Why do more people say the ACA has harmed than helped them?

One ongoing frustration for ACA supporters in public opinion polling is the fact that the number of people say that the ACA has directly harmed them and their families consistently outstrips the number who say it has directly helped them.

Now that the ACA is directly subsidizing health insurance for about 20 million people, that particular perception has narrowed but not closed. Here's a graph from the Kaiser Family Foundation, which polls on this question regularly:

Since last May, the gap has narrowed from 24-14 to 22-19. But it's still there, and the question is where the perception (and/or reality) of direct harm comes from.

Among those who might claim harm are customers in the pre-ACA individual market for insurance who saw their plans cancelled and their rates hiked when the ACA took full effect in January 2014 -- that is, for the most part, people who earn too much to qualify for ACA subsidies, do not have access to employer-sponsored insurance, and do not have a pre-existing condition or a family member with one. This cohort exists, but its numbers are small. The Urban Institute estimates that 2.6 million plan holders in the individual market in 2013 received notices that their plans were being cancelled because they did not comply with ACA requirements. Of those, Urban estimates that a bit more than half qualified for subsidies on the ACA exchanges. Some, too, subsequently found their pre-ACA plans "grandmothered" when the outcry about cancelled policies arose in fall 2013. Only a small number then had their plans cancelled in 2015.

What about employees who saw their hours cut in response to the ACA requirement that large employers provide coverage to employees working 30 hours or more? A recent survey* by SHRM, the Society for Human Resource Management, finds that 14% of respondents (SHRM members) did cut hours in response to the requirement, and those cuts affected 19% of an organization's employees on average. That translates to about 2.7% of employees at organizations responding to the survey.

What about rising premiums and cost-sharing for employees?  According to the Kaiser survey, both have continued to rise since the ACA was passed in 2010, but more slowly than in the 2004-2009 period.  In the SHRM survey, 77%  report a rise in insurance costs from 2014 to 2015, and 40% of those (or about 31% overall) report an increase of 11% or more. That's substantial -- but again, more a continuation of a longstanding trend than a new phenomenon.

A significant number of employers, 33%, say that they plan to take action to ward off the so-called "Cadillac" tax on plans offering particularly rich benefits, scheduled to take effect in 2018. But only 9% have taken such action to date.

The SHRM survey does, however,  provide a hint as to why many may report that the ACA has harmed them:

The biggest changes from 2013 are that more organizations have communicated the impact of the ACA to employees (from 32% o 67%) and to retirees (from 7% to 17%).

The ACA has had and is likely to continue to have a complex and mixed effect on employer-sponsored insurance. Thus far, Kaiser's findings indicate that the marked slowdown in recent years of overall healthcare spending growth -- which may be partly attributable to ACA cost controls and pilot programs --  has offset new expenses to employers such as the requirements to cover employees' children up to age 26 and the ACA's new taxes on insurers and drug and medical device makers.

At the same time, a majority of employers are now attributing changes in health insurance to the ACA.  Usually such changes include hikes in employee costs or reductions in benefits. While such cuts and price hikes have not accelerated in recent years, they've been continuous for so long that many employees are exposed to thousands of dollars in out-of-pocket costs. Many probably now blame what's been a relentless climb on the ACA. The Kaiser survey may support this conclusion:

The main reason named by those who report being hurt by the law is that it increased their health care or health insurance costs (14 percent). Smaller shares say that it made it more difficult to get the health care they need (4 percent) or caused someone in their family to lose their insurance (2 percent).

As I've noted before, another possible cause of the ACA's unpopularity is the fact that most direct beneficiaries are in the the lower 20-25% of the income distribution.  And of course a third cause, building on and grotesquely magnifying the other two, is the nonstop disinformation and smear campaign conducted by the GOP these past six years. That third cause affects primarily Republicans, 40% of whom (in the Kaiser survey) claim the law has harmed them versus just 8% who say it's helped them. The Democratic split is similar but perhaps suggests fewer willing to assert a direct personal effect if they haven't experienced one: 27% say the law has helped them, 8% that it's caused them harm.

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* The SHRM survey reflects input from 743 SHRM members polled from January 21-February 4, 2015. SHRM estimates a margin of error of +/- - 4%.