(Brian Taylor For The Washington Post)

If former Massachusetts governor Mitt Romney and President Obama face off in the 2012 presidential campaign, America will witness the singular spectacle of two candidates getting very little love — and plenty of hate — for the same signature achievement: reforming health care.

Both overcame long odds to pass legislation, Romney in Massachusetts, Obama at the national level. Even the specifics of their reform laws are similar — both include subsidies for private insurance, the establishment of insurance exchanges and a mandate for individuals to maintain a minimum level of coverage. Each man expected to reap credit for his effort. But neither has gotten any political mileage out of it — in fact, both may have lost more ground than they picked up.

Why didn’t health-care reform pay off politically? In another era, we might be celebrating the remarkable fact that both a Democratic president and a leading Republican challenger arrived at fundamentally the same approach to fixing our health-care system. But that is not the America we live in now. Instead of rejoicing at how we’ve finally solved a national problem with a long and acrimonious history, we’re about to plunge into a new phase of that battle, with the Supreme Court agreeing to rule on the health law’s constitutionality in its new term — possibly at the height of a presidential campaign that could come down to the two men most tied to the issue.

In the abstract, many Americans say they want just the kind of moderate, constructive leadership that Romney and Obama exercised in passing health-care reform. But these days, moderate policies don’t necessarily make good politics. Romney’s biggest achievement has become his biggest burden in the GOP primaries because tea-drinking Republicans aren’t much interested in compromises. Likewise, on the left, many Democrats are disappointed that the 2010 Patient Protection and Affordable Care Act didn’t go far enough and, in particular, omitted a “public option” for insurance.

After watching Romney succeed in 2006 with a reform approach descended from a long line of moderate Republican proposals, Democrats gravitated to a similar middle-of-the-road effort that they thought could gain broad, bipartisan support. But in doing so, they made some key concessions to moderation that have proved especially damaging to popular support for national health-care reform. And it didn’t have to be that way.

Primarily to ensure that the Congressional Budget Office would “score” the legislation as reducing the deficit, Obama agreed to delay implementation of the major provisions of the law until January 2014, nearly four years after the bill passed. And contrary to his position during the 2008 campaign, the president also agreed to an individual mandate — again, partly to keep down the program’s cost — even though the mandate predictably became the law’s most unpopular provision and the focus of legal and political challenges.

These concessions have had opposite effects on the emotional commitments in the two parties. While opposition to the mandate has become a rallying point for Republicans, the long delay in implementing reforms has left many Democrats discouraged and uncertain about the law’s benefits. The four-year timetable also undercuts any possible political gain from the reforms; the president will have little to show by the 2012 election and little chance of clearing up the confusion and anxieties about the law.

And what of the CBO’s projections that the Affordable Care Act would produce budget savings, achieved at such great political cost? Those predictions haven’t won over public opinion. According to surveys, large majorities believe (mistakenly) that the legislation will raise the deficit.

With little direct experience to go on, people are generally responding to the law on a partisan basis, though not with equal zeal: Republicans are strongly against the reforms, while Democrats are only weakly for them. An October tracking survey by the Kaiser Family Foundation found that among the public overall, 51 percent had an unfavorable view of the law and only 34 percent a favorable view, a more negative reading than most other polls.

That’s not to say a majority want to get rid of the law. In Kaiser’s September survey, 33 percent said they wanted to expand it, and 19 percent favored keeping it as it is. By contrast, 16 percent favored repealing the law and replacing it with a Republican alternative, and 21 percent just wanted to repeal it (the remainder said they don’t know).

The results can be interpreted in two ways. On the one hand, more people want to keep or expand the law (52 percent) than want to roll it back (37 percent); on the other, only about one out of five is satisfied with the law as it is. Yet with a partisan deadlock in Washington, there is no chance of amending the individual mandate or making other changes to relieve concerns about the program.

