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The ACA and Obama’s Trust Dilemma

Posted by John McDonough  November 11, 2013 09:42 PM

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Last Friday, I heard a presentation on leadership by Dr. Linda Hill from the Harvard Business School. Of many noteworthy thoughts, one struck me as spot-on in relation to our current dilemma with the Affordable Care Act. Dr. Hill presented this handy equation:

Character + Competence = Trust

So we have two dimensions to trust -- that you try to do the right thing and that you know how to do the right thing. It plays into President Obama's current challenges in a compelling way.

First, on the matter of individual health insurance policy holders who will not be able to "keep the coverage you have if you like it," the question is whether Obama said that -- repeatedly -- knowing it was not true. That gets to character.

Second, on the matter of the dysfunctional health insurance exchange websites, the question is whether Obama and his team know how to do it right. That gets to competence.

Both trigger a trust challenge -- and that's why the current double dilemma sticks and matters beyond the ramifications for the ACA.

A significant minority of Americans, say 15, 25, 35%,  already have zero trust in the President, and there is no redemption, no matter what. Another significant portion, say 15, 25, 35%,  trust the president and need more than this to change. And a third group, say  20, 30, 40%,  are up for grabs, can go in either direction, and get more easily influenced by good or bad news. That group is now getting a double-barreled load of bad news on the ACA and Obama.

So let's take another look at the two dilemmas.

First is the cancellation of individual health insurance policies. Clearly, President Obama overstated the extent to which everyone could "keep the coverage you have if you like it." Instead of that applying to 100% of insured Americans, it only applies to about 95% -- the majority of the 5% will find better options, so we're talking about 2% of Americans at most.

It is useful to recognize that the President's statement was an overstatement in response to repeated false statements from health reform opponents that health reform would cause the vast majority of Americans to lose their current coverage, including those with employer-sponsored coverage and Medicare. Obama's was an overstatement in response to an environment of deliberate and misleading scare-mongering to defeat reform.

Yes, some 2-5 million will need to obtain new health insurance policies, and some of those will cost more than their prior coverage. Every one of them will have guaranteed access to more secure and higher quality coverage. At the same time, some five to seven million low-income, uninsured Americans, who would have been able to get health insurance coverage through Medicaid, will be unable to do so because their state governments refuse to adopt the 100%-federally-funded expansion.

I have yet to read a single commentator or opinion maker who is complaining on behalf of the higher-income policy holders express any concern about the millions shut out of Medicaid and who have zero coverage options.

Who is worse off? And who more deserves our concern? Not a hard choice for me.

Second is the website and the Administration's competence. To me, this is more worrisome. If, after surviving all the travails of the ACA's passage and implementation, health reform were to fail over technical incompetence, that's turning tragedy to farce.

One can understand and even empathize with the folks in the Administration working so hard to fix this, and I keep my fingers crossed that they will have it mostly fixed by the end of the month.

But the Obama team's failure to launch has been a real confidence shaker, and trust is hard to summon. I am hoping they will meet their own deadline, it's just hard to summon the trust.

This blog is not written or edited by Boston.com or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »

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