Four months after the botched rollout of Obamacare, things are starting to look up a little for the president and his troubled program: Some threeÂ million Americans have selected a plan through the state or federal exchanges, and numbers in December were seven times that of October and November combined.
And yet reviews of the Affordable Care Act in the wake of its disastrous opening days remain stubbornly negative. While much of the attention has focused on technological and bureaucratic failures, or recently the delayed requirements, the Web siteâ€™s botched launch also illustrates the key weaknesses of this presidentâ€™s leadership style.
The first is President Obamaâ€™s failure to connect his rhetoric with either his actions or with what voters truly value. In 2006 and 2007, I helped develop the messaging that was used by health-care reform advocates and Democratic candidates. We identified three principles that were essential to swing public opinion. The first was to reassure people that if they wanted to keep their doctor, they would be able to do so. The second was that people should have more choices, not fewer. And the third was the central idea behind health care reform: that no American would ever again have to choose between food on the table and a trip to the doctor.
But what the administration never realized was why that first principle â€” keeping your doctor â€” was so important. The relationship between people and their doctors is not just transactional. Itâ€™s intensely personal. People like the feeling of personal control that comes with choosing both their doctor and their health-care plan.
Thatâ€™s what the president never seemed to â€śgetâ€ť emotionally: How even three or four cases of people getting a cancellation notice from their insurance company â€” let alone three or four million â€” would lead to feelings of betrayal. Obamaâ€™s first presidential campaign elicited a strong emotional response from the public, but he has since had trouble connecting in the same way as a leader. He and his advisers embraced a version of those three health-care principles during the 2008 campaign. But in office, they failed to keep these values front and center in their new plan, adding emotional distance between the president and the average American.
That leads to the second way Obamacare is emblematic of the fault lines in Obamaâ€™s leadership. He rarely makes the case for effective government with the full-throated support of a true believer. Yes, he may talk of it in his speeches occasionally (once with passion in a brilliant but obscure commencement address), but the president has shied away from leading that conversation. Perhaps heâ€™s skittish because the right has been relentless in its cries of â€śsocialism.â€ť Still, his half-hearted commitment to the role of government has cost him the support of many in his base and has left public opinion toward government at or near its lowest ebb in recorded history.
The president came of age in the Reagan era and has grown up politically at a time of corporate control over political fundraising. Back in 2009 and 2010, according to many economists â€” including Christina Romer, the first chair of Obamaâ€™s Council of Economic Advisers, one of the leading authorities on the New Deal and the Great Depression â€” the country needed a $1.5 trillion stimulus and a WPA-like jobs program that would kick the economy into first gear. Obama compromised with half a tank. He also didnâ€™t get under the hood and closely supervise the mechanics. The result was an economy running on fumes, seemingly â€śprovingâ€ť to most Americans that government couldnâ€™t solve our economic problems.
The president did the same thing with health care, poorly marketing what health-care reform would mean for tens of millions of people. He didnâ€™t start small with a beta version in a friendly state or two. That would have allowed the administration to work out the bugs and build consumer confidence before going national. It also would have proven that government could do something right, accomplishing precisely what the private sector couldnâ€™t after nearly a century of trying.
In addition to rolling out a flawed product, the administration also failed to emphasize how government was freeing Americans from the tyranny of insurance companies. As they raised premiums and cancelled perfectly good policies, Obama should have been able to make a strong case for how Obamacare would help. Instead, the best the administration could muster was language it never even intended about a â€śpublic option,â€ť which evokes images of long lines, crowded waiting rooms and inferior public care.
In truth, we already had a good public option â€” Medicare â€” and didnâ€™t need to create a new one. From a policy standpoint, allowing people to buy into Medicare as one of the options on the exchanges would have been the simplest way of talking about an alternative to big insurance companies, as well as shoring up Medicare with a population of younger, healthier people. Plus, there would have been a pool of ready salespeople: the many American parents and grandparents who could vouch for their positive experiences with the program.
Finally, Obamacare highlights a third weakness in the presidentâ€™s leadership: his aversion to putting the bully into the bully pulpit. He did not attack the insurance industry, whose CEOs were almost as unpopular as bankers in 2009. Nor did he use the winds of populist change that were at his back, as he is now beginning to do in his calls for a higher minimum wage. Rather, Obama created a basically free-market approach to health reform, albeit one that imposed solid minimum standards that reflect a very popular form of government regulation.
When conservatives shouted about â€śdeath panelsâ€ť in response to even the limited role of government envisioned by the president and his allies, he could have swung back with the obvious response: â€śWe already have death panels â€” theyâ€™re called insurance companies.â€ť
Instead of leaving the crafting of his signature legislation to dozens of politicians who needed the backing of insurance and pharmaceutical companies for their next campaign, he could have proposed his own plan, and made clear he would veto any bill that did not reflect the three principles he had promised would guide it.Â And instead of ensuring that the most important and popular idea of his signature legislation â€” the elimination of preexisting conditions â€” would have taken effect with the stroke of his pen, just before the crucial 2010 midterms, he allowed that provision to be pushed out for years. In the process, the right was able to seize the megaphone.
Eventually, health-care reform will no doubt be this presidentâ€™s greatest legacy. More and more people are discovering they can get health insurance for the first time, and now that many of the Web siteâ€™s kinks are being worked out, the numbers are growing quickly.
But Obamacareâ€™s ultimate success will require years of plastic surgery to cover the scars of leadership failures that were behind its troubled beginning: the poor messaging, the lack of commitment to strong, effective government, and the presidentâ€™s aversion to treating the problem with an aggressiveness that equaled its magnitude. Obamaâ€™s name will live on as part of health reformâ€™s history. But so, too, will the power of Reaganâ€™s messageÂ â€”Â that â€śgovernment is the problem, not the solutionâ€ťÂ â€”Â which the president inadvertently echoed.
Drew Westen is professor of psychology and psychiatry at Emory University and the author of The Political Brain: The Role of Emotions in Deciding the Fate of the Nation, coming out this year in its second edition.