Selling the Affordable Care Act: How the Obama Administration Forgot PR Basics

April 14, 2015

[lynne sladky/ap/corbis]
[lynne sladky/ap/corbis]

Critics of the Patient Protection and Affordable Care Act (ACA) refuse to go away, and five years after the act’s passage, these opponents seem determined as ever to kill it. Their potency will only increase now that Republicans have taken charge of Congress.

House Republicans have filed suit against the Obama administration over what they believe is abuse of executive authority. In March, the Supreme Court heard King v. Burwell, a direct assault on the crucial provision of the act, which permits subsidies if consumers purchase health plans on the federal exchange rather than through a state plan. The court’s decision is expected this summer.

Immediately after Obama was elected in 2008, support for reforming our creaky health care system was sky high. But since then, the public has grown increasingly skeptical of Obamacare, and many would simply like to return to the good old days.

While the Democrats used extraordinarily sophisticated microtargeting, get-out-the-vote drives and other strategies to help Obama win the White House in 2008 and 2012, they simply failed to effectively use Public Relations 101 to sell the Affordable Care Act.

It may still be possible to stem the tide, but time is running out. Here are some of the mistakes that were made:

Keep the promise simple

There are some basic components to a successful issues management program that were mismanaged with the ACA, among them getting out a message that is simple, with a clear explanation of how the product or service works.

From the start, it was unclear what the act included and why it mattered. Compare this with the Social Security Act, which, even though it’s far more complicated than the ACA, has basic tenets that everyone knows. Americans understand the basic premise, and they approve. Similarly, the Health Insurance Portability and Accountability Act (HIPAA) regulates dozens of health care situations, but the public knows the basic gist: Health records are private.

The ACA, however, meant many things to many constituencies: health exchanges, an employer mandate, expanded Medicare, cost controls and other innovations. These all may benefit the public, but the fundamental message was unclear and only marginally relatable to the middle class, whose support was vital to the act’s success. Even the act’s official name, the Patient Protection and Affordable Care Act, was a mouthful.

At the outset, the act could have been christened the “Health Security Act,” which would have subtly linked it to Social Security and Homeland Security — programs that the public understands. The message should have been reduced to a simple promise: Americans will be protected from the calamity of stratospheric medical bills and the loss of health insurance.

Don’t make it personal

The administration misguidedly accepted and used the term “Obamacare.” And while people in Obama’s camp perhaps thought this would be a success tied to the president’s legacy, it only backfired on him by bolstering opponents’ arguments that he was striving to radically change the relationship between individuals and their health care providers. Social Security was not called “the Roosevelt Savings Plan,” nor was Medicare billed as “JohnsonHealth.” Likewise, this program needed a name that was distanced from the president himself.

Explain what is under the hood

In order for the insurance provisions of the ACA to work, all of its components must support one another. This crucial point should have been emphasized in the years leading up to the launch, but it was not.

Everyone agrees that preexisting conditions should not preclude a person from having affordable health insurance. But to do this, everyone — young, old, sick and healthy — has to be in the insurance pool.

In the years prior to Obamacare’s introduction, the administration failed to communicate that some people may not be able to keep their current plans, but for good reason: some, particularly low-income earners, may not have realized that they had “insurance lite” plans that did not cover common, necessary services.

The ACA, in contrast, required all plans to include essential, commonsense benefits, such as maternity and mental health coverage, which were often lacking in many subpar plans. If this had been explained before deficient plans were canceled, there would have been more support for the new plans.

Harness allies

In contrast to the slugfest between the Johnson administration and organized medicine more than 50 years ago, medical societies were generally supportive of the ACA at the start, and support for the act’s goals has not faded over time. 

The American Medical Association, one of the most ferocious opponents of Medicare, has said of the ACA: “We are pleased the law expands coverage to millions of uninsured who live sicker and die younger than those with insurance.”  

In a press release following the Supreme Court’s affirmation of the act’s legality, Dr. James T. Breeden, president of the American College of Obstetrics and Gynecology, stated: “The Affordable Care Act helps ensure all Americans have access to affordable coverage with important consumer protections and benefits. . . . We urge all states to act swiftly to implement these important access and coverage guarantees.”

Support has come from other sectors as well. The insurance industry, which was the administration’s whipping boy leading up to passage of the ACA, now embraces it, though largely for economic reasons.

And while the Catholic Church understandably opposed coverage for birth control, the largest organization of Catholic health providers, the Catholic Health Association (CHA), supported the ACA. Jeff Tieman, chief of staff of the CHA, wrote in Health Progress, a CHA publication: “For the first time since Medicare was enacted, our nation has the opportunity to enroll millions of uninsured — representing many age groups and demographics — in new health coverage. For some families, this will be the first time they have been able to afford meaningful, reliable insurance to cover their acute, routine and preventive medical needs.” 

Despite enjoying this wide-ranging support, the administration made scant use of these allies. Though there are limits on how closely the government can work with nonprofit organizations, there were missed opportunities for speaking engagements, op-eds and media appearances.

Prepare for hardball

From Sarah Palin’s broadside about “death panels” to Rep. Joe Wilson’s indelicate “you lie” shout-out, it was clear that ACA opponents were going to use the harshest possible language to turn the public against the act.

While supporters took the high ground by not responding to every attack, the high ground is usually not where you win hearts and minds. This was bareknuckle politics, yet the administration elected to play tentatively — and lost its audience in the process.

Support with passion

In his book “Reinventing American Health Care,” Obama health adviser Ezekiel Emanuel said that Johnson, one of the most masterful presidents in working with Congress, believed that showing your passion for a bill is vital for getting legislation through a recalcitrant legislature.

While President Obama obviously believed in the ACA, there was little fire in his belly when discussing it. Both he and his putative supporters in Congress rarely spoke out with unalloyed emotion about what the ACA could potentially do to increase health security. As public skepticism of the ACA increased, those voices grew quieter. This was a key mistake. President Obama and his team needed to communicate how they believed ACA would make Americans’ lives better in vivid, emotional language.

Act now

Despite all of this, there are signs that the administration is finally using some deft PR tactics to sell the act. For instance, recognizing that the program’s success depends on enrolling young people, President Obama turned pitchman, appearing on Zach Galifianakis’ irreverent “Between Two Ferns” Internet show. Galifianakis had his fun poking at the President, but Obama got his “sign up now” message across to 6 million viewers.

The administration has also been doing a better job of communicating the act’s successes to date, such as releasing specific information about how many previously uninsured Americans are now enrolled in health plans and how the ACA is contributing to lowering overall health costs. They’ve also enlisted athletes such as Russell Wilson and Richard Sherman of the Seattle Seahawks to encourage enrollment.

But more needs to be done. It is not too late to harness the many organizations — medical societies, patient groups and business organizations — that support the ACA. Though time is limited, the message can be streamlined to how the ACA is helping the middle class without disrupting traditional insurance.

Michael M. Durand
Michael M. Durand is a veteran public relations and communications expert and former head of the Global Health Care Practice of Porter Novelli. Presently he consults with a range of health care clients and is an instructor at New York University.


Larry M. Weiner says:

There's something even more basic than the list of PR missteps itemized by Michael Durand as to why the Affordable Care Act remains so unpopular. It's simply this: even the greatest PR pro can't turn a sow's ear into a silk purse.

May 6, 2015

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