Why Do Americans Still Hate Obamacare?
Jobs, quality of care, premiums; these are the measurable points of success for the Affordable Care Act, the areas of the public’s everyday life that the health care reform primarily influences. Thanks to the how politically divisive Obamacare has been since its inception, and thanks to the huge changes the reform brought to the American health care system, its impact has been closely monitored. As the first year of operation of Obamacare’s individual insurance marketplaces draws to a close, critics of President Barack Obama’s signature legislation, including a great majority of the Republicans running for reelection, are closely examining the available data. The imminent congressional midterm elections have added a sense of urgency to this analysis; and the most important question is whether the Affordable Care Act has helped or hurt the average American. But there is no simple answer.
Of course, the president’s rhetoric paints the Affordable Care Act as an unmitigated success. “There’s a reason fewer Republicans, you hear them running about Obamacare — because while good, affordable health care might seem like a fanged threat to the freedom of the American people on Fox News — it turns out it’s working pretty well in the real world,” he said in a speech at Northwestern University earlier in October. According to data provided by Gallup, that assessment is correct — at the most basic level.
But what does “working pretty well” actually mean? It means that the Affordable Care Act has accomplished (or is in the process of accomplishing) its most important goal. “The ACA starts from a place of wanting to make sure that all individuals can obtain affordable insurance, even if they have a prior medical condition,” as Aaron Carroll MD, MS, wrote in a blog post for the forum of the Journal of the American Medical Association. Data collected over the past several months has consistently shown that significantly more Americans are insured now than before the Obamacare insurance policies went into effect in January of this year. After reaching a high of 18% in the final quarter of 2013, Gallup’s measure of the United States uninsured rate dropped to 13.4% in the second quarter of this year — the lowest level recorded in the seven years since that trend has been tracked. The reversal in the growing rate of uninsured Americans coincided with the activation of the new policies create under the health care reform.
The fact that the uninsured rate has remained steady at 13.4% throughout the second and third quarters of 2014 also suggests that the drop is linked to the implementation of the Affordable Care Act’s cornerstone provision: the individual insurance exchanges. Of course, Gallup’s data is not scientific proof that the health care reform has been successful, but the research firm did note that, “The Affordable Care Act seems to be accomplishing its goal of providing more Americans with health insurance.”
Tempering the president’s optimism and Gallup’s falling uninsured rate is the fact that public opinion remains sharply negative. The most recent Kaiser Family Foundation health tracking poll found that the public is more likely to express an unfavorable view of the health care reform than a favorable one, by a margin of 47% to 35%. Roughly, the percentages of Americans holding negative opinions and positive opinions have stayed constant since the law was passed in March 2010.
That enduring negativity bears further examination. Is it simply a product of the political upheaval created by the debate over the reform? Or is it born out of concerns that the shockwaves the reform sent through the American health care system have not yet subsided? Or are Americans worried that the structure foundation of the Affordable Care Act is weak? Undoubtedly, these are questions best answered by health care wonks. But it is not hard to pinpoint the forces that are shaping public opinion: worries that premiums will increase sharply in the future, the quality of health care provided by these new policies, and potential for job loss.
Especially important to take into account is the fact that as recently as early October, more Americans said that the Affordable Care Act has hurt rather than helped them. Since 2012, the share of Americans reporting the reform has been harmful has increased from 16% to 24%, while the share reporting the reform has been beneficial has risen from 12% to only 14%. These numbers suggest that the Affordable Care Act has benefited only a small sample of Americans — those who qualified for the expanded Medicare program in states that chose to participate or were eligible for insurance subsidized by the federal government. In total, 85% of the eight million Americans who enrolled in individual insurance plans purchased through the Obamacare exchanges received subsidies from the federal government, about 4.8 million people signed up for Medicaid thanks to the reform’s optional expansion of eligibility, and three million young people gained coverage through their families’ plans. That adds up to approximately 14.6 million people, or less than 5% of the United States population. The fact that a significant portion of those 8 million Obamacare enrollees had been previously insured before having their non-compliant policies cancelled means that the number of Americans benefiting from the health care reform is slightly smaller. Keep in mind that context is key for understanding why public opinion remains low.
