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

2. tor as evidence that funds flowing from individ-
Shared participation uals and employers to insurers were no longer a
matter of private purchase but constituted a tril-
in a named program is lion-dollar tax increase, coupled with a trillion-
necessary to link our dollar boost in federal spending.
This political price was too steep to pay during
physical health as the legislative debate prior to enactment of the
law. In contrast, naming the program now is
individuals to the likely to reduce its political vulnerability. Oppo-
nents of reform mainly accuse the new law of
fiscal health of our cryptic complexity. A name such as Americare
offers a straightforward message in response.
country. A national identity would also help counter ac-
cusations of unaffordability. Health care spend-
ing has never been well understood by average
Americans.4,5 During the legislative debate, me-
dia commentators approached the proposed law
as a compilation of personal costs and benefits.
Health improvement is critical to the sustain- They readily explained “how reform affects you”
ability of our health care system. Framing the but seldom considered “how reform affects us”
new law’s initiatives to increase population as a nation.
health as part of Americare would underscore Americans generally favor low taxes and small
the message that individuals and communities government and are skeptical about the connec-
share responsibility for unhealthy behaviors tion between health reform and deficit reduc-
such as smoking, overeating, and avoiding tion. Shared participation in a named program
physical activity. Putting poor health in the same is necessary to link our physical health as indi-
collective context as health insurance might fi- viduals to the fiscal health of our country. Prof-
nally persuade us to connect health care provid- ligate health spending diverts large amounts of
ers to schools, schools to workplaces, and public money from other critical needs, such as
workplaces to other community sites that can education. It represents a drain on employment
preserve and promote health. compensation that crowds out cash wages, and it
Three concerns probably dissuaded the reform poses a long-term threat to the fiscal stability of
law’s proponents from clearly proclaiming its the United States.
identity. First, a named program might have At several points in history, we Americans have
frightened America’s “haves” by suggesting that shown ourselves capable of pulling together on
familiar insurance arrangements would change. health care to provide mutual assistance, express
Second, bestowing a single name on the program patriotism, and invest in our future.6 Naming the
might have seemed socialistic; even the pro- new system Americare would expressly associate
posed “public option” was abandoned in the final both health security and stewardship of scarce
law because it connoted a much-feared govern- resources with citizenship in one of the greatest
ment takeover. Third, the Congressional Budget nations on earth. ▪
Office might have interpreted a unitary descrip-
NOTES
1 Rep. Fortney (Pete) Stark proposed 1995;14(2):143–57. but still American [Internet]. In:
a Medicare-for-all system in the 4 Blendon RJ, Hunt K, Benson JM, Murray TH, Crowley M, editors.
AmeriCare Health Care Act in 2007. Fleischfresser C, Buhr T. Under- Connecting American values with
Names resembling “Americare” have standing the American public’s American health care reform.
also been used by private health care health priorities: a 2006 perspective. Garrison (NY): Hastings Center;
companies. Health Aff (Millwood). 2006;25(6): 2009 [cited 2010 Jun 18].
2 Vladeck BC. The political economy of w508–15. p. 10–12. Available from: http://
Medicare. Health Aff (Millwood). 5 Blendon RJ, Hyams TS, Benson JM. www.thehastingscenter.org/
1999;18(1):22–36. Bridging the gap between expert and uploadedFiles/Publications/
3 Jacobs LR. Politics of America’s public views on health care reform. Primers/solidarity_sage.pdf
supply state: health reform and JAMA. 1993;269(19):2573–8.
technology. Health Aff (Millwood). 6 Sage WM. Solidarity: unfashionable
August 2010 29 :8 Health Affa irs 1497