When they went forward with their plan to shut down the government in order to undo, defund, or otherwise undermine the Affordable Care Act (ACA), conservatives convinced themselves that their plan was going to work because Americans hate Obamacare. If you look at it in an extremely narrow, context-free way, that's sort of true. If you just ask people whether they approve of the ACA, you get between 35 percent and 45 percent approval. But the closer you look, the more complicated it gets. Some people disapprove of it because they feel it didn't go far enough; add them with those who say they approve, and you'll get a majority. Furthermore, and most critical for what I'd like to discuss, the actual components of the law, like giving people subsidies to buy insurance, outlawing denials for pre-existing conditions, and so on, are extremely popular (the one exception is the individual mandate).
One thing's for sure, though: You can't say that the ACA as an abstract entity is overwhelmingly popular. That has led a lot of liberals to blame Barack Obama for doing a bad job selling the law. I must have heard or read this from a hundred liberals over the last couple of years. If only he had sold it better! Then we wouldn't be in this mess. Sometimes, I've actually heard people say that he never really tried to sell it.
This argument is complete bunk. Here's why.
1. Obama did sell it. When somebody says that Obama should have sold the ACA better, you should ask them what, specifically, they think he should have done. I can offer you a stone-cold guarantee that whatever they suggest is something that the administration and its allies did, in fact, do. Take polls to figure out what appeals would be effective? Check. Distribute talking points to their allies to get everyone repeating the same message? Check. Make one speech after another on health care? Check. Run ads touting reform? Check. They did it all. So why didn't it work?
2. Health insurance is inherently complicated. See if you can answer these questions about your own health insurance. What's your co-pay for office visits? What's your deductible? What about cost-sharing for hospital admissions? Your yearly out-of-pocket maximum? Does your policy have a lifetime limit? My guess is you couldn't answer some or all of these questions, and that only scratches the surface of the contract you signed when you got insurance. Did you read it? You probably skimmed it but didn't bother to go through it line by line, just like you did the last time you downloaded a piece of software. Health insurance is incredibly complicated. Even people whose job it is to deal with health policy don't always understand their own insurance.
That means that any comprehensive reform that tried to address the pathologies of the system was going to have a hard time even explaining to people what was wrong with that system. And those pathologies are so numerous that the administration had to discuss multiple things, while the opposition only had to say that Obamacare sucks. We'll get to that opposition in a moment, but first:
3. The Affordable Care Act was an extremely complicated bill. I discussed this in my column last week, but the ACA is a gigantic kludge, a cobbled-together jumble of features each meant to solve a practical or political problem. The administration decided that the simple thing—Medicare for all—couldn't succeed politically. They also decided that it was vital to be able to tell people, "If you like your current insurance, you can keep it." They also had to keep conservative Democrats on board to get above the 60 votes necessary to defeat a Republican filibuster in the Senate. They also decided to co-opt the various interest groups like insurance companies, doctors, and hospitals that benefit from the current system, which required more complexity. They also decided that every penny of it was going to be paid for, which required new taxes and spending cuts. In and of themselves each of those decisions may have been reasonable, but they added up to a complex bill that was going to be difficult to explain, no matter how good their pollsters were and how effective a speaker the President is.
4. The American public is not particularly well informed or sophisticated when it comes to understanding policy. We don't have to go into all the details here, but anybody who sets out on a project to explain something both new and complex to a public that doesn't understand these things very well to begin with and doesn't much care is going to be fighting an uphill battle.
5. They were facing an extraordinarily well-financed, united opposition that would say or do pretty much anything. All that complexity made it easy to just lie to the public about what the ACA does. When people hear about some new horror the ACA allegedly includes, many are ready to believe it, since it contains so many different things they already don't understand. So conservatives could tell them that there are death panels, or that Obamacare forces doctors to collect information on your sex life, or that the IRS is going to have your medical records, or that Congress "exempted itself from Obamacare," or whatever else they were able to dream up.
The opposition also had the benefit of being against something, which is always easier than being for something. We're naturally more attuned to negative information than positive information, which is why it's so easy to use fear to create opposition to a new policy, and change is always frightening. "You're going to love this change!" is an inherently more difficult case to make than "Be afraid!"
Furthermore, the alliance opposing the law has virtually limitless resources at its disposal. Yesterday The New York Times published a revealing story on the network of conservative funders and activists that have made it their mission to destroy the ACA, including masterminding the current shutdown. Just one Koch brothers-linked organization no one has ever heard of called Freedom Partners Chamber of Commerce distributed an incredible $200 million last year alone to various groups fighting the ACA.
Let me close this discussion with a little historical reminder. In March of 1994, when the Clinton health-care reform was being debated, The Wall Street Journal published an article about polls and focus groups it had conducted on the plan. The article was titled "Many Don't Realize It's the Clinton Plan They Like," and it detailed how, while majorities of the public expressed disapproval of Bill Clinton's health-care plan, when its features were described to them without saying whose plan it was, majorities expressed approval of it. That's exactly the same thing we find now with the ACA. The problem wasn't that Barack Obama didn't try hard enough to sell it.
Fortunately, the success of the law won't depend on whether you can get a majority of the public to tell pollsters, "I approve of Obamacare." Once it's fully implemented, the only thing that will matter will be whether, in all its different component parts, it works.