With health reform, familiarity is breeding contempt
In closing the deal on health-care reform, Democratic leaders assured wavering legislators that the plan would grow more popular with time as its benefits became clear. "We have to pass the bill," argued House Speaker Nancy Pelosi, so that the public "can find out what is in it." Presidential adviser David Axelrod predicted that Republicans would pay a political price for their opposition. "Let's have that fight," he said. "Make my day." Consistent with this belief, the administration recently has been rolling out attractive elements of the law, including coverage for dependents up to age 26.
But after a brief bump, support for Democratic health reform has declined. A Kaiser Family Foundation health tracking poll shows erosion in the intensity of support. Last month, 23 percent of Americans held "very favorable" views of the law. This month, that figure is 14 percent, with most of the falloff coming among Democrats (Republicans and independents already being skeptical). Other polling reinforces these views.
On the theory that the distribution of lollipops usually doesn't provoke riots of resentment, opposition to the health entitlement requires explanation.
One cause is simply economic. At a time when Americans are focused on recovery and job creation -- and how deficits and debt may eventually undermine both -- the economic case for Democratic health reform has been weak, contrived, even deceptive. Recent events in Congress make the point. Two months after passing a law that supporters claimed would reduce federal deficits, largely through Medicare cuts, the House is moving toward a temporary "doctor fix" that would add tens of billions in Medicare costs. Even more expensive fixes are likely in the future. Congressional leaders knew this spending would be necessary when they passed health reform in March. Yet they didn't include this liability in the law, in order to hide the overall cost of the entitlement. In a failing corporation, this would be a scandal, investigated by Congress. In Congress, this is known as legislative strategy.
The economic arguments for reform -- that it would reduce the deficit and health inflation -- were questionable from the beginning. Now they have been revealed as absurd. There is a social justice case for expanding health coverage. But Americans have not found it credible that the creation of a massive new entitlement will somehow help the economy.
There is, however, a deeper explanation for public skepticism about health reform. Since the New Deal, Democrats have viewed times of economic crisis as opportunities for government expansion. In the current case, government itself was implicated in the crisis. According to a poll by the Pew Research Center, public satisfaction with government plunged just as the financial collapse took place. Only 22 percent of Americans report that they trust government all or most of the time -- among the lowest levels in 50 years. One and a half years after a financial meltdown that some supposed would be a crisis for capitalism itself, 58 percent of Americans agree that "the government has gone too far in regulating business and interfering with the free enterprise system." Favorable opinion of the Democratic Party -- now firmly associated with the stimulus package, assorted bailouts and health reform -- has fallen 21 points in one year.
In this ideological environment, the administration's emphasis on publicizing the desirable details of the health law is beside the point. Americans are troubled with health reform, not because they lack knowledge of its provisions but because they are uncomfortable with social democracy.
When entitlements began in America, they were mainly focused on the elderly (through Social Security and Medicare) and the poor and disabled (through Aid to Families With Dependent Children and Medicaid). Benefits for the middle class were largely given through tax deductions for mortgage interest and the purchase of health coverage by businesses.
America eventually retreated from some entitlement commitments to the poor because they involved a moral hazard -- discouraging work and responsibility. Entitlements for the elderly have remained a strong, national consensus.
But the idea of a middle-class entitlement to health care, achieved through an individual mandate, subsidies and aggressive insurance regulation, seems to change the nature of American society. Entitlements in the Obama era are no longer a decent provision for the vulnerable; they are intended for citizens at every stage of life.
Americans resist taking this lollipop precisely because America is not Europe -- which even Europe, it seems, can no longer afford to be.