Public opinion is more nuanced than a simple explanation of the Obamacare have and have nots would suggest. But, with significant portion of the American people far removed from the obvious benefits of the health care reform, the politics of the Affordable Care Act — rather than the realities of the health care reform — have more power to influence public opinion. The shadows hanging over the Affordable Care Act’s distant future — those that grab headlines and that politicians drag out on the campaign trail — weigh more heavily on how the reform is perceived if its obvious benefits, like subsidized insurance, are not available. This is not to say that a portion public opinion is misguided, but to say so does serve to explain differences in public opinion.
Take fears about job loss and deficit inflation, for example. Conservative politicians have long warned that the passage of the Affordable Care Act may cause employers to shrink their workforces to compensate for the additional labor costs imposed by the reform’s requirement that larger companies provide coverage. Fears that the cost of subsidies will cause the federal deficit to balloon have also long been circulated. But it will take many years for these problems to materialize and to be understood. Furthermore, the true extent of these problems are much more difficult to quantify for the untrained eye, and therefore are much more political, much easier to manipulate, and much more easy for Obama to gloss over.
By comparison, of all the complexities and changes the Affordable Care Act brought to the United States health care system, the one most easily felt by the average American and the one most easily exploited by politicians is the price of health insurance. Obamacare premiums — those of policies purchased through the insurance exchanges created by the Affordable Care Act — are not rising uniformly across the country, which is to be expected, given each state has a very unique and independent insurance market. However, in Louisiana and Iowa, states where Senate races are the most competitive, rate increases will fall in the double-digits.
Louisiana Representative Bill Cassidy described the double-digit increases levied by some insurers, including Blue Cross Blue Shield of Louisiana, as “another hurdle for families and businesses already struggling under the demands of Obamacare.” He also blamed Democrats for making “false promises” that premiums would drop. Iowa Senate candidate Joni Ernst criticized the Democratic candidate, Representative Bruce Braley, for supporting the law, claiming that, “Thousands of Iowans are paying for it” in the form of sharp premium increases. These accusations seem to indicate that the health care reform is the sole cause of rate hikes, but, in reality, premiums in most states are not increasing any more than they would have before the law was implemented, and in many cases, rate increases are slowing. “In general, the premium increases have been pretty modest. But there are exceptions, and the exceptions happen to be in states with competitive races,” according to Kaiser Health Foundation’s Larry Levitt, who studies premium trends across the country.
Obama himself has been touting the reform by claiming that, “If we hadn’t taken this on, and [health insurance] premiums had kept growing at the rate they did in the last decade, the average premium for family coverage today would be $1,800 higher than they are.” But just as his 2008 campaign pledge that the health care law would reduce the cost of premiums by $2,500 was woefully overoptimistic and overgeneralized, this assertion also comes with a major, never-mentioned, caveat. The calculation is the result of averages and fails to take into account the slowdown in spending caused by the recession.
This misinformation, from the right and the left, is a breeding ground for political ammunition. According to Kantar Media, a firm that tracks political advertising, the dominant subject of campaign advertising (especially Republican ads) is health care. It makes sense to exploit the law’s great unpopularity, as campaigning Republicans have done throughout the 2014 election season. Generally, the specific predictions made by conservatives have not materialized — insurers have not fled the exchanges, insurance premium increases are well-within normal bounds, fewer Americans are uninsured, and overall health care costs have not ballooned. But the GOP is getting millage out of its critique of Obamacare as a welfare handout, which is ultimately the root of the party’s opposition. Echoing Texas Senator Ted Cruz, Iowa Republican Senate Candidate Joni Ernst explained on Radio Iowa: “We’re looking at Obamacare right now. Once we start with those benefits in January, how are we going to get people off of those? It’s exponentially harder to remove people once they’ve already been on those programs … we rely on government for absolutely everything.” As of October 17, The New York Times placed Ernst’s odds at winning at 66%. Comparatively, Democrats have been more silent on Obamacare’s successes.
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