Health care: Who cares?

As I write this, medical underwriting, the practice of asking prospective health insurance customers who are self-employed to first prove that they don't need it, has been illegal for 459 days, thanks to Obamacare. As someone who thinks it should be illegal, I was amused by the efforts of Congresswoman Cathy McMorris Rodgers, an ardent Obamacare opponent who has voted multiple times to repeal the law, to elicit Obamacare horror stories on her Facebook page. Apparently she was overwhelmed with stories of how Obamacare had helped people, an outcome that evokes a recent Jonathan Chait article: "The Obamacare Doomsday Cult Struggles to Adapt to World That Did Not End."

This is a surprising, albeit welcome, outcome. It's surprising because Kaiser Family Foundation polls show support for Obamacare roughly equals opposition. Why wouldn't supporters and opponents show up in equal numbers?

My theory is that supporters support the law more intensely than opponents oppose it. If true, it has profound implications for the trajectory US health care takes in the coming years. Here are some reasons to think my theory might be true.

Let me start with myself. Having experienced medical underwriting while it was still legal, it is hard to imagine someone opposing the law anywhere near as intensely as I support it. Medical underwriting is humiliating and time consuming. It produces a lifetime of worry; you get to imagine being told, as you are being wheeled into the operating room, that your insurance was rescinded because you failed to disclose the freckle on your left elbow. And because medical underwriting is so painful, it precludes you from shopping around for a better plan. A nation which subjects any of its citizens to medical underwriting cannot be considered a first world nation. No "Death Panel" obfuscation can distract me from my hatred of medical underwriting. I'll listen to anyone who proposes changes to Obamacare, but repeal amounts to resurrecting a practice that should have been banned in the Eisenhower administration.

And I am perfectly healthy. Imagine what a self-employed person with preexisting conditions might think of medical underwriting! If Congresswoman McMorris Rodgers and other Obamacare opponents think medical underwriting is such a good idea for the self-employed, why, in God's name, aren't they proposing it be applied to those with employer-provided insurance, those on Medicare, and veterans?

Even though Obamacare supporters and opponents roughly equal each other currently, polls show that banning medical underwriting is very popular, as are certain other Obamacare provisions, such as allowing children to stay on their parents' health plan until their 26th birthday (see below for what Rep. McMorris Rodgers has to say). Could support for those provisions be more intense than opposition to some of Obamacare's essential but less popular provisions, such as higher taxes on the wealthy or the tax penalty for remaining uninsured (technically called a "shared responsibility payment")? I think so.

It's also important to remember opposition to Obamacare is far from homogeneous. I was reminded of this recently when I saw, not for the first time, a "Single Payer - Now!" bumper sticker.

Finally, significant majorities believe the law should not be repealed. That means at least some of the people who oppose the law don't want it repealed, suggesting their opposition isn't that intense.

Ezra Klein at vox.com wrote an insightful article arguing that the mismatch in intensity of Obamacare friends versus foes extends into the political realm. Votes to repeal Obamacare are politically effective only to the extent they fail. Actually coming up with, and passing, a credible alternative involves making difficult compromises and investing huge amounts of political capital. Republicans just aren't interested enough:

This is, fundamentally, the difference between the Democratic Party and the Republican Party on health-care reform. Democrats cared so much about health reform that they based their work on a plan Republicans came up with in order to give themselves a better chance of success. Republicans care so little about health reform that they haven't even bothered to choose one of their own plans to unite behind, much less made any painful ideological concessions to clear a path to passage.

So while I haven't seen a study that definitively measures intensity, there are strong indications Obamacare supporters support the law more intensely than the opposition opposes it.

Circling back to Congresswoman McMorris Rodgers' Facebook experience that started me on this intellectual journey, in comments to the Spokesman-Review she dismissed the crescendo of Obamacare support:

McMorris Rodgers said Monday that many of the success stories seemed to be centered on reforms that both parties agreed on, rather than her concerns with the health care package.

“The stories are largely around pre-existing conditions and those that are getting health insurance up to age 26,” she said. “That’s broad, bipartisan support for those provisions.”

If there were a law against hypocrisy, this would be a felony, considering she voted to repeal the entire law, including all the provisions she admits have "broad, bipartisan support," as recently as February 3rd, 2015. In explaining her earlier vote to repeal Obamacare on July 11th, 2012, she said she "supported and advocated a better health care bill." Her summary of that bill refers to high risk pools (something that appears in many Republican proposals), a dead giveaway that she wants to resurrect the medieval practice of medical underwriting. (Her link for that better health care bill, http://www.gop.gov/solutions/healthcare, yields a 404 "This page was not found" error. A similar url, http://www.gop.gov/solution/health-care/, contains no specifics.)

That's not surprising, because to do what she wants - cut tax credits and dump the tax penalty for remaining uninsured - you need to resurrect medical underwriting in order to avoid the "adverse selection death spiral," where the people who sign up are those insurers will lose money on. And resurrecting medical underwriting means you touch a new third rail in politics. The voltage may not yet be as high as it is for Social Security and Medicare, but it is rapidly rising, as well it should. When it comes to health care policy discussions, people like Rep. McMorris Rodgers won't have a seat at the table.