Cries of Crisis: Rethinking the Health Care Debate

5. The Health Insurance Crisis

102 S i n c e t h e e a r ly 1 9 7 0 s , advocates of national health insurance framed debates over universal coverage using the language and imagery of crisis. A familiar cycle emerged during each reform period, as elected officials and interest groups raised warnings of an emerging crisis in the nation’s health insurance system. Reformers argued that the impending implosion of the nation’s health insurance system demanded immediate action, and public officials and the mass media hailed the passage of reform as “inevitable.” Opponents, however, succeeded in redefining the terms of public discourse each time national health insurance appeared on the policy agenda. Ideological foes and affected interest groups defined reformers’ prescription for the uninsured—universal coverage—as worse than the disease itself. Crisis narratives appeared in a variety of different settings, including political campaigns, legislative debates, news coverage, popular magazines, and televised documentaries. The narrators of this story varied, and included political candidates, interest-group representatives, reporters, and even characters in popular television programs and movies. Each narrative of crisis varied, but all reinforced the sense that the system was rapidly deteriorating . The principal protagonists in these stories of crisis were hardworking families facing circumstances beyond their control. Similar arguments reappeared during the contentious debates over health care reform in 2009–10. Ironically, the passage of the Patient Protection and Affordable Care Act (Public Law 111-148) illustrated the dysfunctional characc h a p t e r f i v e the health insurance crisis By any reasonable definition, there is a crisis in insurance coverage when tens of millions of Americans remain uninsured and live in constant fear of bankruptcy should they become ill. —“Yes, There Is a Health Crisis,” editorial, New York Times, January 30, 1994 There are an estimated 46 million Americans who don’t have health insurance. . . . This is a national health care crisis. —Peter Jennings, “Breakdown: America’s Health Insurance Crisis,” Prime Time Live, December 15, 2005 t h e h e a l t h i n s u r a n c e c r i s i s 103 ter of public discourse about health care reform. Within a year of its passage, the fragile consensus in support of universal coverage began to fray. The PPACA was also the first major social reform to be enacted by Congress on a party-line vote, without a single Republican vote in either chamber. Ironically , the principal beneficiaries of the new law were Republican challengers and Democratic legislators who cast votes against the bill. Public disillusionment with health care reform contributed to the “shellacking ” suffered by President Obama and congressional Democrats in the 2010 midterm elections. During the fall campaign, Democratic candidates distanced themselves from the bill, or sought to explain their votes to a skeptical electorate. Remarkably, more Americans believed that their families would be worse off after the passage of reform than felt they would benefit from the new law. Less than a year after the passage of the PPACA, a plurality of Americans (46 percent) favored its repeal. Reformers, in short, had failed to weave a persuasive policy story for voters. By January 2011, more members of the House cast votes to repeal the PPACA (245) than had supported it (219) less than ten months earlier, and twenty-seven states banded together to challenge the constitutionality of the new law in federal courts. The result, as Atul Gawande has observed, is that “the battle for health-care reform has only begun.”1 This ongoing stalemate has its roots in the language of health care reform and, in particular, in the narratives of crisis used to frame public debates about the need for universal coverage. Supporters of the new law— including President Obama and congressional Democrats—blamed “misleading ” attacks and a “stunningly effective misinformation campaign” waged by Republicans for stoking public opposition. As President Obama noted in his address to Congress in September 2009, “Given all the misinformation that’s been spread over the past few months, I realize that many Americans have grown nervous about reform.” Media analyses denounced the “lies and fantasies about health care reform” and dismissed attacks on the new law as a “sort of lunatic paranoia—touched with populism, nativism, racism, and anti-intellectualism [that] has long been a feature of the fringe, especially during times of economic bewilderment.” Surveying the continued controversy over health care reform after the passage of the PPACA, academic observers attributed public hostility...