Why the affordable care act needs a better name: 'Americare'.

Abstract

The culmination of a century's effort to enact universal coverage in the United States is a law with an uninspiring title, the Patient Protection and Affordable Care Act, and an even more awkward acronym, PPACA. The Obama administration has decided to call the legislation the Affordable Care Act, but the expansion of health coverage that the law sets in motion has no name, and therefore no identity. It badly needs one.

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By William M. Sage
ANALYSIS & COMMENTARY
Why The Affordable Care Act
Needs A Better Name: ‘Americare’
ABSTRACT The culmination of a century’s effort to enact universal
coverage in the United States is a law with an uninspiring title, the
Patient Protection and Affordable Care Act, and an even more awkward
acronym, PPACA. The Obama administration has decided to call the
legislation the Affordable Care Act, but the expansion of health coverage
that the law sets in motion has no name, and therefore no identity. It
badly needs one.
T
technicalpathtowardtheseobjectives.However,
itsnameoffersinsufficientinspirationtostayon
course. The law comes up short on what legal
scholars call “expressive value,” meaning sym-
bolism. A name such as Americare would tie the
new law’s many complex strands together,
encouraging a sense of solidarity among ordi-
nary Americans that will be necessary to achieve
the legislation’s goals.
The name Americare, or something like it,
would reinforce public understanding that the
law entitles all Americans to health insurance,
ensures access to care, and protects against fi-
nancial catastrophe. These are long-standing
and important ideals. In 1993 and 1994,
PresidentBillClintonattemptedtobuildsupport
for his reform proposal by distributing thou-
sands of “health security cards” bearing the
presidentialseal.Today,“Americarecards”could
serve an equally important, and noble, symbolic
purpose.
Over time, a program called Americare, like
Medicare, would become something that bene-
ficiaries would not only accept, but would also
defend. Behavioral economics recognizes an en-
dowment effect: People demand more to part
o be sustainable as a system, health
care must be accessible, available,
and affordable. The U.S. health
reform law passed in 2010, awk-
wardly named the Patient Protec-
tion and Affordable Care Act (PPACA), charts a
with something they own than they are willing
to pay for an identical item they lack. This is why
congressional Republicans attacked the reform
legislation as undercutting Medicare, a program
many of them had long sought to privatize and
eventually eliminate. They departed from that
position because Medicare is, whereas an un-
namednewprogrammerelymight be,andwould
be undervalued by the public as a result.
Were the Affordable Care Act’s programs to be
rebranded, all eligible participants would sign
upforanAmericareplanwiththespecificsource
of coverage appended.1One person might have
an Americare—Blue Cross plan, while someone
else would have Americare—Medicare. A com-
mon identity would convey the point that uni-
versal participation makes it possible to have
universal insurance that does not discriminate
against the sick. It would also remind insurers
that they are no longer permitted to compete by
avoiding risk and are now expected to compete
by improving care.
The name Americare would assert a collective
interest in health system value and efficiency. It
would build courage to do more than tinker at
themarginswithnewpaymentmethods,organi-
zationalstructures,andprofessionalskills.Most
important, a shared identity would signal our
decision to rein in special interests and begin
a social conversation about redesigning health
care delivery to produce the most cost-effective
results.2,3
doi:
HEALTH AFFAIRS 29,
NO. 8 (2010): 1496–1497
©2010 Project HOPE—
The People-to-People Health
Foundation, Inc.
10.1377/hlthaff.2010.0465
William M. Sage (wsage@law
.utexas.edu) is vice provost
for health affairs at the
University of Texas at Austin,
where he holds the James R.
Dougherty Chair for Faculty
Excellence in law.
1496
Health AffairsAugust 201029:8
After Health Reform

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Health improvement is critical to the sustain-
ability of our health care system. Framing the
new law’s initiatives to increase population
health as part of Americare would underscore
the message that individuals and communities
share responsibility for unhealthy behaviors
such as smoking, overeating, and avoiding
physicalactivity.Puttingpoorhealthinthesame
collective context as health insurance might fi-
nally persuade us to connect health care provid-
ers to schools, schools to workplaces, and
workplaces to other community sites that can
preserve and promote health.
Threeconcernsprobablydissuadedthereform
law’s proponents from clearly proclaiming its
identity. First, a named program might have
frightened America’s “haves” by suggesting that
familiar insurance arrangements would change.
Second,bestowingasinglenameontheprogram
might have seemed socialistic; even the pro-
posed“publicoption”wasabandonedinthefinal
law because it connoted a much-feared govern-
ment takeover. Third, the Congressional Budget
Office might have interpreted a unitary descrip-
tor as evidence that funds flowing from individ-
uals and employers to insurers were no longer a
matter of private purchase but constituted a tril-
lion-dollar tax increase, coupled with a trillion-
dollar boost in federal spending.
This political price wastoo steep to pay during
the legislative debate prior to enactment of the
law. In contrast, naming the program now is
likely to reduce its political vulnerability. Oppo-
nents of reform mainly accuse the new law of
cryptic complexity. A name such as Americare
offers a straightforward message in response.
Anationalidentitywouldalsohelpcounterac-
cusations of unaffordability. Health care spend-
ing has never been well understood by average
Americans.4,5During the legislative debate, me-
dia commentators approached the proposed law
as a compilation of personal costs and benefits.
They readily explained “how reform affects you”
but seldom considered “how reform affects us”
as a nation.
Americans generally favor low taxes and small
government and are skeptical about the connec-
tion between health reform and deficit reduc-
tion. Shared participation in a named program
is necessary to link our physical health as indi-
viduals to the fiscal health of our country. Prof-
ligate health spending diverts large amounts of
public money from other critical needs, such as
education. It represents a drain on employment
compensationthatcrowdsoutcashwages,andit
poses a long-term threat to the fiscal stability of
the United States.
Atseveralpointsinhistory,weAmericanshave
shown ourselves capable of pulling together on
healthcaretoprovidemutualassistance,express
patriotism,andinvestinourfuture.6Namingthe
newsystemAmericarewouldexpresslyassociate
both health security and stewardship of scarce
resources with citizenship in one of the greatest
nations on earth.NOTES
1 Rep. Fortney (Pete) Stark proposed
a Medicare-for-all system in the
AmeriCare Health Care Act in 2007.
Names resembling “Americare” have
also been used by private health care
companies.
2 Vladeck BC. The political economy of
Medicare. Health Aff (Millwood).
1999;18(1):22–36.
3 Jacobs LR. Politics of America’s
supply state: health reform and
technology. Health Aff (Millwood).
1995;14(2):143–57.
4 Blendon RJ, Hunt K, Benson JM,
Fleischfresser C, Buhr T. Under-
standing the American public’s
health priorities: a 2006 perspective.
Health Aff (Millwood). 2006;25(6):
w508–15.
5 Blendon RJ, Hyams TS, Benson JM.
Bridging the gap between expert and
public views on health care reform.
JAMA. 1993;269(19):2573–8.
6 Sage WM. Solidarity: unfashionable
but still American [Internet]. In:
Murray TH, Crowley M, editors.
Connecting American values with
American health care reform.
Garrison (NY): Hastings Center;
2009 [cited 2010 Jun 18].
p. 10–12. Available from: http://
www.thehastingscenter.org/
uploadedFiles/Publications/
Primers/solidarity_sage.pdf
Shared participation
in a named program is
necessary to link our
physical health as
individuals to the
fiscal health of our
country.
August 201029:8Health Affairs
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