Don’t Dare Call the Health Law ‘Redistribution’ - But the redistribution of wealth has always been a central feature of the law and lies at the heart of the insurance market disruptions driving political attacks this fall.

John Harwood writes in The New York Times:
      

“Redistribution is a loaded word that conjures up all sorts of unfairness in people’s minds,” said William M. Daley, who was Mr. Obama’s chief of staff at the time. Republicans wield it “as a hammer” against Democrats, he said, adding, “It’s a word that, in the political world, you just don’t use.”

      

These days the word is particularly toxic at the White House, where it has been hidden away to make the Affordable Care Act more palatable to the public and less a target for Republicans, who have long accused Democrats of seeking “socialized medicine.” But the redistribution of wealth has always been a central feature of the law and lies at the heart of the insurance market disruptions driving political attacks this fall.

      

“Americans want a fair and fixed insurance market,” said Jonathan Gruber, a health economist at the Massachusetts Institute of Technology who advised Mr. Obama’s team as it designed the law. “You cannot have that without some redistribution away from a small number of people.”

      

Mr. Obama’s advisers set out to pass the law in 2009 fully aware that fears among middle-class voters sank President Bill Clinton’s health initiative 16 years earlier. So they designed the legislation to minimize the number of people likely to be hurt.

      

Instead of a sweeping change to a government-run “single-payer” system favored by Democratic liberals, members of the administration sought to preserve the existing system of employer-provided health insurance while covering the uninsured through the expansion of Medicaid and changes to the individual insurance market.

      

They also added benefits available to any family, such as the ability of children up to age 26 to remain on their parents’ health plans.

      

But throughout the process, they knew that some level of redistributing wealth — creating losers as well as winners — was inescapable.

      

They were nonetheless acutely aware of how explosive the word could be. When Mr. Obama ran for president in 2008, Republicans tried to wound him by accusing him of waging “class warfare” to achieve wealth redistribution. That fall, the Republican presidential nominee, Senator John McCain, derided Mr. Obama as the “redistributor in chief” as he seized on Mr. Obama’s comments to an Ohio man later known as “Joe the Plumber” that he wanted to “spread the wealth around.”

      

Mr. Obama survived that episode and other instances when Republicans deployed old recordings of him using the word “redistribution” as evidence that he was a closet socialist. But Mr. Obama had learned a lesson.

      

After he took office, he cast his goal of rolling back President George W. Bush’s tax cuts for higher earners not as economic redistribution, but as the restoration of top-end rates from the Clinton years.

      

The Affordable Care Act was a similar semantic sidestep. The law targeted high earners, too, by raising their Medicare taxes enough to reduce their after-tax incomes by nearly 2 percent, according to the nonpartisan Tax Policy Center. That revenue helped finance coverage for those currently without insurance, who tend to have lower incomes and who in many cases will receive government subsidies to make their premiums cheaper.

      

And yet for those nervous about potential changes, the president promised stability. “If you like your current insurance, you will keep your current insurance,” Mr. Obama said the day he signed the legislation in March 2010, a promise he made repeatedly as the Oct. 1 opening day of the online health insurance marketplaces approached.

      

Hiding in plain sight behind that pledge — visible to health policy experts but not the general public — was the redistribution required to extend health coverage to those who had been either locked out or priced out of the market.

      

Now some of that redistribution has come clearly into view.

      

The law, for example, banned rate discrimination against women, which insurance companies called “gender rating” to account for their higher health costs. But that raised the relative burden borne by men. The law also limited how much more insurers can charge older Americans, who use more health care over all. But that raised the relative burden on younger people.

      

And the law required insurers to offer coverage to Americans with pre-existing conditions, which eased costs for less healthy people but raised prices for others who had been charged lower rates because of their good health.

      

“The A.C.A. is very much about redistribution, whether or not its advocates acknowledge that this is the case,” wrote Reihan Salam on the website of the conservative National Review.

       

Having obscured much of that vulnerability before, Mr. Obama has responded to recent political heat by apologizing — and expanding the scope of his discredited “you can keep it” promise.

      

Mr. Gruber of M.I.T. called redistribution a convenient tool for Republican opponents who would fight the law anyway.

      

In the end, America’s political culture may have made it unrealistic to expect a smooth public reception for the law, no matter how cleverly the White House modulated Mr. Obama’s language or shaped his policy to minimize the number of losers.

      

“The reality is, any big thing you take on, any big change, is hard to accomplish,” said David Axelrod, the president’s longtime strategist. In America, he said, “we’ve created a sense that everyone can expect to win — nobody has to sacrifice.”

      

At the same time, Mr. Axelrod argued that widening income inequality has, to some Americans at least, changed the meaning of redistribution. “The whole redistribution argument has shifted in the country because there’s a sense that a lot of redistribution has been to the top and not the bottom,” Mr. Axelrod said.

      

Still, the word is hardly a favorite of the president these days. The last time Mr. Obama used it in public, according to Federal News Service transcripts, was 18 months ago during his re-election campaign in Elyria, Ohio.

      

“Understand this is not a redistribution argument,” the president told his audience then. “This is not about taking from rich people to give to poor people. This is about us together making investments in our country so everybody’s got a fair shot.”