Given the negative media in the weeks leading up to the first official deadline for signing up for health coverage under the Affordable Care Act — not to mention the multimillion-dollar advertising scare campaign financed by opponents — the expectation was for the White House to be licking Obamacare wounds this spring. The “failure” would be the fault of a problematic healthcare.gov and insufficient enrollments in the new exchange-offered insurance plans.
But guess what? Everybody got the story wrong — even the Obama Administration. Not only did Obamacare not fail, it managed to best its goal for exchange-provided policies, now topping 8 million, even after the Administration had tried to temper expectations by lowering the goal to 6 million.
It turns out that Americans really do need health insurance, and they decided to overcome a poorly designed website and the inherent complications of buying coverage to get some. In addition, 3 million young people between the ages of 18 and 26 were able to get health insurance through their parents’ plans, and millions more were able to sign up for coverage under Medicaid. Even people who already had insurance are better off since the law requires policies to cover more procedures, particularly preventive care; forbid cancellations based on pre-existing conditions; and eliminated annual and lifetime caps on benefits.
So why were the expectations so wrong? One of the most frequent charges has been aimed at the efforts to communicate/sell the law to the American people. Just six months after he signed the law, President Obama himself said, “Sometimes I fault myself for not having been able to make the case more clearly to the country.” Politico, Washington’s favorite inside clubhouse, graded the Administration’s Obamacare communications efforts with a Gentleman’s C.
But all the criticisms were being lodged before we knew how enrollments were actually going to go. The Gentleman’s C may now be at least an A minus, maybe even an A — because at the end of the day the most important goal was to sign people up, and that is in fact what happened. We seemed to forget that deadlines are there because most of us don’t do anything until they arrive.
While it may have seemed like nothing was going on or the Administration was engaging in sketchy attempts to promote enrollment — President Obama’s quirky appearance on Funny or Die’s Between Two Ferns or Vice President Joe Biden’s guest spot on Rachael Ray — it was exactly those unexpected partnerships that ended up bringing the issue to people in more everyday, digestible ways.
Having spent most of the past four years working on Obamacare, I have a vested interest in its success and can’t claim an unbiased view. But there are three lessons to take away — for policymakers, the media and the public:
Lesson #1: It’s hard to sell what you can’t see.
Obamacare was enacted on March 23, 2010, after a bitter, highly partisan yearlong debate in Congress. The final vote was entirely along party lines, highly unusual for any major law enacted in the past century. While there were some immediate benefits, including the ability of parents to keep their kids on their plans, rebates for seniors with high prescription drug bills, and a prohibition against cancellations based on pre-existing conditions and lifetime benefit caps, most of the major benefits didn’t go into effect for nearly four years. Think about how you would put together a campaign to sell a new product that consumers couldn’t see or touch for four years. You and your client would say that’s impossible. And it was — at least up until the deadline loomed and then the Administration masterfully used it to its advantage. This also may be a lesson in patience for the media, which has been way too eager to jump on any tidbit — true or false — to further a storyline of controversy and conflict.
Lesson #2: When you try to sell something to everyone, you succeed in selling it to no one.
From the start, Obamacare’s proponents failed to identify their core customer audience. For a variety of reasons, the White House tried to convince all Americans that the law would help them — but that was never the case. The most direct benefits were aimed at incredibly vulnerable populations: those who live at or near the poverty line; those with medical conditions that locked or priced them out of the insurance market; and African-Americans, Latinos, young adults and women, who stood to benefit most because of high rates of uninsurance. The Administration’s efforts became much more successful once it decided to focus on women and young people. By adopting the same microtargeting approach they used in two successful elections, Team Obama could have changed the dynamics of the communications effort earlier.
Lesson #3: Never underestimate your opponent’s commitment.
The Obama White House believed (hoped) that the political fight over the healthcare law would end with the President’s signature. After all, that was the pattern for most of the major political battles over legislation in the past. The losing side tended to gripe for a while and then moved on to the next fight. This time was different: Republicans knew that they had an issue that continued to inflame their base and kept hammering away at the law. This helped the GOP win the House of Representatives in 2010 and figures prominently in the 50+ votes to repeal all or part of the law taken since then. Trying to cut through that fog of war and successfully market the benefits of the law was akin to shouting into a hurricane and being heard by anyone. Once it was clear that the fight wasn’t over, the White House should have continued the war room approach used to get the law passed. After all, Obama succeeded where presidents as far back as Teddy Roosevelt had failed.
The next big phase of Obamacare starts Nov. 15 with the next open enrollment period. But in a sense, this is only Round 1 in a protracted battle to make U.S. healthcare accessible and affordable. The next battle will be over how to bring down the cost of the system — currently the most expensive, but not the most effective, in the world. And if you thought this one was strident and unrelenting, just wait.