Why Obamacare’s Success May Hinge on a Website

Who's winning, who's losing, and why.
Sept. 26 2013 3:49 PM

The Medium Is (Most of) the Message

Why Obamacare’s success may hinge on a website.

U.S. President Barack Obama
The Affordable Care Act's chief evangelizer may not be President Obama, but healthcare.gov.

Photo by Alex Wong/Getty Images

On Oct. 1 Americans will begin to sign up for health care plans as part of the Affordable Care Act. Despite all the efforts to sell Obamacare, a majority of Americans are still fearing the day. According to the latest CBS News/New York Times poll, 51 percent of Americans disapprove of the health care law and only 39 percent approve of it. Seventy-nine percent believe implementation will either not affect them or leave them worse off. On the eve of this long-fought-over moment—the day Obamacare takes affect—President Obama’s best sales tool may come down to a website: healthcare.gov.

John Dickerson John Dickerson

John Dickerson is Slate's chief political correspondent and author of On Her Trail. Read his series on the presidency and on risk.

That’s because that website will be able to give people real numbers about how the plan will affect them specifically—the abstraction will become a reality. "You may have heard a lot of things, but check it out for yourself," says David Simas, a White House deputy senior adviser working on the rollout, imagining a conversation with a skeptical consumer. "That young man will go online, fill out an application that will probably take him eight minutes, and the first thing he is going to see, depending on his income, is that he is getting money. You get a subsidy of $1,000 or $1,500, and we have seen with young people—and older people—when they see right away [that they get a subsidy], that changes immediately the perceptions of affordability."

Simas, the much-praised director of polling and research for the Obama 2012 campaign, is meticulous about data, so he was careful to manage expectations in a Wednesday morning session at the think tank Third Way. He doesn’t expect a wide swing of people rushing headlong into the program. He expects enrollment to be slow in the first two months with an uptick before Jan. 1, 2014, when coverage starts. Simas expects between 4 million and 9 million of the 40 million uninsured Americans to sign up in the first year. (The Congressional Budget Office has predicted 7 million will sign up.)

Bill Schneider, the CNN political analyst and host of the event, asked Simas about the most important and hard-to-reach customer he’s hoping to sign up: the under-30 apathetic slacker. (Schneider said he’d been asked about the Affordable Care Act by just one such specimen at a Walgreens; the fellow referred to Schneider as a “news dude.”) If millions in this age group don't sign up, the health care premiums will rise as insurance plans are stuck with only older or sicker customers. These younger Americans are irritated that they have to sign up, and remain skeptical that they will need the coverage. Some may decide to just pay the fine and not bother with the homework assignment. The website optout.org, funded by the Koch brothers, is encouraging them to do just that. 

"[The Koch brothers] have a profound misunderstanding of the people they are trying to approach," says Simas, who spent much of the last few years getting these young people to vote for Barack Obama. His argument is that three out of four young adults are open to buying insurance because they think it is valuable. What gives them pause is the cost. If Obamacare can come in under $100 a month, says Simas, they are likely to sign up.

That's where the healthcare.gov website comes in. When users sign in, they will be asked to plug in their income, age, and state. Most will be surprised to learn that they qualify for federal subsidies if their income is low enough. Some will find that they qualify for Medicaid if they live in one of the 26 states that have accepted the federal funds. Simas points to the example set by Mitt Romney in Massachusetts. Twenty-six percent of the state’s young people were uninsured. After Romney’s plan was introduced, it shrunk to 6 percent.

Simas’ argument must overcome two headaches. First, is it true that young people value insurance?  The administration's own social media campaign lists one of the core problems in reaching young, healthy Americans is that they don't see the "value" of insurance, not that it is too expensive. Second, as effective as the website may be, will uninsured Americans even visit it? A Commonwealth Fund study found only 27 percent of 19-to-29-year-olds are aware of the health insurance marketplaces.

The biggest problem associated with the healthcare.gov website is the “gov” part of it. The Affordable Care Act was the product of a long, corrosive battle and it is being administered by the government, which people don’t trust. So when Simas makes the pitch, you can hear how carefully he tries to sell signing up as detached from the politics that surround it. “This isn’t about Democrats or Republicans, the blue team or the red team. Check it out and you decide if this works for you.” Signing up is set up as an act of personal and individual empowerment. Simas is not inviting people to recline into the massive government maw, he’s leading them to the place where they can make their own choice.

If people come to the conclusion on their own, they're more likely to evangelize about it, post it on Facebook, or share it on Twitter. That's where the Obama administration wants this conversation to take place. It learned from the presidential campaign that when it comes to an issue with competing claims, people have to come to knowledge on their own or they don't believe it. Simas recounted the story of a woman at a focus group during the campaign who was frustrated by hearing conflicting spin from both sides. " ‘I don't know where to go and find the truth. If I go to one website it tells me one thing, and if I go to another website it tells me another thing.’ Well, ma'am, what do you believe? ‘When my neighbor or my co-worker or someone else I trust tells me so, because they're not going to spin me like everybody else.’ "

Of course, the White House can’t risk this conversation rising up organically. The president and his advisers have been pushing the merits of the Affordable Care Act in every possible way, and people are still confused. That’s why the administration has enlisted celebrities and other sideways approaches to reach Americans impervious to official propaganda. "There's that 27-year-old guy in Walgreens who is maybe following Marc Anthony on Twitter, maybe his friend is a Baltimore Ravens fan,” says Simas, “and he will get, week after week, subtle messages, ‘Go to healthcare.gov and check it out.’ At some point that man or that woman will."

This week, as Congress flirted with a shutdown linked to a Republican-led effort to defund Obamacare, there was never any chance that the rollout was in danger of being derailed. Administration officials say even a government shutdown wouldn’t delay the Oct. 1 plan. But House Republican leaders may have a Plan B: to ask for a one-year delay of implementation. After all, the president delayed the regulations on businesses with more than 50 employees, and they’ve just added a new small-business delay. Why not let regular folks have a break, too?

No chance. It’s not just that a delay would allow opponents another year to pick at the law (perhaps with a Republican Senate after the 2014 elections) or that a delay would crumple the ramp-up set to launch in just a few days. A delay, Simas believes, would postpone necessary economic relief for those who have already waited long enough.

To make this point, Simas holds up a chart that he carries with him everywhere. It tracks productivity growth, GDP per capita, and average household income. From 1992 to 2002, all signs follow the same upward trajectory. Then in 2002, household income plateaus. “What you hear all over, all the time, is this expression: ‘I'm working harder and harder and falling farther behind.’ When you probe people about what this means to them, one out of two will bring up health care.

This goes to the heart about how people feel about the economy. … That's why this isn't just about health care. This goes to the core of middle-class security.”

It’s that thinking that has guaranteed there is no way the president would give in to Republican demands. If Obamacare is delayed, it would deprive middle-class Americans of the one economic benefit President Obama has been able to deliver for which people are likely to give him credit. Now the president just has to hope that on launch day, healthcare.gov can handle the traffic.

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