The U.S. has spent four years arguing about the political, legal and technological impediments to Obamacare. We may have missed an even higher barrier: the American stigma around feeling like a freeloader.
The New York Times's Abby Goodnough spent some time with Kelli Cauley, a navigator for the Obamacare exchange in Kentucky, talking to people who are newly eligible for coverage under Obamacare. Here's the encounter that stood out to me:
At a sign-up sponsored by AARP last month, a well-dressed woman approached Ms. Cauley with a problem: She had learned that she would be eligible for Medicaid under the new law, but she was unwilling to enroll because of what she saw as a stigma attached to the program. A substitute teacher, she wanted to know whether she could afford full-priced private exchange plans.
“I don’t want to be a freeloader,” said the woman, who asked to be identified only by her middle name, Kay, because she said she was embarrassed about qualifying for Medicaid. “I believe in paying our way in life.”
Ms. Cauley ... found that Kay’s cheapest option through the exchange would be a plan with a $356 monthly premium and a $6,300 deductible. “Holy cow,” Kay said, shaking her head at the cost. Ms. Cauley thought for a moment and offered an alternative: Kay could sign up for Medicaid, but only use it in catastrophic events. For checkups and other routine care, Kay could pay her own way, perhaps negotiating a discount with her doctors.
“You’re giving me an alternative I can live with,” Kay said.
Kay's argument is similar to one made by the law's conservative opponents: If you want health care, you should go out and earn enough money to buy it yourself. What's noteworthy, and what supporters of the law should tune into, is hearing that argument coming from someone who actually pays the personal cost of that philosophy. When Paul Ryan argues about what the working poor ought to do, it's hypothetical. When Kay makes those same decisions, the effects for her are real.
Yet she still had to be talked into accepting Medicaid coverage, and then only for emergency care. Even if she was exaggerating her reluctance for a reporter's benefit, the idea that she would feel compelled to appear reluctant in the first place is testament to the power of the cultural values at play.
The liberal response, perhaps best captured by Thomas Frank, is that people like Kay have been duped by Republicans into embracing values that contradict their material interests. But that explanation is too easy, and also demeaning. There's something distinctly American about the idea that signing up for a government health-care program represents a failure of character, comparable with accepting charity.
You don’t have to be Ayn Rand to appreciate the virtue of self-reliance; it comes from the same mix of optimism and assertiveness that characterizes so much of American culture. In many cases, it's a praiseworthy attribute.
But not when it means that somebody can't afford to see a doctor, which makes her more likely to wind up in the emergency room, less likely to be a productive employee, and less likely to be a healthy parent to her children. Being a freeloader means taking without giving back; Kay is giving back without taking.
Democrats need to find the right way to talk to people like Kay, moving the debate over health insurance away from a responsibility to ideals and toward a responsibility to ourselves and one another. That won't be easy.
But for Obamacare to win broad support, Democrats should stop assuming that opponents to subsidized health care are being opportunistic or selfish. Kay's story suggests they're reflecting something deeper in American culture -- something that will take effort, and understanding, to change.
(Christopher Flavelle is a member of Bloomberg View's editorial board. Follow him on Twitter.)