The Patient Protection and Affordable Care Act, The Obamacare in United States

Since it passed in 2009, The Patient Protection and Affordable Care Act, otherwise known as the ACA or Obamacare has been put up for repeal over 50 times. Despite the multitude of efforts to repeal the ACA, it remains the law. In fact, according to a Quinnipiac poll that “56 percent” of Americans approve keeping the ACA in contrast to the “17 percent” that support the American Health Act, the Republicans current replacement, a few puzzling questions start to arise (Quinnipiac), Why is there such a divide in opinion when it comes to government healthcare programs and what has sown the seeds that have led to this campaign against the ACA? And are these forces the reason that the United States has never adopted a universal health care system like their other western democracy counterparts?

This question of universal health care that is access to healthcare for all citizens, usually at the expense of the state, can be traced back to when most other nations implemented their national health plans around the 1940’s. It was around this period in the 20th century that Western democracies universal healthcare programs, such as the United Kingdom’s NHS, began to take shape, and capture the popular political imagination. With a health insurance focused Truman becoming President in 1945 after the death of FDR, the creation of an American welfare state never seemed more likely. Yet within the next few years, the public’s interest in a universal health care system would sharply fall, and ultimately any bill that sought to provide national health insurance would never make it out of committee, much less pass a vote in both houses.

The root of this drastic change is found in the actions of lobbying organizations and the Republicans during that time. These groups made use of common cultural fears and the political power of money and social pressure to change the perception of a universal health care system in the American consciousness, ultimately dooming any major health care legislature right from the start. This lobbying done by medical organizations such as the AMA set the stage for the capitalistic stronghold and fear tactics that are still used to disincentivize health care legislation today.

As briefly mentioned above, the story of American universal health care is both born from, and was ultimately ended by the American populace in the 1940’s. President Truman, having been thrown into the presidency due to the death of FDR in 1945 was intensely committed to national health insurance, but faced an uphill battle. In 1947, with Truman only two years into his first term and facing the Republican-controlled 80th Congress, he struggled to get health legislation in a viable place to become law. To make his dream a reality Truman “appointed Oscar Ewing to head the Federal Security Agency (the precursor of the Department of Health, Education, and Welfare)” (Quadagno 2006, pg 29). Ewing’s nomination as head of the FSA is where we first start to see the lobbying power of the American Medical Association, and its opposition to National Health Insurance. The AMA had long been against government action on health care, as it feared the uncertainty it would bring to the very prosperous medical profession and the AMA in this period was no different. The AMA’s utter distaste for national health care was foreshadowed by Dr.Robins, a “Democratic national committeeman from Arkansas and a high-level AMA official” who “ warned Ewing before his Senate confirmation that “the AMA might oppose Ewing's nomination if he gave” what the AMA saw as “the wrong answer” in regards to health insurance (Quadagno 2006, pg 29). When first questioned on his opinion of national health insurance during this confirmation hearing, Ewing managed to appease the AMA and get confirmed by stating that he did not know enough about the subject to stand against or for national health insurance. However, the AMA would not be pleased with Ewing for long.

With Ewing confirmed, Truman tasked him to use "all the resources within the Federal Security Agency for vigorous and united action toward achieving public understanding of the need for a National Health Program” (Quadagno 2006, pg 30). This mission led Ewing to create “the National Health Assembly” which Ewing hoped "would” ensure he “[had] the people of the country with [him]" and Truman in the pursuit of government-backed care. However, this 1948 committee kept on the friendly side of the AMA by not focusing on National Health Insurance and instead sought to get a reading of American's access to health care in general. The work of the committee ultimately culminated in Ewing writing The Nation's Health: A Report to the President in the September of that year which outlined not simply the health-related ills of the country, but what Ewing saw as the best solution to them. His report found that only a staggering “3 percent” of the population had "anything approximating [to] comprehensive insurance protection," and that in Ewing’s opinion, national health insurance was the best solution to this problem. In his words, "the group purchasing power of the people" through such a system would, “"help build a more effective organization for providing the best in prevention, diagnosis, and treatment” and would solve the woes of individuals who had a “problem... paying for medical care. . . And” would “create a stable and assured financial basis for health services"(Quadagno 2006, pg 30).

