If it is done right, the Affordable Care Act (a.k.a. Obamacare) may well promise uninsured Americans a lot more than cheap, reliable medical care. It can also open the door to the democratic empowerment of millions of poor people, who are often alienated from much of the nation's civic life, by strengthening the organizations that give them a voice.
This year more than 30 million uninsured Americans are to begin signing up for Obamacare, but the vast majority of those eligible for either the expanded Medicaid program, or for subsidized private health insurance through state health exchanges, have no idea how to enroll. Surveys and focus groups have found that up to three-quarters of Americans who might directly benefit from the program are skeptical that the law can provide high-quality insurance coverage at a price they can afford.
This is dangerous, not only for their health but for the viability of the law. Many people think that with the Supreme Court ruling upholding the law and President Obama's reelection, the Affordable Care Act finally made it out of the political and judicial woods. After all, the last few weeks have seen half a dozen Republican governors sign up their states for its expanded Medicaid coverage.
But confusion, fear and ignorance among millions of potential beneficiaries can still doom the reform. In California, nearly 7.2 million people — more than 20% of the population — lack access to health insurance. Most of these people are poor, and for many, English is their second language.
Obamacare's success depends on maximum possible participation. If too few healthy people purchase insurance through the state exchanges, not only will the flow of premiums and subsidies to hospitals, doctors and clinics prove inadequate, but insurance companies, which will be prohibited from turning anyone away, will be providing coverage for too many of the old, the ill and the desperate. Insurance rates will skyrocket. Then the young and relatively healthy may drop out of the system, only to face a penalty — $695 a year for an individual by 2016 — a politically toxic burden.
The Affordable Care Act would implode.
The law's stakeholders are well aware of this danger. Enroll America — a Washington nonprofit funded by hospitals, insurance companies and the pharmaceutical industry — will launch a media blitz this summer designed to explain how the new law works and what subsidies are available for working families.
In California, Covered California, the state health exchange, has geared up its outreach and publicity campaign, including an initial $43 million in grants to health clinics, community groups, trade unions and other nonprofits that have "trusted relationships with the uninsured markets that represent the cultural and linguistic diversity of the state."
Covered California expects that by Oct. 1, when enrollment in health exchanges begins, they will have trained as many as 21,000 "assisters," volunteers and employees of such groups. These people will knock on doors and sit around kitchen tables to guide the uninsured through the process.
Such hand-holding is essential because signing up for Obamacare will be complicated. Covered California and the other states' health exchanges are creating streamlined Web portals, but the process of completing the template will be like filling out a tax return. And just as H&R Block has hundreds of offices and thousands of employees who guide clients through the tax preparation process, so too will the state exchanges need organizations and knowledgeable and trusted people who can make the process understandable and reassuring.
And here is where Obamacare's peril turns into a promise of enormous social and political benefit. As the poor, alienated and fearful realize that tangible benefits can be won through their neighborhood clinic, civic group or local trade union, and are drawn into civic life and grass-roots action, these organizations that are essential to the health reform's implementation will be strengthened as agents of civic engagement and citizen mobilization.
This is not a case of creating more voters who will support Obama because of Obamacare. This is a 21st century example of Alexis de Tocqueville's 19th century observation that the health of American democracy depends on the vibrancy of numerous voluntary organizations.
In recent history, we've seen the way such groups feed activism and are fed by it.
This was the case during the Depression when national labor organizations and their local chapters pushed for new labor laws and then gave them a tangible reality as the locals burgeoned in workplaces across America, and in the years after passage of the 1965 Voting Rights Act, when African American churches, the NAACP and other civil rights organizations reached out to millions and brought them to the registrar's office and the polls.
Likewise, activists from the women's movement and the environmental community were indispensable when the laws they had helped push through Congress were put to the test in thousands of communities.
In California, Obamacare civic activism has the political and administrative wind at its back. But in Texas, Louisiana, Georgia and other Southern states, where the political establishment still stands in opposition to the healthcare reform law, the enrollment of the uninsured in federally run health exchanges will require some of the courage and dedication last seen in those precincts when civil rights workers sought to end segregation half a century ago.
The task will be difficult, but the payoff will transform far more than the American health insurance system.
Nelson Lichtenstein directs the Center for the Study of Work, Labor, and Democracy at UC Santa Barbara.