What we’re talking about when we talk about Obamacare
What we’re talking about when we talk about Obamacare
Why this bit of language matters, plus Healthcare.gov insurance enrollment tips and deadlines
Folks in the U.S.: A quick reminder to check your eligibility and sign up for a new health insurance plan through Healthcare.gov before Dec. 15 if you haven’t already! More info on open enrollment at the end of this post.
The words we use to talk about money matter.
“From the crafty redefinition of existing words (and the invention of new ones) to powerful euphemisms, secret codes, renamings, buzzwords…even hashtags, language is the key means by which all degrees of cultlike influence occur,” writes language scholar
in her book Cultish: The Language of Fanaticism, which I read in my research for You Don’t Need a Budget.Euphemisms, renamings and buzzwords are especially potent in shaping how we feel about work, money and the economy, and our politicians know it. Nearly all of politics is skilled wordsmiths creating or co-opting words that capture the electorate’s attention and sway us in one way or another.
The problem is they don’t take care to consider the effect of their words in people’s everyday lives.
Political buzzwords by necessity collapse complex, nuanced subjects into simple, one-dimensional ideas. So much understanding (or potential for understanding) is lost when those words settle into our vernacular.
Obamacare is one of those words I hear too often.
As we’re in the midst of what I not-at-all-fondly think of as health insurance season in the United States — the open enrollment period for Healthcare.gov and many workplace insurance plans — let’s examine this word and bring some nuance back into our conversations about health care in this country.
No one “has Obamacare”
The most irritating way I hear the term used is in a sentence like I had Obamacare before I got this job.
No. You. Did. Not.
No one “has Obamacare,” because Obamacare isn’t a health insurance plan.
I’m not splitting linguistic hairs. This term is an example of the way our language obfuscates the bigger picture and keeps us from critiquing and changing our systems.
This term is an example of the way our language obfuscates the bigger picture and keeps us from critiquing and changing our systems.
Obamacare is a political term that describes the Patient Protection and Affordable Care Act (commonly known as the Affordable Care Act or ACA), legislation that created some rules and subsidies for private health insurance.
Using the term is a fun political win for Democrats. Republicans coined it during President Barack Obama’s administration when Congress was debating the legislation, hoping to taint it with the president’s name. Unfortunately, Americans saw the benefits of the program, and the term backfired on Republicans by giving Obama all the credit.
But continuing to use the term the way we do now — referring to health coverage purchased through the Health Insurance Marketplace as “Obamacare” — flattens our health care system and makes it hard to see what could change.
What’s hidden by the way we talk about health care
We don’t have anything close to a comprehensive, government-backed system of health care in the United States.
Most civilian health care1 in the U.S. is private, whether it’s for-profit (like prescription drug companies) or nonprofit (like many hospitals). If you pay for health care services (like doctor visits, surgeries and medications) with insurance, you’re using private health insurance, no matter how you signed up for that insurance.
At best for most of us, our federal and state governments are subsidizing private health insurance, which helps us pay for private health care providers.
When you say someone “has Obamacare,” there’s a suggestion of a comprehensive government system happening. Americans mostly know we don’t have this kind of health care in the U.S., but the more we frame health insurance coverage this way, the more we reduce our understanding of the system to a simple picture that doesn’t exist.
What you actually have if you “have Obamacare”
When someone says they “have Obamacare,” they most likely mean they shop for health insurance through the federal government’s Health Insurance Marketplace, housed at Healthcare.gov.
The Marketplace helps you learn whether you’re eligible for federal health insurance programs, state-administered Medicaid, or an advance tax credit to cover or reduce the out-of-pocket cost of your insurance premium (the monthly payment you make to have coverage). It also lets you sign up for a health insurance plan — but your coverage is not provided by the government; it’s provided by a private health insurance company.
Another important distinction: When I say “coverage,” I don’t mean “health care.”
We often use the terms health care, health insurance and health coverage interchangeably, but this couldn’t be more wrong.
Health care describes the services you receive — from a hospital, a primary doctor, a surgeon, a clinic, etc.
Health insurance is a plan that helps pay for those services.
Coverage describes the services your particular health insurance plan helps you pay for and in what timeframe. (e.g. you have in-network coverage for 2023).
No single entity, like the federal government, is responsible for providing health care in the U.S., the way the U.K.’s National Health Service (NHS) is. Instead, we get tax subsidies that help pay for private health insurance, which helps pay for private medical care providers, and medication produced and sold by private companies.
We’re addressing the wrong problems
The ACA was a monumental milestone for access to health care in the United States. As of early 2023, 40 million people have health insurance because of the subsidies, Medicaid expansion and other insurance programs the legislation created.
