Dear Republicans, welcome to the Health Reform PR Fire Swamp (HRPRFS)! Like the Fire Swamp from the Princess Bride, the HRPRFS features several obstacles that did tremendous damage to the Affordable Care Act. As Republicans are hurtling forward with their ACA replacement bill, now called the American Health Care Act, it’s time to reflect on the Democrats’ failures. Here’s how Democrats fared against the Fire Swamp’s terrors, and how Republicans might avoid the same fate:
Flame Spurts: In the Princess Bride, flame spurts erupt seemingly unexpectedly in the Fire Swamp. But on closer inspection, it is discovered that a distinctive popping sound precedes each flame spurt, making them easier to avoid.
In the HRPRFS, it’s very clear that flame spurts erupt every time a blanket claim is made by a health care reform bill’s proponents. Case in point: former President Obama’s claim that “if you like your health care plan, you can keep it.” This statement will go down as one of the worst PR blunders of the Obama Administration. The reality was that 4 million people on the individual market had to switch plans, in many cases because their old plans did not meet the minimum creditable coverage standards imposed by the ACA. But it’s too late for explaining once the flame spurts have burned you—ask Princess Buttercup.
Republicans seem to have learned something from the Democrats’ failure to avoid these flame spurts. HHS Secretary Tom Price, speaking earlier this month, stopped short of saying everyone would be able to keep their doctors with the ACA replacement bill, instead saying “Our goal is absolutely to make certain that individuals have the opportunity to select their physician.”
Rodents of Unusual Size: The Fire Swamp in the Princess Bride featured giant, gnarly rats with sharp teeth. The ACA, meanwhile, got hit with Premium Increases of Unusual Size. When it was reported last fall that premiums on the Arizona Health Exchange would grow by an average of 116 percent for a mid-level plan, those affected were outraged, and Republicans found a new rallying cry for their claims that “Obamacare is collapsing”.
Just one insurer remains in the market, down from eight health insurers last year, after the payers priced the products too low to adequately cover the costs of a sicker risk pool than had been predicted. It was reported at the time that just a small percentage of Arizona’s population buys their insurance on the ACA marketplace and that most of those receive subsidies to absorb those large increases. But it almost doesn’t matter.
After hearing those Premium Increases of Unusual Size, everything else just sounds like a dull hum. Those big numbers stick in the imagination of the public and explaining, again, is fruitless. Earlier this month, The New York Times tried again, publishing an interactive feature explaining that only 3 percent of Americans face ACA premium increases, because everyone else either has employer-sponsored health plans, which have faced modest increases in recent years, or they receive subsidies to cover large premium increases.
Republicans faced their own Rodent of Unusual Size when the Congressional Budget Office estimated that 24 million Americans would lose their health insurance under their proposed replacement bill. They attempted to defuse the anticipated RUS by discrediting the CBO ahead of time, explaining that the non-partisan agency had previously been wrong on ACA insured estimates. But that tactic mostly failed, and Republicans are busily amending the bill to try to reduce that 24 million uninsured number, while also appeasing conservatives who want to further limit Medicaid spending.
Lightning Sand: Another of the three terrors of the Princess Bride’s Fire Swamp is lightning sand, a drier and quicker form of quicksand that swallowed up Buttercup in an instant. When it comes to health reform PR, the lightning sand tends to suck in any positive PR, making it instantly disappear in the shadow of bad news.
The dominant story of the ACA over the past several months has been high prices and few choices for consumers. This narrative has drowned out more positive stories, such as how the ACA has enabled a large number of small business owners and entrepreneurs to access health coverage. The health reform PR lightning sand has also tended to bury encouraging ACA cost data. For instance, the federal government saved $7.4 billion in avoided payments to hospitals to cover the uninsured—known as the uncompensated care pool—in one year alone, 2014. More than two-thirds of these costs were avoided due to Medicaid expansion, a part of the ACA which is now in Republicans’ crosshairs.
Republicans are getting their first taste of the lightning sand, as the CBO estimated that their ACA replacement bill would save $337 billion, but it was quickly buried by the fact that the bill would increase the ranks of the uninsured by 24 million (See: RUSes, above).
Bog of Eternal Stench: The pitfalls of health reform PR cannot adequately be contained by one 1980s fantasy film. So, I’ll offer Labyrinth’s Bog of Eternal Stench as an important cautionary tale for Republicans as they move their ACA replacement bill through Congress.
When it comes to PR, a botched launch stinks for a long, long time. The healthcare.gov debacle haunted the ACA for years. It severely hobbled the credibility of the Obama Administration’s health reform efforts, as well as causing actual harm for some consumers who were unable to sign up for new health plans in time. Reporters continued to write about it as late as 2016.
Republicans will necessarily have to overhaul—or completely replace—the federal exchange. State exchanges will also have to change dramatically to accommodate new plan designs, pricing structures and tax credits.
If Republicans decide to eliminate the exchanges, they will need to figure out how Americans will access these new plans instead. In any event, this upcoming transition is ripe for technical and operational challenges that are likely to have real human consequences. Republicans would do well to prepare the public ahead of time for road bumps, while maintaining realistic internal timelines.
Putting the Fire Swamp in the Rearview
In the Princess Bride, Buttercup and Westley manage to best all the Fire Swamp’s challenges and live happily ever after. Robin Wright has moved on from hapless Princess to shrewd First Lady, as Claire Underwood on House of Cards, with a very promising political future.
But that’s only in Hollywood. The only escape from the health reform PR Fire Swamp, it seems, is to hand off responsibility for crafting and executing the legislation to the other party. Democratic House Leader Nancy Pelosi has been clear, it’s the GOP’s Fire Swamp now. It’s Republicans’ turn to listen for the popping sounds before the flame spurts, and do their best to set Americans’ expectations about what this new incarnation of health reform will and won’t accomplish, and within what timeframe.