The roadshow is on. With healthcare reform now a reality, President Obama and congressional Democrats are stumping across the nation to explain all the good things the new law will do for voters. They're likely to hit a wall of skepticism.
As the historic law finally passed, a Gallup Poll found that 49 percent of Americans approved the effort, while 40 percent opposed it. Other polls show less support and more opposition. Legal challenges to the law, antireform rallies, and threats of violence against supporters suggest that healthcare reform will remain a white-hot issue. In Gallup's poll, 42 percent of respondents said they're either disappointed or angry that reform passed. Republicans, not surprisingly, are the most disenchanted, but 47 percent of independents also said they're disappointed or angry. And they're the ones who could swing the November elections one way or the other.
Americans also remain confused about what the complex bill will actually do. In a poll by the Kaiser Family Foundation, for example, 41 percent of respondents believed that people who already get insurance through their employer will now have to change their coverage, even though the new law doesn't require that. Overall, the intensity of the rhetoric and the confusion over the details suggest that many Americans really don't know what to expect.
The Democratic charm offensive is meant to shore up support for the sweeping new legislation. But after 14 months of rancor over healthcare reform, voters seem unlikely to be moved by more speeches or rhetoric. Actual developments, however, could sway them. Here are 5 things that could either build or undermine support for the new reform law—depending on how the Democrats handle them:
The budget. The Congressional Budget Office, official arbiter of the cost of legislation, projects that the new healthcare reforms will reduce the federal debt by $143 billion over the next 10 years. Many voters doubt it. "There were so many accounting gimmicks in there," says Scott Schilling of Oviedo, Fla. "What has the government ever overseen that has run smoothly and not gone bankrupt? I'm sure there are one or two things, but would you bet your child's future on those, against all of the ones run so poorly?"
Schilling has a point about the CBO analysis, which counts on a 21 percent cut in payments made to doctors under Medicare to generate a big pile of cash that will help pay for new benefits. Those proposed cuts are part of an annual budget dance—dubbed the "doc fix"—in which Congress routinely overrides rules that say Medicare payments to doctors must decline every year. Instead, Congress typically approves a modest increase in payments. And it's likely to do that again this year, which will change the accounting on reform. In a separate analysis, CBO said that if Congress passes the new "doc fix" bill, it will add about $200 billion to the debt over the next 10 years. That would make health reform a budgetbuster, not a budget reducer; CBO says that the net effect of all the legislation combined would be a $59 billion increase in the debt over 10 years.
There are other plans to rewrite the dysfunctional doctor-payment rules. And the new law establishes a powerful new Medicare oversight board tasked with lowering costs by directing payments toward treatments proven to be the most effective. That's a major change likely to reduce the role of politicians in a program they continually throw more money at, to appease voters. But lowering Medicare costs will take time, leaving Democrats the tricky near-term task of rescinding some of the cuts that made reform a money-saver, then explaining why their plan went over budget within weeks of passing. Fuzzy math that obscures the details will probably produce more skepticism. Concrete new initiatives that show a determination to get costs under control would be more convincing.
"Socialized medicine." Some people worry that the new reforms are just the beginning of a much bigger government role in healthcare, similar to the systems in Canada, Britain, or France. "It's naive to think this crew in Washington just wants to fix a 'broken' system," says Chris Meyer of Hendersonville, Tenn. "They want socialized medicine plain and simple."
Do they? Some liberals obviously favor a government-run insurance plan—the "public option"—that would compete with private insurers and, in theory, use its heft to force down costs. But there wasn't enough support to pass the public option this year, and it's not clear if there ever will be. To some extent, people's comfort with the new reforms will depend on what comes next. If Democrats start pressing for a public option or an even bigger government role, fears about "socialized medicine" might start to look justified. If Congress backs off and leaves healthcare alone for a few years, voters will get more comfortable with the changes.
Republican ideas. Some of them are reasonable, with mainstream appeal. Republicans took an all-or-nothing approach toward the Obama reforms, gambling that total opposition would be more politically profitable than a compromise that got some of their own priorities included. Still, that doesn't preclude Democrats from adopting some Republican ideas down the road, such as limits on medical malpractice lawsuits, better competition among insurance companies, and new incentives for consumers to lower the cost of their own healthcare. The reform law includes some pilot programs to test such ideas. Putting government muscle behind them could make more voters feel like Washington has addressed their concerns. But if health reform remains a Democrat-only initiative, it will continue to be polarizing.
Entitlements. Social Security, Medicare, Medicaid, and other social programs now account for nearly 60 percent of all federal spending. To some critics, the new government subsidies to help 32 million uninsured Americans get health coverage sound like another huge entitlement program that America can't afford. "If you believe that the program will be run efficiently and not require huge amounts of additional money, then you are incredibly naive," says Jay Hines of Spring Hill, Kan. Democrats might mollify some critics if they started to develop real plans for reining in entitlement spending that is vastly outstripping the revenue streams meant to pay for it. But that's going to require benefit cuts, tax hikes, or both—radioactive topics that no politician wants to touch.
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Enforcement. The new law will require most Americans to have health insurance, starting in 2014. Economically, that makes sense, because a bigger pool of people paying for coverage will make it easier for the system to absorb patients with costly needs. But the requirement is still off-putting to many who don't trust the government and feel protective of their freedom. The IRS gets the thankless job of verifying if people have coverage and imposing penalty fees if they don't. It's not clear how the IRS will do this, but a light touch would be a good start. It seems inevitable that there will be scare stories—apocryphal or not—about invasive IRS agents hunting down well-meaning citizens and disrupting their lives. If most Americans have a more genial experience, it will take the air out of the scare. But if the IRS goes into vigilante mode, Washington might get its money but lose the battle for the hearts and minds of voters. And that's how you lose the war.