Americans know there are still tons of problems the legislation didn’t address. We complain about people who fall through the cracks and can’t buy insurance. We complain about changing doctors when our preferred provider is no longer in-network under a new insurance plan. We complain about Medicare restrictions and swap recommendations for the best Medicare supplement insurance.
All of these complaints are valid — and they completely miss the point.
We don’t need better health insurance. We need free health care. We need to stop paying for health care the way we do in the U.S.
We don’t need better health insurance. We need free health care.
The NHS in the U.K. was founded on a principle that health care should be available to all “based on clinical need, not an individual’s ability to pay.”
It’s such an obvious concept, it shouldn’t need to be said out loud.
In Canada, every citizen or resident receives a health care card that gives them access to services for free.
“When something happens, you don’t have to think about, is this going to cost me a lot because I’m not in network?” explains
, an entrepreneur and a Canadian who’s also lived for stints in the U.S.When I spoke to a friend who’d moved to the U.S. from the Netherlands for work, they were baffled to arrive and discover they’d have to pay for prescription medications at the pharmacy.
Networks, deductibles, copayments and out-of-pocket costs feel like normal parts of a health care conversation to Americans — but this is not normal.
Around the world, it’s normal to schedule an appointment with any doctor and get a check up for free. It’s normal to walk into any hospital when you need urgent care and be seen without filling out a litany of paperwork. It’s normal to walk out of an emergency room visit and never receive a surprise medical bill. It’s not normal for medical debt to be among the leading causes of bankruptcy.
Misleading language sends us down the wrong path
Using Obamacare as short-hand for the way you access health care erases all of these layers of the system. It creates an entity to chip away at; opponents highlight its shortcomings, and proponents suggest improvements. It lets everyone off the hook for talking about an alternative.
When you talk about the need for universal health care, make sure you’re talking about care and not insurance.
When you talk about the need for universal health care, make sure you’re talking about care and not insurance.
When you complain about limits in your coverage and network, notice that the limits are designed by a private insurance company — not by doctors or the government.
When you worry about the cost of health insurance for your family, ask why you have to buy insurance in the first place. Why do you have to pay for health care? And why are those costs so great that you need insurance to cover them?
When you hear someone vent about a change to their tax subsidy that leaves them with a higher monthly bill, suggest that our taxes shouldn’t be going to profit-seeking insurance companies at all. What if they went directly to health care services?
Examining what someone says when they say “Obamacare” (or “health care” or “coverage” or any other shorthand) lets you understand the nuances in this conversation and see the holes in the system more clearly.
Enroll in Marketplace coverage before Dec. 15
Because it’s the best we have for now, I’ll remind you to take advantage of open enrollment and check your options for lower-cost health insurance through the Marketplace — don’t fork over any more money than you need to to receive care.
If you purchased insurance through the Marketplace for coverage for any part of 2023, you’ll be automatically enrolled in the same or a similar plan to start Jan. 1, 2024, if you don’t make any changes (your premium could change).
You have until Dec. 15 to check your options and enroll in a new plan to start coverage Jan. 1. The final deadline for open enrollment is Jan. 15; if you sign up for a 2024 plan by that date, your coverage will probably start Feb. 1 (so you might have no coverage for January).
Even if you have a plan you like, go through the quick questionnaire in the Marketplace to see if you qualify for new subsidies or a different plan. You can always re-enroll yourself in your existing plan at the end of the application.
Open enrollment is the period when anyone can sign up for a new health insurance plan through the Marketplace. If your access to health insurance changes throughout 2024 (job loss, relationship change, income change, relocation, adding a child, etc.) you’ll qualify for a special enrollment period to sign up for a new plan through the Marketplace. For Medicaid and Children’s Health Insurance Program (CHIP), you can see if you qualify and sign up anytime, no enrollment period limits.
🍎 Bring the nuance back into your personal finance classroom!
Are you a financial educator, coach or advisor ready to have a more expansive conversation about money with your clients? My Budget-Free Fundamentals series gives you everything you need to help participants gain a fresh perspective on their relationship with money.
Share your health care experience!
What has it been like for you to get the care you need? Where have you struggled, and what’s surprised you? If you’re in the U.S., does this examination clarify any of your experience? If you’re outside of the U.S., how does your experience differ from the one I described above?
Read more about the dangers of our for-profit health care system from
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Notable exceptions include insurance coverage through Medicare Part A or B and health care services provided by facilities owned by the U.S. Department of Veterans Affairs (i.e. VA hospitals).
I love that you're tackling the terms we use when we describe "health care".
This is such an important big picture look at the US health insurance landscape.
Excellent information and analysis, Dana. Interesting point about the label "Obamacare" and how it implies a national health care system, when it is not. Also, it's not a common point of discussion (but should be) that we pay for health insurance and only sometimes receive the medical care we need.
And thanks very much for the newsletter mention!