The President's Health Care Predicament

Published March 31, 2011

Kaiser Health News

Last week marked the one-year anniversary of President Barack Obama’s health reform law. It’s an appropriate time to take a look back at the events of last year, and what they might mean in 2012 when the president will almost certainly be seeking reelection.

In early 2010, after Republican Scott Brown was elected to the Senate from Massachusetts, Obama had no choice—if he really wanted the health bill enacted—but to turn its passage into a make-or-break moment for his presidency. Nothing else would have worked. He wasn’t winning the public argument over its merits, and wasn’t going to. The balance of public opinion had been solidly against it ever since the first trillion-dollar cost estimates were released in mid-2009. The only way he was ever going to get it across the finish line was by tying the measure’s success to that of his presidency, thus forcing the hand of wavering Democrats, who didn’t want to vote yes on the legislation but were even more squeamish about derailing their own party’s fresh and promising administration. And so he made that his closing argument. As numerous press accounts documented, in private conversations with lawmakers, the president pleaded with his allies to save his presidency by voting yes on the health measure.

In the end, it worked. The health bills did pass—but at a great political price. Congressional Democrats were worn down by the lengthy process and unwilling from that point on to take any more large political risks. They didn’t even want to consider a budget bill before the November 2010 election. Consequently, other than the 2009 stimulus bill, the health law is the only legislation passed in the president’s first two years that is likely to register with a broad cross-section of voters.

Moreover, passage of the health plan with only Democratic votes enraged opponents and fueled a populist movement that propelled Republican candidates to historically large gains in the midterm elections.

Having spent so much political capital to secure its passage, one might think that the health law would feature prominently in the president’s planned reelection campaign. Certainly other presidents have used early legislative successes, even on controversial measures, to make the case that their policies were working. President Bill Clinton’s tax and spending-reduction measure of 1993 was highly controversial and polarizing. It contributed heavily to the loss of Democratic control of Congress in 1994. But Clinton also used it as the foundation of his economic message throughout his presidency, and especially in 1996, when he tied the economic recovery then underway to its passage.

But Obama is not likely to follow that model, because, unlike Clinton’s budget program, the health law provides almost nothing that the president can claim he delivered for voters.

The main selling point of the law—that it will cover everyone, or nearly everyone, with health insurance, at least according to official estimates—won’t be tested until at least 2014, when the “big bang” reforms kick in. That’s when the individual mandate, the employer requirements, the Medicaid expansion and exchange subsidies, and the new insurance rules regarding benefit packages and premium-setting all go into effect. Until those changes are actually implemented, they are simply theoretical selling points that may or may not work out as planned. That’s not going to cut it with an electorate focused on results in the here and now.

Between now and 2014, a lot of regulation will be issued, but there won’t be any real action on the ground where Americans live (other than some tax increases and Medicare cuts the administration will never mention anyway). And so the law’s proponents are left with little to talk about except the law’s “early benefits,” like coverage of 26-year-olds on their parents’ plans and the new high-risk pools for those with pre-existing conditions.

But these provisions are minor matters in the scheme of things. They are not at all central to the rest of the law, and could easily have been addressed in other legislation. Moreover, so few Americans have benefited or will benefit from them that they hardly register at all in the public consciousness. Only about 12,000 people have signed up so far for the risk pools, and no one expects the other insurance regulations to help more than a tiny percentage of the population. For most Americans, these “early benefits” are simply non-events. That makes it very difficult for the president to tout them as significant achievements.

Meanwhile, opposition to the law is unlikely to subside. If the president were to make health care a central message point in 2012, he would immediately alienate a large number of independent voters who are extremely skeptical that the law will work as planned, especially with regard to premium hikes and costs to taxpayers.

No doubt, the president will defend the new health law from every attack, even as he tries to deflate the repeal push with concessions aimed at undermining opposition without giving real ground.

But it is the law’s opponents who are most likely to bring up health care, not the president.

And that’s ironic. Because it’s clear Obama and those who passed the law consider it to be an historic achievement. But, having exhausted his first term securing its passage, the president will have to find some other rationale to justify requesting a second one.

James C. Capretta is a fellow at the Ethics and Public Policy Center.

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