This move put Ewing at odds not just with the AMA and the Republicans, but with the National Health Assembly itself, who did not take such a strong position in regards to government health care. With the United States fresh off a war with Nazi Germany, tensions boiling with communist Russia, and the Labour Party of Britain having just installed the National Health Service, Republicans and the AMA responded to the threat of a national healthcare program with the tools of fear and fiscal favors. Chief among these concerns at the time was the very fresh threat of fascist socialist governments, or even worse, the threat of communism creeping into the USA. By this knowledge, the Republicans retaliated by painting a grim, and a socialism heavy future in the United States with universal health care. They said that “it would only be a matter of time until Washington likewise moved into the field of education,” or constitutionally guarded areas such as freedom of “religion” or even “the press, [and] the radio” until “freedom“ itself ” would be in total eclipse.". Some even went further to suggest that national health insurance was “an insidious communist plot” that planned to use federal funds in support of Moscow. To make matters even grimmer, this anti-American and red scare fervor was appearing just as Truman was seeking reelection. Instead of backing away from Ewing’s health policy proposals “Truman responded by focusing, even more attention on a national health bill the 1948 election” and in contrary to the expectations of the time, he won a second term with a Democrat controlled Congress in tow(Quadagno 2006, pg 31-32).

With the Democrats firmly in the seat of power and President Truman as popular as ever, “the AMA thought Armageddon had come” and pulled out all the stops. The AMA would not only continue the Republican’s campaign of the threat of communism in America, but they would strike at the very heart of American life itself, the local town doctor. The AMA “assessed their members an extra $25 each to resist national health insurance” through what they called a “National Education Campaign.” The AMA used these funds to hire Whitaker and Baxter, a PR firm that had successfully helped “the California Medical Association...to kill” a similar “health insurance bill” at the state level to head their national campaign(Quadagno 2006, pg 34).

During this one project, the AMA “spent $1.5 million on lobbying efforts” and while 1.5 million might not seem all that rich compared to that of the “ $240 million” spent by drug companies “for lobbying purposes” in 2015, this campaign by the AMA was, at the time, “the most expensive lobbying effort in American history”(Physicians;Chon). With a palpable money bag at their feet, the experienced duo of “Clem Whitaker and Leone Baxter....applied the tactics they had honed in California” to quick effect, wasting no time in producing literature from “posters [and] pamphlets” to “cartoons and materials for “state medical agencies.” All of this effort was in support of “ keep[ing] public opinion hostile to national health insurance.” In the words of Whitaker to take control of a situation, “you have to give it a bad name, and have a Devil” but with “Truman... too popular” to be targeted, “Ewing [was] the perfect Devil” and there was no greater smear for Ewing’s plan than to label “national health insurance ‘socialized medicine.’”(Quadagno 2006, pg 35). This branding would stick, and with “anti-Communist sentiment” continuing to rise with the first stages of the Korean war, there was no greater poison pill to a bill than to associate it with anything even close to the socialist and communist policies of America’s foes.

The AMA’s campaign was able to lodge this new branding of national health insurance as socialized medicine into the American mind through the pressuring of their A.M.A members on a local level.The “AMA national headquarters” even went so far as to get “every county” to start up a “hard-driving campaign” against socialized medicine by encouraging doctors to spread this propaganda-like message by writing letters, and even asking doctors “to approach local newspapers to” make sure they were getting “the ‘real facts’”. Additionally, doctors' offices were flooded with “copies of the pamphlet The Voluntary Way is the American way” along with “reception room...posters with the caption ‘The Doctor: Keep Politics Out Of the Picture” .Any doctor that didn’t play along “chanced being expelled from membership…[and] risked losing appointments and referrals” which meant risking your neck for national health insurance meant risking your business and career as well.

With all of this pressure coming from the ground up, even Ewing “admitted….[that his] proposed legislation was getting nowhere with the Congress.” For all the fervor Truman might have whipped up on the campaign trail, now Ewing found that he “would talk to a Congressman” or another official that was once for National Health Insurance, and suddenly they would say “‘you have no idea what political influence a doctor has in his local community, and I don’t want them to get stirred up against me”(Quadagno 2006, pg 35;38). The power of local doctors among patients was the final nail in the coffin, with the very concept of national health care rebranded, it seemed that the AMA’s haze of misinformation had won the day. This drastic change in public perception was so palpable that when Truman first became president “in 1945 75 percent of Americans supported national health insurance;” but “ by 1949 only 21 percent favored” the same plan. This more than 50 point drop shows just how much power and influence exist within a well-funded lobbying campaign, and Truman’s response to it would be a sentiment on the nature of lobbying that feels relevant even to this day. Truman, after seeing his defeat accused “the American Medical Association” of “distor[ting] and misrepresent[ing]” his national insurance plan to the point where it became vital for politicians “to go out and tell the people just exactly what” the government was trying to implement. In a government, where money can talk so loud, as to the point where they change the meaning of what it means to be a politician, as the AMA did for Truman and his push for National Health Insurance, then there is an apparent imbalance of power at play within our legislative system. To quote a congressman and supporter of national health insurance at the time, Representative John Dingell, the AMA had pulled off “one of the most cold-blooded lobbying operations in American history” and this precedent that they had set, as well as the success that came from it, set a very dangerous norm that has led to our increasingly business, and lobbying friendly future(Quadagno 2006, pg 38-40).

