Can we please get some clarity on the politics of the Affordable Care Act?

A front-page article in the New York Times recently described Democratic officeholders facing fall elections “anxious about an onslaught of television ads hitting vulnerable Senate and House candidates for their support of the new health law.” The conventional wisdom seems to be that masses of Americans, feeling ripped off by the new policy, are ready to pounce. But does this correspond to reality? (See "Catastropic Coverage.")

To the extent the ACA has been misrepresented by proponents, the dishonesty boils down to a reluctance to identify winners and losers. This reluctance is hardly restricted to Obamacare. On issue after issue, our politicians fail to treat us like grownups in this regard. Truth is, all major policy changes create winners and losers; the goal is to maximize overall benefit by creating more of the former than of the latter. But lonely is the politician willing to say, straight out, that there will be any losers at all—never mind tell us who they’ll be! Instead we get pie-in-the-sky rhetoric about Policy X being “good for America” and “good for Americans.” Well, which Americans?

What President Barack Obama should have said was: “The ACA will help the 40 million Americans who currently have no health insurance. Those who stand to gain are the poor, the unemployed and underemployed, those with preexisting health problems, and working-class citizens barely earning enough to put food on the table.

“This will have to be paid for. If you are a healthy young person who previously opted not to buy health insurance, you’ll face an expenditure. If you’re a wealthy person with a Cadillac health plan, you can expect it to cost more. And if you’re a self-employed person currently paying for a bare-bones, ripoff catastrophic plan with an enormous deductible, you can also expect to pay more —in exchange for much better coverage.”

Can you not sell that in this country?

I think you can. Because the ACA creates far more winners than losers. I know a lot of ACA skeptics who go onto the health-care exchange website and are startled by what they find. One friend, self-employed like me, formerly got health insurance through his wife, but when she lost her job they were out in the cold. They’ve just signed up for a plan costing $180 per month. 

Let’s look at cases. The federal poverty level for a family of four is a household income below $24,000. At that income level, health care in my state, Connecticut, is free. Let’s say you fall a full 50 percent above the poverty line, with a household income of $36,000. Well, you and your kids still all qualify for Connecticut’s Medicaid plan—low-cost or free. And what about the middle class? Median household income in Connecticut is $64,000. If that’s you, with two kids, you’re looking at $306 per month for the Bronze plan, $440 for the Silver.

In my family’s case, we have an eight-year-old daughter, my wife is in her forties, and I’m in my fifties and have racked up impressive medical bills in recent years. We make more than the state median income, though not all that much more; pop in our figures, as I did five minutes ago, and we get the Bronze plan for $269 and the Silver for $512. Cheap? Not exactly. But it’s way more affordable than the monthly COBRA payment we made last year—$1,200!—when my wife was between jobs.

Finally, let’s look at the “Young Healthies” whose forced enrollment is helping fund the system. This mandate is a linchpin of the ACA, but—again—proponents have cravenly avoided stressing its mandatory nature and the escalating penalties for those who do not enroll. They shouldn’t; young people need insurance just like the rest of us. I know, I know, healthy twenty-somethings tend to view themselves as immortal, and their decision to refuse health insurance can be viewed as rational. Yet they are not immortal. My wife has a friend whose twenty-four-year-old uninsured son suffered a horrific car accident that left him and his family saddled with years of debt. He should have had health insurance, as should all Young Healthies. And how onerous is it, actually, to buy in? In Connecticut, a twenty-five-year-old making $28,000 can get a Bronze plan for $93 per month.

Is the picture of Obamacare becoming clearer? The fact is that federal subsidies will make winners of the unemployed, the working poor, and the true middle class, while the wealthy will be able to cover premium increases without pain. The primary losers will be those self-employed who prefer a bargain-basement, catastrophic health-care plan that covers little; and the Young Healthies, though as we have seen, many of them will pay only modest premiums and get insured in return—a win on any scorecard except the GOP’s.

It’s not that opponents won’t continue to find issues to demagogue as the program unfolds; for instance, as a means of keeping premiums down, some new plans do shrink provider networks and out-of-network coverage. But every policy analyst knows that rationalizing health-care provision—and, in some measure, rationing it—are essential to curbing the runaway rate of cost increases in our system. And preliminary evidence suggests that Obamacare is already helping do this by contributing to what Douglas Elmendorf, head of the Congressional Budget Office, calls “structural changes in the health-care system.”

Demagoguery notwithstanding, the ACA poses an overall benefit to our society, bringing millions of Americans in from the cold of being uninsured, with millions more to follow. That is something to stand up for—and run on—in this election year.