Wrong Prescription?

The failed promise of the Affordable Care Act

By Trudy Lieberman
Harper's, July 2015

In July 2009, as the Affordable Care Act moved through Congress, Steny Hoyer, the second-ranking Democrat in the House of Representatives, laughed at the idea that any legislator would actually read the bill before voting on it. If such full-body immersion were necessary to support the A.C.A., he said, “I think we would have very few votes.” In March 2010, just before the law passed, speaker of the House Nancy Pelosi made a similar point. Addressing a national conference of county officials, she declared, “We have to pass the bill so that you can find out what is in it, away from the fog of the controversy.”

Five years after its passage, the A.C.A. is not only the most hotly debated and vituperatively denounced law of the era — it is still shrouded in a fog of controversy. Many Americans have no idea how the bill works or what it was designed to accomplish. In March, a Kaiser Family Foundation study found “significant” knowledge gaps in the public’s understanding of the law. A third of the participants were unaware of the law’s key provision: offering subsidies for the uninsured.

It is no wonder Americans have been hard-pressed to learn anything about the actual workings of the A.C.A. There has been little criticism of the A.C.A. from the left, with prominent figures such as Paul Krugman, the economist and New York Times columnist, acting as cheerleaders. The right has confined itself to disinformation and risible smears, with G.O.P. presidential hopeful Ben Carson memorably defining the A.C.A. as “the worst thing that has happened to this nation since slavery.” A lack of clarity on both sides — and some deliberate bait-and-switch tactics — dogged the very creation of the law.

The A.C.A. was sold to the public on the pledge of “affordable, quality health care.” This slogan, crafted in the shop of the Democratic pollster Celinda Lake, was incessantly pushed by everyone from grassroots advocates to top government officials, even as, the new A.C.A. website, was crashing down around them in the fall of 2013. Trying to spin the disaster on Meet the Press, Pelosi grandly promised her viewers “more affordability, more accessibility, better-quality care, prevention, wellness, a healthier nation honoring the vows of our founders of life, a healthier life, [and] liberty to pursue their happiness.” President Obama, too, repeated the mantra at every opportunity. Shortly before the exchanges established by the law opened for business, he affirmed that uninsured Americans would now have “the same chance to buy quality, affordable health care as everyone else.”

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