in a similarly pejorative fashion. The term, of course, would gain far more popularity during the long period of congressional debate and backroom deal-making that led to the creation of the Patient Protection and Affordable Act and then during the subsequent election cycles. The term invites you--encourages you--to view PPACA as you view the president. If you are a conservative who dislikes the president, the name "Obamacare" sends a signal to you on a rather visceral level that "Affordable Care Act" does not. It should come as no surprise, then, that polls have found that Republicans support the "Affordable Care Act" more than they support "Obamacare." There's no dog whistle in the former, just wonkery.

Liberals like to view this contrast with a mix of mockery and frustration: "Look at those conservatives who like the Affordable Care Act more than Obamacare. They're the same thing!" And then those liberals will continue to use the term "Obamacare," even though they know that it strengthens conservative opposition. The GOP has well-paid spin doctors and pollsters who focus group various options for framing key issues. The GOP would not be using "Obamacare" as incessantly as they do if they didn't think it advanced their goals.

A Hint of Authoritarianism

The name "ObamaCare" (or "HillaryCare" or "RomneyCare," for that matter) connotes a sense of paternalism or authoritarianism, an echo of the personality cult even (these aren't mutually exclusive in the slightest). One gets the impression that the namesake of the program (And it connotes a discrete program, not a policy framework) branded his or her name on every newly issued card---that rather than get an Independence Blue Cross card, you'll get a Barack Obama card or a Hillary Clinton card, with the namesake's face eerily smiling back at you. Merge the "nanny state" of the conservative imagination with "Big Brother."

And this aspect of the term feeds into another Republican talking point: that the Affordable Care Act is "putting the government between you and your doctor." The "Big Brother" aspects of the term "Obamacare" advance such a frame, conveying that the president is trying to place himself directly there in the doctor's office. The power of the executive appears bloated and intrusive. (Never mind, of course, that Republicans want to put the government in your bedroom or between you and your doctor if you are a woman seeking consultation on terminating a pregnancy.)

Stoking Public Confusion

The use of the suffix "-care" in the nickname evokes the most prominent program with that suffix, Medicare. In other words, it implies that "Obamacare" is a health insurance plan. It is not. The Affordable Care Act is a Rube Goldberg structure of regulations, subsidies, and programs expanded or created anew.

It should come as no surprise then that 57% of people thought that the Affordable Care Act "create[d] a new government-run health insurance plan to be offered along with private plans" according to a Kaiser poll from March. Only 28% of people surveyed correctly knew that the law did not do this. And those percentages have barely changed since the first Kaiser poll in 2010.

Remember the story from the Huffington Post from last month about the insurance exchanges?

A middle-aged man in a red golf shirt shuffles up to a small folding table with gold trim, in a booth adorned with a flotilla of helium balloons, where government workers at the Kentucky State Fair are hawking the virtues of Kynect, the state’s health benefit exchange established by Obamacare.

The man is impressed. "This beats Obamacare I hope," he mutters to one of the workers.

“Do I burst his bubble?” wonders Reina Diaz-Dempsey, overseeing the operation. She doesn't. If he signs up, it's a win-win, whether he knows he's been ensnared by Obamacare or not. It is no surprise that he is confused. He probably thinks that "Obamacare" is a government-run health insurance plan as the name implies, rather than a complex health policy framework including state-administered market-based exchange through which he would be required to purchase private health insurance.

The inspiration for writing this piece came from a tweet I saw the other night. Al-Jazeera English tweeted a link asking, "Are young people going to sign up for Obamacare?" After reading that, my response was "Well, what the heck do you mean?" Do you mean "Will young people sign up for the insurance exchanges in their state through which they would buy private insurance, perhaps with government subsidies if they qualify?" Do you mean "Will young people sign up for Medicaid if they fall in the threshold of the expanded coverage?" You can't "sign up for Obamacare" because "Obamacare" is not a health insurance plan. Equating the exchanges (the part) with the law itself (the whole) creates a corrupted, reverse synecdoche that just furthers public confusion. And confused people dislike what is making them confused.

The use of the term "Obamacare" to refer simultaneously or alternately to the "state-level health insurance exchanges" and the "Patient Protection and Affordable Care Act" also creates confusion about what the law has already done so far. It is lazy or just inaccurate to say that "Obamacare" starts when the exchanges begin or when the individual mandate takes effect. A number of provisions of the law have already taken effect, some immediately. Let's take a look at the timeline provided by

Here's what took effect immediately in 2010 after the signing of the law:

Coverage for children with pre-existing conditions

Coverage for young adults under 26

No more lifetime limits on coverage

No more arbitrary cancellations or rescissions

Right to appeal health plan decisions

Consumer Assistance Program

Small business tax credit

Temporary coverage for people with pre-existing conditions

Community Health Centers 
And then in 2011, the following pieces were implemented:

Prescription drug discounts for seniors

Free Medicare preventive services for seniors

The 80/20 Rule (Medical Loss Ratio)

Rate Review
And then in 2012:

New preventive services for women

Summary of Benefits and Coverage 
As you know, the insurance exchanges are slated to start next month.

Many provisions take effect next year or, because of recent self-imposed delays, the following year.

January 1: Coverage begins in the Health Insurance Marketplace

Coverage for pre-existing conditions

Savings on monthly premiums and out-of-pocket costs

Medicaid expansion

No more yearly limits on coverage

Expanded small business tax credit

March 31: Open enrollment closes

2015: Employer Shared Responsibility Payment 
(If you want an explanation of any of these pieces, just go to the website.)

In other words, the health policy framework created by PPACA has not yet been fully implemented. However, many changes have already been made. Equating "Obamacare" with the full law and then also with the "exchanges + mandate" makes people forget the changes that have already been made and not realize some of the benefits they may have already received. For example, because of PPACA, I was able to stay under my dad's insurance during grad school and during my job search several months after graduation. But the language used to speak of the law allows people to forget about those comparatively small changes that nonetheless have very real and important impacts on people.

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