PPACA and the Uninsured #3

My research on the Patient Protection and the Affordable Care Act comes to an end.  All that’s left is dotting the I’s and crossing the T’s.  Over the course of my research, I’ve learned quite a bit about the public policymaking process, the political strategies behind legislation, and the health care system.  As the preeminent reform law in health care, the ACA was the perfect vehicle to explore how political insiders interact with outside pressures, how they manage to use policy to create support.  At the heart of my research is the question:  Did the ACA create a self-sustaining constituency yet?  The answer is no.  Although the legislation still has a long way to go, the opposition’s organized and systematic response has clouded the benefits of the legislation from the public.  The ones who should be the most ardent in defending the ACA, the uninsured, have not rallied around the legislation.  Ad campaigns, vitriolic propaganda, and drawn out legal battles have turned the image of the ACA from revolutionary health care reform to an invitation for increased government bureaucracy.

The uninsured are prepared for increased government intervention.  They desire a more active, regulatory government.  58% indicate they want health care costs to be equally shared throughout the United States.  52% are in favor of mandatory health care coverage.  Of that 52%, 42% strongly support the individual mandate.  72% of uninsured patients believe government should provide health care rather than private insurance.  46% support greater government regulation of healthcare while 35% oppose increased regulation.  69% of uninsured patients support the expansion of Medicaid in the ACA.  Medicare is even more popular.  78% support the program.  Only 11% oppose the Medicare program.  54% of patients are dissatisfied with the state of health care in America.  Only 20% indicate satisfaction.  44% believe the majority of the blame for the state of health care falls onto private insurance companies.  31% do not.  And 56% of uninsured patients would like to see a national health program like that of Canada or Britain implemented in the United States.  Only 18% oppose such a change.  Clearly, the uninsured population favors a more liberal health care scheme as opposed to the current private insurance model.

As my survey discovered, the patients are supportive of many ACA reforms.  They like that Medicaid is expanding and the Medicare D “donut hole” is closing.  They believe in greater government involvement.  These provisions directly affect them.  What is unpopular?  The financing of health care reforms brings down popular opinion of the ACA.  My survey found divided support for an income tax to finance the ACA.  33% oppose an income tax.  36% support an income tax.  28% remain undecided.  After explaining to the patients that the ACA would tax the upper 3% of the population, quite a few felt guilt ridden and reflected their emotion in the response to the question concerning individual responsibility.  75% of uninsured patients considered individual responsibility to be a paramount value in health care.  Only 8% felt individual responsibility to have no or little importance.

This population appears ready to defend more liberal legislation.  53% feel that they have average or greater knowledge of the ACA.  Even though 31% felt they were not very informed on the legislation, about a third of Americans who have health insurance feel the same way.  Moreover, 77% of the uninsured patients feel the ACA is personally important to their health care.  But would the uninsured defend the ACA in election season?  64% of the uninsured voted in the 2008 presidential election, well above the national voter turnout rate.  It is quite possible the uninsured would be willing to vote in favor of politicians who engineered the ACA if the law was popular.

The problem is that the uninsured population are not as invested in the ACA as a package.  Although most are favorable to the provisions of the ACA and enjoy the benefits of health care reform, they are at best lukewarm to the law.  The most radical provisions of the ACA were delayed until Americans could become more comfortable with the law.  Theoretically, senior Americans would enjoy the benefits of Medicare D payments and better quality Medicare procedures.  Parents were given the option of keeping their dependents on insurance until age 26 and purchasing health coverage despite preexisting conditions in their children.  High risk pools immediately helped those who did not possess employer-based insurance or government-provided health care.  As Americans became more comfortable with these beneficial changes, they would view the ACA more favorably.  This strategy, however, failed on two fronts.  One, the delay granted the opposition of the law to launch a negative campaign that confused would-be supporters of the ACA.  Two, the strategists behind the ACA overestimated the popular appeal of the law.

Conceptually, the ACA would speak for itself.  The public would become enamored with the law and its successful reforms, enriching its supporters on Capitol Hill with political capital.  But the ACA needs a strong pitch to the American public even if the policy is effective and beneficial.  The ACA is difficulty enough to dissect and understand without a good campaign.  The law is essentially a smorgasbord of various patches to the health care system.  Many of them act in tandem like gears and cogs in a machine.  Explaining how the reforms work is a monumental task the Obama administration and its allies in Congress neglected to complete.  Complicating the process, the ACA disguises many of its more controversial pieces through what Jill Quadagno calls “delegated governance.”  The federal government assigns multiple tasks to be handled at the state level, including the expansion of state Medicaid and liability provisions.  This delegated governance vastly complicates the ACA because it draws into question intergovernmental cooperation.  While the White House failed to convey the policy’s advantages, its opponents quickly misdirected the public.  False ads claiming the existence of Soviet-style “death panels,” inaccurate deficit analyses that contradicted the Congressional Budget Office, apocryphal accounts of government-created health plans, socialist name-calling, and an outlandish claim that Congressmen were exempt joined honest assessments of the health care reforms.  Citizens who had heard of the ACA’s provisions were also treated to false accounts of the ACA removing employer-based insurance, raising premiums, eliminating Medicare, or somehow disrupting their current health care coverage.  Both the insured and the uninsured alike found no end to negative ads directed against the ACA.  It is not surprising that the public became divided over the sweeping law.  Most polls show a fifty-fifty split since the law’s passage in 2010.  Instead of the widespread support and loyal commitment by the law’s beneficiaries, the ACA has become a hotly contested campaign issue.  The controversy harms the law’s ability to effectively carry out necessary reforms.