Behind the public ambivalence lie deeper obstacles to public support for health-care reform. During the mid-20th century, the United States created an increasingly complicated and expensive system that enriched the health-care industry and satisfied the majority of Americans — but artfully concealed the true costs. Ever since, as the system’s costs and the number of uninsured people have risen, reform has become a politically treacherous national imperative: Every remedy has excited a reaction from the insured public and from health-care interest groups.

The resistance to reform doesn’t arise because Americans are such determined individualists that they reject all government help. In fact, much of the opposition has come from an entitled majority: seniors on Medicare, veterans and employees with good health benefits, who receive a substantial tax subsidy. The potency of these entitlements lies in the psychology they instill; the beneficiaries do not see themselves as receiving government assistance. They believe that they have earned their coverage, whereas others have not, and they can be indignant that other people expect the government to help them.

Seniors — the age group best protected by national policies and the most consistently opposed to a universal health insurance program — exemplify the political challenge. They are particularly susceptible to anxiety about any changes in health policy. Starting with claims about “death panels,” conservatives have played on the fears of the elderly that reform will come at their expense.

The tragedy is that there were alternatives. A new health-care program does not inherently require four years to implement. Medicare went into effect one year after adoption, and Massachusetts carried out Romney’s program in about a year. If the White House and Democratic congressional leadership had made it a priority, they could have written the 2010 law with a more accelerated timetable.

The most practical option was a “rolling start” — that is, providing federal funds to states as quickly as they qualified for the program, ahead of a final deadline. This is not a fanciful idea; it was the approach of the 1993 Clinton health plan and of the 2009 bill approved by the Senate Committee on Health, Education, Labor and Pensions. Instead of dragging their feet, states would have had strong fiscal incentives to carry out reforms expeditiously. By 2012, Obama would probably have been able to point to states where the law was already in effect, and with additional states coming online in January 2013, the reforms would have been a fait accompli, even if he lost reelection.

Obama could also have avoided the battle over the individual mandate. The mandate is a curb on “free riding” — people opportunistically paying for insurance only when they need it and refusing to pay when they’re healthy. But there are other options besides the mandate. In one alternative I’ve proposed, people could opt out for a fixed period (say, five years) if they signed a form on their taxes agreeing to forgo the benefits of the law, including the insurance subsidies and the guarantee of a policy with no exclusions for preexisting conditions. Another option would be to require higher premiums for those who do not sign up during an initial enrollment period. The national law could have given states a menu of policies to control free-riding, including an individual mandate, which, if enacted at the state level, as in Massachusetts, would not have raised federal constitutional questions.

But because the federal law did include an individual mandate, the fate of Obama’s health-care reforms — and his reelection — may hinge on what the Supreme Court decides about the mandate’s constitutionality. The ruling, which many expect to come next June, in the middle of the campaign, could have far-reaching implications for national politics as well as health care. If Romney had won the presidency in 2008 and signed national legislation along the lines of his Massachusetts reforms, he might now have been the one hoping to see the mandate upheld. But instead it’s Obama who needs the high court’s approval.

When Congress passed the Medicare prescription-drug benefit in 2003, surveys indicated that senior citizens opposed the law; they viewed it more favorably only after it went into effect in 2006. Supporters of national health-care reform are hoping for just that kind of swing. Much as Romney’s program gained support in Massachusetts after being carried out, so the national law may win approval in 2014 if people can see how it works in practice.

But even if the Supreme Court upholds the individual mandate, the law may never reach that point if Obama fails to earn any credit for it and loses the election, only to see a Republican successor — perhaps, in a final irony, Romney — sign a repeal and complete a cycle of national frustration.


Paul Starr, a professor of sociology and public affairs at Princeton University, is the author of “Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform.”

More on health reform from Outlook and PostOpinions:

Five myths about health care around the world

Five myths about the politics of health reform

Is health reform constitutional?

Miller: My Supreme Court health-care brief

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