Friday, March 22, 2013

The Affordable Care Act at 3

This weekend, the Patient Protection and Affordable Care Act (derisively or fondly known as “Obamacare”) turns 3, and according to a new poll from the Kaiser Family Foundation, the public remains largely uninformed or misinformed about the law.

People both (a) don’t know what is in the law and (b) think things that are not in the law are.

Less than half of the population surveyed knew that the Affordable Care Act closes the Medicare “doughnut hole” (the gap in prescription drug coverage from Medicare Part D) and established a minimum medical loss ratio of 80%, mandating that no more than 20 cents per dollar of insurance be spent on overhead. Almost as many people thought the ACA did not control the medical loss ratio (37%) as knew that it did (40%). This lack of awareness is unfortunate because both  provisions have cross-partisan majority support. 81% of respondents supported closing the Medicare “doughnut hole,” making it the second most popualr provision of those tested; 90% of Democrats, 80% of Independents, and 74% of Republicans viewed the provision favorably. Although the medical loss ratio did not achieve quite as high of support, it still saw an overall favorability rating of 65%--72% with Democrats, 60% with Independents, and 62% with Republicans.

Of the 11 provisions tested, only 4 of them had at least 60% recognition: subsidy assistance to individuals (62%), extension of dependent coverage (69%), employer mandate (71%), and individual mandate (74%). The individual mandate, a philosophically conservative policy that originated at the Heritage Foundation, was both the most well-known provision and the least popular, with only 40% favorability—55% among Democrats, 39% among Independents, and 21% among Republicans. The employer mandate was both the second most well-known provision and the second least well-liked, with only 57% overall favorability (79% among Democrats, 54% among Independents, and 36% among Republicans).

Of the four misperceptions tested, a majority or plurality of respondents answered incorrectly in each case. In what can be considered a mark of tragic irony, a majority (57%) of respondents thought that the Affordable Care Act included a public option. A strong plurality (47%) thought that undocumented immigrants were able to receive subsidies to purchase insurance, and slim pluralities thought that the Affordable Care Act cut Medicare benefits (44%) and established a government panel to make decisions about end-of-life care for people on Medicare (40%). In other words, “government takeover,” “Get your government hands off my Medicare,” and “death panels” live on in the public imagination.

There are several key takeaways from this report. First, most people do not feel that they have enough information to understand how the Affordable Care Act will impact them. By a 2:1 ratio, the uninsured, those whom the law is supposed to help, said that they did not have enough information. Second, as the graph below demonstrates and my comments above explained, many of the most popular provisions are among the least widely recognized—and vice versa.


Moreover, despite the fact that 10 out of the 11 provisions polled garnered at least a 50% favorability rating, and 9 out of 11 garnered over 60%, the bill as a whole remains unpopular. 40% viewed it unfavorably, compared to only 37% favorably and a rather high 23% unsure. A strong party divide remains, but even Democrats don’t seem overly fond of the health reform law. Only 58% view it favorably; however, that’s obviously positive compared to the 31% support from Independents and 18% from Republican.

Interestingly, since the election, Democratic support has dropped quite significantly, falling 14 percentage points. Democratic and Independent support have both been trending downward since the summer of 2010, with Republican consistently low but prone to fluctuation.

The other day, I was re-reading Mike Lofgren’s The Party is Over, and in one of his early chapters, he discusses how Republicans are significantly better at naming and messaging legislation than Democrats are; Republicans communicate like marketing executives, Democrats like professors. The Patient Protection and Affordable Care Act is hardly a user-friendly, relatable name. Would it have been that difficult to name the bill the Helping Every American’s Long-Term Health and Cutting Appropriate Rates and Expenditures (HEALTH CARE) Act—or something similar? Of course, the popular impression of the health reform law would likely have also stayed higher had the Democrats not tried to run from it during the 2010 election, when many ran as Republican-lite. As the provisions continue to roll out, such as the exchanges, the administration has a lot of work ahead of it if it wants to connect with and educate the public and have the law actually achieve its stated effects.

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