Without the public support, implementation could be vastly complicated at the local and state levels of government.  Non-cooperation can drag out the implementation process.  Witness the states’ fight against the expansion of Medicaid or the allegations that the ACA penalty is a tax.  Without an effective campaign to convince the public, and more importantly, the direct beneficiaries of the ACA’s benefits, the White House and congressional Democrats face an uphill battle.  Poor support leads to poor and harried implementation at the state level.  Poor implementation fails to secure the necessary support.  In a classic loop of policy feedback, the ACA fails to gain traction.

As if cumbersome implementation was not enough, legal challenges attacked the ACA.  Due to the rhetorical aptitude of the ACA’s opponents and their extensive lobbying campaign, only a minority (28%) believes the individual mandate is constitutional.  Although the Supreme Court affirmed the mandate’s constitutionality under the general taxation clause, a Kaiser Family Foundation poll found 81% would not feel different about the law.  7% feel slightly more positive.  But 11% would have felt more negative had the mandate been unconstitutional.  This demonstrates that the intensity of opposition to the ACA is greater than the degree of support for the health care reform law.  Even though the legal battles appear to be over, the lawsuits have cast doubt on not just the effectiveness of the ACA’s policies but its very legitimacy.

Beset on all sides, legal and political, one wonders how the supporters of the ACA will fight in defense of the law.  Whatever the altruistic intentions of its policy designers, the ACA was meant to reap political capital for dozens of politicians.  Ideally, the health care reforms would convince a number of uninsured to vote for politicians who engineered the bill’s passage or continue to support it.  Thus far, the ACA lacks a loyal constituency that will come to bat for it and the politicians associated to it.  On the current pace of reforms and public support, the next generation of politicians will receive widespread support rather than the current members of the Democratic Party.

The current administration appears to have abandoned the public relations war.  The White House initially designed a website to educate voters on the merits of the ACA, www.healthcare.gov/law/index.html.  The website’s design is counter-intuitive as each link leads an endless number of scroll-down menus, which yield more links.  Trying to find a specific section is like trying to slay a hydra.  Just as one link is clicked, two more take its place.  Worse, some links simply lead the user back to the main menu.  The result is a frustrating web design.  In contrast to the Clinton Health Security plan in 1993, very few printed pamphlets have been dispersed.  To some degree, this seems intentional.  Vagueness and ambiguity helped the bill to be passed in Congress.  The lack of a visible target prevented the opposition from zeroing in on the health care reform law.  Now that the law has been passed, the efforts to communicate to the public are still lacking.  Politicians who voted for the bill are not using it as a selling point in their elections.  Of course, with the economy as the predominant issue among voters, this is to be expected.  But several congress members have made strides to distance themselves from the law entirely.  As far as a spin war is concerned, the Republicans have won this round.

The supporters of the ACA rely on rapid, effective implementation to make their argument for them.  In fact, they have anticipated the opposition and raced ahead of schedule to implement multiple provisions.  At the same time, multiple Democrats hope a recovering economy will allow more uninsured patients to afford health insurance and reduce the antagonism towards the ACA.  Whether these two strategies are successful will depend in large part on the ability of the federal and state bureaucracy to solve economic and health care policy problems.

The ACA is a transformative piece of health care.  In my interviews, multiple staff members expressed support of the law.  They believed the journey to a successful, efficient health care system to be difficult and arduous.  None of the interviewees believed the ACA to possess all the answers.  In fact, they all felt nervous about the upcoming prospects and challenges of implementing health care reform.  Nevertheless, most would rather see something than nothing.  Interestingly, the staff members of the health care clinics do not feel inclined to draw upon the health care models of other nations.  Each finds the answers to be in the American system of health.  Like many experts, they acknowledge that the U.S. has the best health care in the world.  The issue is getting that health care to those that need it at prices that are affordable. Some find the answer in Medicare, others in the ACA.  Clearly, the medical staff is equally divided over the law.

My research has led me to believe that such divergent opinions over health care reform indicate a lack of cohesion among the public.  The uninsured patients who should be a critical group in touting the benefits of the ACA have not been convinced.  Whether the ACA builds a loyal coalition rests upon the law’s capability to deliver tangible benefits and the ability of politicians to alter the ACA as fit in the future.  The first requirement secures support for the law.  The second connects a popular policy to the politicians.  The process will take years to unfold and initial success is no guarantor of future support.  An old doctor’s maxim applies to this situation, one must “wait and see” whether the cure can fix the patient—in this case—the health care system of the United States of America.

For raw data on my project, see attached files.