While the AMA might have been the first big campaign against government action on health care, they were not the last. In fact, due to realizations by companies about the power of lobbying Congress, as well as reusing the tactics of fear and misinformation that the AMA perfected in the 1940’s, health care legislation such as the ACA is just as antagonized as ever by businesses in the medical field. This antagonizing of health care not only affects the constituents who vote for our legislators but hurts the legislators themselves. With industry now spending “about 2.6 billion a year on reported lobbying expenditures” and the health medical services industry responsible for “$245,812,399” dollars spent on lobbying in 2016 alone, the amount of money spent with hopes of influencing legislators now regularly “exceeds the combined House-Senate budget” with no sign of slowing down(Drutman;"Pharmaceuticals/Health Products," Open Secrets).

This money has been a particularly persuasive force in changing the perception of former President Obama’s signature healthcare bill, the Affordable Care Act. Not only does opinion on the law change drastically depending on one’s partisan affiliation, with “80 percent of Republicans strongly disapprov[ing]” of the bill, even it's named seems to be a point of confusion (All Things). In a poll conducted by Morning Consult, it was found that over “35 percent of respondents...thought that Obamacare” the Republicans derogatory nickname for the ACA, “and the Affordable Care Act were different policies.” This affirms that quite similarly to the AMA’s labeling of national health insurance as socialized medicine in the 1940’s, today’s lobbying groups and the Republicans have labeled the ACA as Obamacare to spur similarly negative feelings about the law(All Things). This divide can be traced back to the source of the law’s name, Barack Obama, whom was incredibly polarizing during his presidency. Obama garnered very different reactions from people depending on party affiliation and according to Gallup’s polling data during his presidency, “an average of 79% of Democrats and just 9% of Republicans approved of the job he was doing” that’s a gap of 70 percent, just based on party affiliation.

It is this divide in opinion about Barack Obama that was the motive for labeling the ACA as Obamacare, and why the law itself is also so divisive becomes coherent. With that sort of adverse reaction associated with the president’s name alone, there was little more for the lobbyists and Republicans to do to try and drive public opinion against the ACA than to associate it with the figure the Republican opposition disliked the most..Much like the campaign of Whitaker and Baxter, modern day politicians and corporations had found their perfect devil: the President himself. In fact, this rebranding was so effective at demonizing the Affordable Care Act that “45 percent of [Americans] said they didn't know that if Obamacare were repealed that would mean that the Affordable Care Act would disappear”(Jones; All Things). With a majority of the American populace seemingly unaware of Obamacare's real name, or the nature of the law's possible effect on their health care, it seems to prove that these lobbying tactics are as effective in dismantling the legislative conversation around health care as ever. In fact, in today's world of money and politics, for "every dollar spent on lobbying by labor unions and public-interest groups together, large corporations and their associations now spend $34" what once began as a group of medical professionals pressured into protecting a profitable existing system, has become a business unto itself. The medical lobbying initiated by the AMA "has built itself up over time, and...has increasingly come to overwhelm every other...countervailing force" or even worse loops the legislator's constituents into joining their campaign through partisan branding, as was done with the ACA. Lobbying has "fundamentally changed" since American lawmakers tried creating a national health insurance system. While once they wanted "to keep government out of its business all together" with more money, and less informed resistance these "companies are now...bringing government in as a partner" no longer is Congress an enemy to be won over, but rather a tool to be used "for [their]" own gain (Drutman).

To come full circle, the increasing attempts to repeal Obamacare, and the law's unpopularity among Republicans looks to be the status quo for the foreseeable future. The fear tactics that plagued Truman and Ewing’s attempt to solve America's health crisis in the 1940’s planted seeds and those seeds have grown to become the effective cold lobbying we still see being used against the ACA today. The time period might have changed, but the power of fearing the other or what is different, and the power of money in politics has stayed the same. In a system where corporations and business interest groups have a way to influence public opinion, and legislators themselves through money and poisoned perceptions, the United States have been unable and is still not in a viable place to implement such monumental legislative changes such as universal health care. Only when there is a level legislative playing field between lawmakers, companies, and the citizens, can a healthcare system for all truly come to fruition.