Democrats Confront Vexing Politics Over the Health Care Law

ATLANTA - When Franklin D. Roosevelt established Social Security, he created generations of loyal Democrats. When Lyndon B. Johnson signed Medicare into law, he built on that legacy, particularly with older Americans. And when George W. Bush instituted a new prescription drug benefit for Medicare, it helped reclaim elderly voters for Republicans.

But President Obama's Affordable Care Act, the $1.4 trillion effort to extend health insurance to all Americans, is challenging the traditional calculus about government benefits and political impact.

Even as Mr. Obama announced that eight million Americans had enrolled in the program and urged Democrats to embrace the law, those in his party are running from it rather than on it, while Republicans are prospering by demanding its repeal.

The reasons are complex and layered in the early assessments, but say much about the nation's political polarization, its shifting fault lines of class and race, and a diminished faith in government.

Democrats could ultimately see some political benefit from the law. But in this midterm election, they are confronting a vexing reality: Many of those helped by the health care law - notably young people and minorities - are the least likely to cast votes that could preserve it, even though millions have gained health insurance and millions more will benefit from some of its popular provisions.

'The angry opponents are more mobilized than the beneficiaries,' said David Axelrod, the longtime adviser to Mr. Obama.

Young adults and minorities tend to vote in midterms at lower rates than older and white voters. And a poll by the Pew Research Center and USA Today found that more Republicans than Democrats will be influenced by a candidate's stance on the health law.

As of last month, about 140,000 Georgians had signed up for coverage through the law's exchanges, and about 28 percent of those were ages 18 to 34. Of the uninsured population in the state, 47 percent are white, 37 percent black, 10 percent Hispanic and 4 percent Asian, according to the Department of Health and Human Services.

Turnout among blacks in the state, who make up 30 percent of the registered voters, typically drops by about five percentage points in a midterm election, when the gap in black and white voter participation widens.

Increasing turnout beyond what is typical in nonpresidential years is particularly crucial to Democrats' hopes here. But two Democratic scions in Georgia, Jason Carter, the grandson of former President Jimmy Carter, who is running for governor, and Michelle Nunn, the daughter of former Senator Sam Nunn, a candidate for the Senate, are not invoking the health law as a way to stoke voter energy.

They have spoken in public about the law mostly to criticize it, did nothing to promote enrollment for insurance before last month's deadline and declined interviews to even discuss the law. In a state where nearly 1.8 million people still lack medical insurance, the word 'health' can scarcely be found on either candidate's webpage.

Across the country, many Democrats have made the calculation that embracing the law offers more risk than reward.

The architecture of the law almost ensured this outcome. To win over centrist Democrats, the administration proposed a complicated, market-based overhaul that was undergirded politically by Mr. Obama's promise that individuals could keep their existing health plans.

'It was sold as small, minor change because of the need to pass it through Congress and assure the vast majority of people that it wouldn't disturb their existing health insurance,' said Stanley B. Greenberg, a Democratic pollster. 'But why defend it, why mobilize behind it if it's just small change?'

Mr. Obama's loyalists say a broad-based, 'single-payer' system was never politically feasible, and yet it was the lack of universality that made it easier for Republicans to portray it as an income transfer program from the better-off to the poor.

'I think it is viewed more as a social welfare program than a social insurance program, but that's not right because it is social insurance,' Mr. Axelrod said.

That contrasts sharply with Medicare and Social Security, which remain popular because almost everyone who benefits paid something into the system. 'That was done because it sat better with the American cultural idea of self-reliance,' said David M. Kennedy, a Stanford University historian.

In addition, Republicans argued effectively that the law was changing the status quo, affecting people who already had private health insurance, said Representative David E. Price, Democrat of North Carolina.

'There was an ability to exploit the unknown, to exploit the fear of people losing something that they have,' said Mr. Price, a political scientist. 'That wasn't true with Social Security and Medicare.'

The focus on the law's expansion of coverage for those of modest means has also overshadowed popular, more broadly enjoyed benefits like allowing parents to keep their children on their plans until they are 26 and barring insurance companies from denying coverage because of pre-existing conditions.

'This is where the communications failure has been so problematic,' said Ezekiel J. Emanuel, one of the law's architects. 'We haven't really alerted Americans to the fact that there is much more to this than the exchanges that's going to be really, really positive for all of us, not just those getting insurance.'

That view has not taken hold, especially among white voters who see the law as an act of government redistribution to the 15 percent of the population that is uninsured. In a New York Times/CBS News poll in December, just 17 percent of whites said the health law would help them while 41 percent said it would hurt; among blacks, 42 percent said it would help them while 15 percent predicted it would hurt. Four in 10 whites and blacks said it would have no effect on them.

This divide was easy to detect in Atlanta, where symbols of ethnic diversity abound - the city's hip new barbecue restaurant, Sweet Auburn, is named after Atlanta's historically black neighborhood and owned by a Chinese-American - but reminders of old divisions are just as evident.

Judy McDaniel said outside an enrollment event that she had 'mixed feelings' even after her 42-year-old son was finally about to sign up for health insurance under the law. 'I've been lucky enough in my career to afford my own insurance, and I'm not sure how I feel about supporting others,' said Ms. McDaniel, who is white and said she had voted against Mr. Obama.

At Ebenezer Baptist Church, where the Rev. Dr. Martin Luther King Jr. served as pastor, black health insurance professionals signing up people on the final enrollment day predicted that the law would become more popular once it was less infused with politics.

'It's going to happen when Obama is no longer the president,' Harold Hardee said. 'You try taking Medicare away from folks now and they fight you.'

But when Medicare was passed in 1965, Americans had more faith in the federal government. Just 2 percent of those surveyed in a recent Quinnipiac Poll said they trusted Washington to do what is right almost all the time.

'In the '60s, we felt like we could do anything,' recalled Joseph A. Califano Jr., a top domestic aide to Johnson. 'We could feed the hungry, cure disease and clean the air. Now there's just a lot more skepticism.'

Conservatives say that skepticism is well founded. 'Systems that would have worked 30 years ago don't work now,' said Newt Gingrich, the former House speaker. 'Outside the military and air traffic control, tell me a large bureaucracy that functions. It's not that the country has changed. It's that the country's experience with systems has changed.'

This indifference was readily apparent on a recent morning at Octane, an Atlanta coffee shop filled with younger customers. As they sipped $4.60 lattes, several in their 20s said that they were supportive of the health law but that it would not have much bearing on their vote - if they voted at all.

Michael Martell, 26, a student teacher in North Carolina visiting a friend, said he had learned how vital it was to have health care from living in Spain. But as of now he is not eligible to vote in North Carolina's pivotal Senate race because he is still registered in his native Illinois.

'I'm not really tied down to a single community, which makes it harder to be involved in politics,' he said.

Democrats say opinions of the law are destined to improve over time.

'There's the reality of the program and the popular perception of it, and the more the perception aligns with reality the more you'll see Democrats embrace it,' said Stacey Abrams, a Democrat and the minority leader of the Georgia House. But, she acknowledged, 'we're not there yet.'