Some years ago, while working on a doomed presidential campaign that staked too much on a detailed, flawed health-reform proposal, I organized a meeting of the policy and communications staff tasked with explaining the plan. The hardest thing for young, healthy, insured policy wonks like us to keep in mind, I recall saying, is that the place in our brain where we think about health and security is close to the brain's locus of anxiety. And the voters most interested in health policy are also most likely to be anxious about their health or insurance coverage. And so, as frustrated as these voters may be with their current health insurance or lack thereof, they will be the least receptive to wonky explanations about how a complicated health proposal will improve the system for everyone.
A standard lesson of behavioral economics is that people weigh the risk of losing something they have more heavily than the chance of gaining something better. That's even before coming to any question of trust in government or Democrats or liberals. Getting over the hurdle of convincing people that a complicated change will be for the better must always overcome that basic psychology. Overcoming that obstacle, whether in the minds of voters or politicians, is the basic story of the yearlong journey toward health reform's passage. Democrats were aware of that challenge as early as the 2008 campaign, which, remarkably, forged a shared approach to health reform, rather than a half-dozen incompatible alternatives. Hillary Clinton and then Barack Obama tried to buy anti-anxiety insurance with the promise that "if you like the coverage you have, nothing will change." While this strategic maneuver represented a lesson learned from the overblown promises of 1993, it created a perception that the legislation would benefit only the uninsured and offered nothing but costs for those of us with insurance.
Much of the rest of the year's journey can be seen as a struggle to hold back the tide of anxiety. On the political side, there was the anxiety of House and Senate Democrats who sought the double-insurance of being able to say they voted "no" on health reform, even if they hoped it passed. There was the odd fact, as Harold Pollack has noted, that members of Congress who represented districts with higher rates of the uninsured -- the group most likely to benefit -- were more likely to either oppose the bill or be among the wavering Democrats than those whose constituents were more secure. The ranks of anti-reform Tea Partiers appear to be filled with people whose toeholds in the economy are shaky enough that they would benefit enormously from the protections in the legislation and from access to a real market for individual health insurance. However, they seem to have convinced themselves that they worked hard for what precarious economic and personal well-being they have, and any change will more than likely threaten it, especially if government is involved or if people like "the uninsured" benefit.
It's not a big "What's the Matter with Kansas?" mystery why people without health insurance -- or at high risk of losing it -- would have opposed this bill. In a high-risk, high-inequality economy, people desperately grab onto whatever shards of security they have. This behavior goes well beyond health care. For example, anxious workers might not join unions to demand a greater share of their employers' profits, but they can be persuaded to worry instead about the company's survival. In the 2006 and 2008 elections, the Chamber of Commerce and other business groups helped companies set up Web sites for their employees on issues that should matter to them, usually topped by causes like eliminating the estate tax or reducing federal regulations.
A high-risk, high-inequality, high-anxiety economy is a breeding ground for reactionary views. As those voters with only a little grab tightly to what they have, a vicious political cycle reinforces itself. Those who casually urge Barack Obama to be more like Franklin Roosevelt or Lyndon Johnson should acknowledge the very different climates in which those men governed: FDR's world was one in which the entire edifice of American capitalism had fallen in, much of the population had lost everything, and people were willing to try anything. LBJ's moments of triumph came at the peak of American postwar optimism, world dominance, and unionized middle-class security. Transformative social innovations may grow in a climate of total despair or great hope. But low-grade anxiety lies somewhere in between and provides a much less hospitable and even toxic environment for change.
It is a staggering achievement that Nancy Pelosi, Barack Obama, and others have carried this reform to the end despite these circumstances. Unfortunately, the toxic -- and easily manipulated -- political environment remains, and a lot of anxious moments still lie ahead. It's certainly dangerous to launch such a major program with one political party entirely committed to stirring up a backlash; "Repeal and Replace," we're told, will be the Republican motto in the fall. It's possible that the law's popularity might not rest on its true success – it may be blamed for insurance rate increases or credited for unrelated improvements.
But that's too narrow a view of the bill's long-term effect on our political culture and the possibilities for further progressive movement. Social Security, for example, is not just politically successful in the sense that it's popular. It's successful because it dramatically reduced the fear associated with old age or disability. It gave Americans a confidence that they would be protected, a confidence that led to a greater generosity when it came to later efforts, such as Medicaid and Medicare. Health reform will succeed politically not by being popular but by working. That is, by giving Americans a much greater sense that they are not on the brink of losing everything, that they can change jobs or start their own business or admit to a medical condition without risking disaster. It will widen the distance between the place in our brains where we think about health and the place of anxiety. And people who have that kind of confidence, over time, will be willing to do more to end the vicious circle of risk, unease, and inequality.