Obamacare: The best-covered story that remains a mystery

On Tuesday, the Affordable Care Act made its official debut, adding another patch to America's patchwork quilt of health insurance. This fix retains the system of private health insurance and private delivery of care but aims to brings another 24 million or 25 million people under the insurance cover. They are people who, for the most part, did not have insurance before, because they had no employer providing it, were too poor to buy it on their own or were so sick insurance companies didn't want them. Given that retaining private insurance was the only solution this political system would tolerate, the ACA's debut should be cause for cautious celebration.

But it isn't, judging by the public pulse. In mid-September, a Kaiser Family Foundation poll found that 43 percent of Americans have an unfavorable opinion of the law, while 39 percent view it favorably — roughly the same split that has existed since the law passed in 2010. About half the public and two-thirds of the uninsured continue to say they don't have enough information about the law to know how it will affect their families.

Why is that? There was tons of coverage of the ACA before and after it passed. Zillions of words have been written. Harold Pollack, a health policy wonk from the University of Chicago, called it the best-covered news story ever. Yet it apparently has not quite connected with the average man and woman on the street.

This summer, a Kentucky woman told Politico, "Oh, I've heard of Obamacare, yes, but I didn't know all that was involved. Everybody that I have ever talked to is totally against it. They're afraid all the doctors are going to pull out, and you're going to have to be like Canada and have to be on a waiting list."

Is the press at fault for Americans' misconceptions about international health care systems and, more important, for the lack of understanding of their own system and the ways Obamacare does or does not change it? There have been all-too-familiar shortcomings in coverage: too much following the leader, recording and reporting what others say, succumbing to spin every which way. During the debate on the Affordable Care Act in the years between its passage and now at implementation, reporters too often followed the lead of the president, members of Congress, and, in the last several months, Republican politicians who, fueled by well-funded conservative groups, have shut down the government. As recently as a couple of weeks ago, reporters passed along selective facts from the Secretary of Health and Human Services.

But beyond some of these too-common press shortcomings, I've identified five points that the press, for the most part, failed to adequately cover. These are threads that would have helped people understand what the law is all about, as well as comprehend the ongoing backlash.

1 The press did not make clear enough to the public what the law would do. "There was no sustained media commentary, no coherent discussion about what the law was and what would happen to whom," says Theodore Marmor, Yale professor emeritus and a longtime of observer of health care politics. There continues to be a great deal of confusion about who is eligible for coverage in this market — people on Medicare want to know if they can buy a policy, people in the employer market aren't clear that they can't shop in the exchanges. This confusion would not be as widespread and persistent had reporters explained from the beginning that this is not wholesale reform, but instead one more patch in the patchwork, this is bringing in (a relatively small number of) people who couldn't shop in the individual market or were uninsured.

2 Reporters did not adequately explain how Obamacare was financed, and why — why the modest wealth redistribution the ACA calls for is necessary to bring health insurance to more Americans. There was little coverage of what Marmor says is the "distribution of benefits and burdens." After all, the Affordable Care Act does call for wealth redistribution with its benefits distributed to the neediest. Those with the lowest incomes get the biggest subsidies. A few years back, Drew Altman, who heads the Kaiser Family Foundation, got to the nub of American health care. "It's a problem of reallocating wealth in America, and we don't do that very well," Altman said.

Just take a look at what the business community and insurers are doing, pushing for repeal of various provisions that require them to pay higher taxes to fund subsidies for the uninsured. During debate, the media focused on the pols' claims that the law would cost less than the magic number of $1 trillion, but gave short shrift to the question of where the money was coming from. Coverage of what the business community is up to is still lacking, even as the industry and employers are working hard to repeal part of this law.

Case in point: The ACA called for a 2.3 percent tax on medical devices that the industry has been working to repeal, and its fate is now tied up in the politics of the government shutdown. Lack of public understanding of how Obamacare is financed has made it easy for the business community to marshal opposition, particularly in small-town America, where people are clearly confused. One Nebraska woman was so angry at even the mention of Obamacare helping the uninsured that she vowed to cancel her subscription to a paper that ran a piece I wrote simply explaining one provision of the law.

Reporters rarely touched the very basic notion of why business and very wealthy people had to pay more taxes to support coverage for those who couldn't afford it. Instead, they passed along the superficial good-news nuggets from the administration about young adults staying on their parents' policies, preventive benefits for Medicare beneficiaries and no lifetime caps on coverage — a boon to very sick people for sure, but irrelevant to most Americans. It's not surprising, then, that the Kentucky woman thinks Obamacare is like Canada's health system or that many people believe it's government-run health care, or that a fierce, almost petulant backlash has erupted, with a Republican candidate for Congress in Alabama throwing a copy of the law in the garbage can and Florida Gov. Rick Scott preventing navigators from enrolling people on the premises of state and county health departments.

3 Another tough topic the press has avoided is the individual mandate and why it is necessary. CJR urged the press to explain that if the government was not going to provide insurance (a government mandate) or all employers didn't have to give workers coverage (an employer mandate), then individuals would bear the responsibility. If more were to be covered, then everyone must have insurance to make the system work. The mandate is now tied up with cries of taking away personal freedom, and it has become part of the backlash rhetoric that distorts what it does and why it's necessary.

4 The media failed their audiences by passing along the spin from the law's supporters. As a selling strategy, ACA supporters demonized insurers and blamed them for the high costs of medical care. Their CEOs earned too much, and they denied claims, reinforcing the public's dislike for the industry. That message, however, obscures the more important role of the medical establishment in setting the high prices to begin with, and the very large part employers play in directing insurers, which claims they want paid. (Employers, after all, are the payers for 160 million Americans with employer coverage). If reporters don't point out this misallocated blame, it will continue to be hard for the United States to get a handle on costs — not to mention for the public to get a complete picture.

5 Reporters failed to truly explain Obamacare's Republican roots — and the irony of the Republican backlash against the law. Obamacare is really a Republican plan with most of its central features — the individual mandate, subsidies, penalties — based on conservative theology advanced two decades ago as a market-based alternative to Bill Clinton's proposal for managed competition and an employer mandate. Health reform advocates believed — as President Obama noted himself — that if they adopted Republican ideas, that would quell the expected opposition. After all, Mitt Romney had embraced these ideas in Massachusetts, which became the model for Obamacare. When the ACA passed, former labor secretary Richard Reich, writing for Talking Points Memo, noted the GOP parentage of Obamacare. So did the Washington Post's Ezra Klein writing in the New Yorker last year. But how many folks — in Nebraska or Kentucky or at all — get their news from Talking Points Memo or the New Yorker? The press needs to help the public understand the backlash now and what it may mean in the future.

Going forward, Obamacare becomes three distinct stories: the consumer story that helps people buy a very complicated product; the business story that comes with myriad questions about how the law will actually work, and the ongoing political story that gets at Altman's point about wealth redistribution and who will support those who cannot pay for their medical care. But to tell all these stories well, to better explain to the public what Obamacare does and does not do (and why, and how), reporters must go beyond what the politicians and other stakeholders are talking about. Every time.

Trudy Lieberman is a fellow at the Center for Advancing Health and a longtime contributing editor to the Columbia Journalism Review, where this article first appeared. Follow her on Twitter: @Trudy_Lieberman.