Tuesday, April 22, 2014

In December 2008, support for ACA linchpins was broad and shallow

As the Affordable Care Act's first open enrollment season wraps up with a major surge, the law's implementation remains as polarized as public opinion and party rhetoric. States that ran their own exchanges and accepted the Medicaid expansion reduced their uninsured populations by three times as much as states that abstained on both counts, according to Gallup polling. California and Connecticut reached 175% of the CBO's projection for first-year private plan signups; Oklahoma, just 28%, according to Charles Gaba's spreadsheet. Meanwhile, as Obama declared, "the repeal debate is and should be over” and “the Affordable Care Act is working," Republicans geared up once again to make repeal and denigration of the law the centerpiece of their election strategy.

At this juncture, after five years of political mortal combat, it's instructive to look back at Americans' reactions when first confronted with the proposed core provisions of the ACA. The Kaiser Family Foundation probed opinions about those measures back in December 2008, polling over 1600 adults (thanks, Larry Levitt). By that point, the prospective law's outlines were clear, as all three Democratic candidates had proposed similar healthcare reform plans.

At first blush, respondents were enthusiastic about the mechanisms for expanding private-market health insurance: requiring employers to cover employees, and requiring individuals to buy affordable coverage. When asked to consider potential consequences of those mandates, however, respondents turned ambivalent.  The poll results might have been read to provide cover to Democrats to move forward. But they also pointed to multiple entry points for Republicans to exploit the pending legislation's tough tradeoffs.

With a new Democratic president poised to take office, support for major reform could be viewed as either strong or soft. Only 24% favored leaving the healthcare system more or less untouched; 74% wanted to see a new health plan. But only 48% wanted to see a plan that would make "a major effort to provide health insurance for nearly all uninsured Americans and involve a substantial increase in spending." Another 26% said they favored a more limited plan that would "cover only some new groups but would involve less spending." Viewed another way, 52% opposed a drive toward universal coverage.

When it came to the linchpins of the ACA, a superficially startling 71% favored "requiring employers to offer health insurance to their workers or pay money into a government fund that will pay to cover those without insurance (47% favored "strongly," 24% "somewhat"). 67% favored "requiring all Americans to have health insurance, either from their employer or from another source, with financial help for those who can't afford it (40% strongly, 27% somewhat).

The Kaiser questionnaire pushed for some reflection on those snap answers, however. Regarding the employer mandate, it asked, "What if you heard that paying for this may cause some employers to lay off some workers?  Under such conditions, only 41% reported they would "still favor" the measure; 55% opposed. For the individual mandate, the qualifier was "What if you heard that this could mean that some people would be required to buy health insurance that they find too expensive or did not want?" And lo, if such were the case, suddenly 69% would oppose the mandate, and only 28% still favor.

Notice how open-ended the qualifiers are. That strikes me as both a strength and a weakness -- perhaps an unavoidable one. Of course a major new required expense would cause some employers to hire fewer people (or reduce hours); the question is how many. (Not many, according to the latest CBO projection.) Of course some people would find the individual mandate either a financial burden or an imposition or both; the question, again, is whether it imposes real hardship or forces bad options on a significant number of people.

That question is hard to answer and involves an irreducible element of subjectivity. The New York Times today has a good profile of several people who opted to forgo insurance and accept the tax penalty. One would not fully explore his options; two made debatable but understandable cost/benefit/risk calculations.  The high deductibles for low-cost plans made the premium seem not worth it to two of them; essentially, they were rejecting coverage they saw as merely catastrophic. Whether that is rational depends in part on how much you have to lose in bankruptcy or whether you would be likely to qualify for charity care (which few people can gauge in advance, I would think).

Kaiser also asked whether several possible side effects of reform would make people less likely to support a proposed law. Not surprisingly, majorities said they would be less likely to support a law that limited their choice of doctors, increased people's premiums or out-of-pocket costs, or would "get the government too involved in your personal health care decisions" (how much is too much, and who wouldn't object to that?). A large plurality, 43%, also said they would be less likely to support a law that would make them switch plans. 

Other core provisions of what became the ACA had unambiguously strong support: offering tax credits to help people buy private insurance (65%); expanding Medicaid and CHIP (73%); offering tax breaks to businesses for providing insurance (85%); and helping the unemployed afford insurance (82%).

The questions about the downside of key provisions could only start a dialogue; they could not lead people into a nuanced consideration of the inevitable cost/benefit tradeoffs that would be required by any attempt to make coverage approach universality (though there was some nuance: 72% said they would favor requiring insurers to cover anyone who applies, even if doing so raised premiums "somewhat" for healthier people).  What they did reveal was a political opening for an opposition willing to exaggerate and demonize the downside of every tradeoff.

And that, of course, is exactly what the Republicans did -- and then some.  They have exploited inevitable ambivalence about the mandate and raising costs for the healthy to cover the sick; helped foster ignorance about provisions that attract overwhelming support; and simply invented bugbears that do not exist in the law.

Kaiser's most recent polling about the ACA demonstrates the continuing success of the demonization campaign. While those who disapprove of the law outnumber those who approve of it, 46% to 38%, most individual provisions remain popular -- except the individual mandate, for which approval, at 35%, is in range with the 2008 response to the qualifying question, "What if you heard that this could mean that some people would be required to buy health insurance that they find too expensive or did not want?" For all other provisions, Kaiser notes, awareness lags far behind approval:

For Most ACA Provisions, Awareness Lags Behind Favorability (Individual Mandate Is Exception)

Moreover, the GOP lie that the ACA created "death panels" lives on in many American minds (thanks, Sarah!). Asked whether the ACA "establish[es] a government panel to make decisions about end-of-life care for people on Medicare," 34% said that it does, and 24% were unsure.

The takeaway for me is that if one party wants to relentlessly demonize a major undertaking that involves inevitable tradeoffs, it can. Distortions, smears and lies work if repeated often enough with a united front. Undoing the effects of the disinformation campaign will take years, and probably won't be complete until no one remembers the origin of the ACA's various provisions.

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