Blood Pressure Rising on Health Care Implementation

by John Lawrence

In the summer of 2011 – nearly a year and a half after President Obama signed into law the Patient Protection and Affordable Care Act (ACA) – I found myself engaged in a health care discussion with another fervent supporter of both the President and the new law.   I was on vacation in Nantucket, and not terribly interested in discussing the finer points of reimbursement differentials for regional disparities, but neither was the person with whom I was speaking.  He had a much more basic question in response to my extolling the landmark achievement: “If the law is going to do so many good things for so many people, why isn’t anybody talking about the benefits?  Where’s the message?”


A couple of days later, my younger son fell while ice skating (yes, in August) and managed to put a two-inch gash into his chin.  While sitting in the emergency room, a young mother brought in her newborn for a well-baby visit and was told by the receptionist, “No charge, at least, not unless they repeal the new health law.” The mother’s face looked completely blank.  No one had informed her about the cost-free well-child care visits included in the law.


They may not have been sold on the virtues of the health care law, but I got the message.  Returning to my Capitol Hill office, I asked our communications team to put together a brief pamphlet detailing the benefits under the ACA in effect already, and those designed to phase in over the next three years.  The resulting four page brochure was used not only by Leader Pelosi and her staff, but disseminated to all House Democrats who were being peppered with constituent inquiries and needed simple, accurate answers about the law’s provisions.


We are now closing in on October 1, when key implementation actions begin for the remaining provisions of the law, including the requirement that businesses and individuals purchase coverage.  And yet according to a new Kaiser poll, two-thirds of those without insurance still are without information about how the law will impact them.  Other polls put the number of befuddled beneficiaries at 3 out of 4.


I recently delivered the Levitt Lecture at the Eagleton Institute of Politics at Rutgers on the subject of the benefits of the ACA (@  I recounted the challenges surmounted in passing the law through Congress, its key provisions, and its beneficial impact on the economy and the delivery of health care services.  I also spoke to Eagleton funders, taught a class on politics, and participated in a dinner with New Jersey health care experts, public and private, Democratic and Republican, supporters of the ACA and maybe a few doubters.  Surprisingly, the question asked at each venue was not what I had anticipated – “Why did you give up (sic) on the Public Option/Single Payer?!” – but rather,  “Why isn’t anyone talking about the good things in this law?  Where’s the message?” 


I wish I had a better answer.  But the fact is that with full implementation drawing closer daily, it is less a strategic or historic question than very practical concern.  People in the Administration may think they have effectively spent the last three years selling the ACA and its benefits, but if so, they are assuredly the only people I have encountered who would agree.

Effective messaging about the law was high on the agenda of congressional Democrats even before the law was passed or signed.  Many legislators felt burned by the White House’s lethargic promotion of the American Recovery and Reinvestment Act (ARRA) that President Obama had signed on February 17, 2009.   Negotiations on the stimulus established the formula for all major legislation that followed in the 111th Congress: virtually total Republican opposition, despite substantial concessions to Republicans on the size of the package and its design, which poured hundreds of billions of dollars into tax cuts rather than specific job creation efforts.  Facing GOP intransigence, Speaker Pelosi and Majority Leader Sen. Harry Reid struggled to keep on board Democrats who wanted a bigger package, including more job creation.


Yet almost immediately after the enactment of ARRA, Members began asking why the new Administration’s promotion of the law seemed so fainthearted.  Vice President Biden was put in charge of the effort to publicize the law’s benefits, but he seemed to lack a strong commitment from others in the White House.  As weeks went by, the grumbling began in earnest: when was the Administration going to really sell the recovery package?


Wary that this unsatisfactory experience might be repeated, we sought a commitment to a rigorous health care messaging effort in numerous meetings with Administration officials up to and including the President himself, even before the law was signed. Without fail, we were assured, no effort would be spared to sell the legislation.  Promises like, “You will see an effort like you have never seen before” were made to concerned legislators.  They are still waiting.


The White House initially promised to support an independent organization to proselytize the health care message, but it fizzled before accomplishing anything.  Senior staff were reportedly assigned to manage the selling of the new law, also with little or no apparent impact.  Others were drawn off to the expanding re-election campaign.  When I asked one senior White House aide why no one was working on selling the most important initiative of the President’s first term, I was told, “We were working on the policy and the message sort of got lost.”  My response was, “Why were the message people working on policy?”


Now, three years after the fact, there is growing apprehension that the October 1 date for open enrollment will arrive without legislators or the general public knowing exactly what to do.  More than half the states are contributing to the confusion by refusing to create insurance exchanges, bucking the responsibility to the federal government.  Members of Congress who faced angry (if misinformed) constituents at town hall meetings in the summer of 2009 now worry they will reappear, and in greater numbers, at their district offices asking for help with signing up for insurance coverage. Members definitely do not feel prepared to provide needed instruction.


The Administration assures that facilitators are being trained and will be sent to regional offices of the Department of Health and Human Services to assist in the enrollment  campaign later this year, but many Members are skeptical that will be sufficient.  A lot more than a facilitator here and there is going to be needed to respond to the barrage of complex questions Members know are heading their way.


Efforts have emerged to ease people through implementation, in particular Enroll America, a 501(c)(3) whose board of directors includes key players in the coalition that helped achieve enactment of the ACA including Ron Pollack of Families United and Sister Mary Carroll, who defied the Catholic bishops to support enactment during critical days of the ACA negotiations.  Representatives from the health care and insurance industries also serve on the board.  HHS Secretary Sebelius has been vocal and effective; at a House hearing, she recently decimated clueless Republican questioners who were diligently reading the alarmist (and inaccurate) accusations prepared by their staffs.  But nothing will substitute for an aggressive and persistent effort from the White House, and specifically, from the President.  Yet too often, questions about the President’s role in an ACA messaging campaign were answered with a terse, “He’s going to be giving a speech.” 


We all know that the detractors will be assiduously working the House and Senate floor, the op ed pages, blogs and cable shows, wagging their fingers on TV and reminding Americans that they had warned Obamacare would be problematic.  We all know the media and press will highlight the defiant “patriot” who will refuse to sign up for care and dare the government to impose a fine.  We have long known those push backs would crescendo this fall – because House Members, who go home to their districts every week, have endured them ever since the law was signed.  The question now is: will there be a persistent, concerted and sophisticated effort at marketing and education that has so far been more a promise than a plan? 


Or is everyone still working on policy?