Sunday, December 18, 2011

How does the public *really* feel about healthcare reform?

(This post was originally posted on the National Physicians Alliance blog December 18, 2011)


Opponents of the Patient Protection and Affordable Care Act (PPACA) are fond of pointing out how much the public opposes the law.  Now, these voices calling for the law's repeal--with the most prominent voices coming from Republicans (including all the current presidential candidates)--usually overlook one important fact: a substantial portion of opposition to the law come from those who feel the law did not go far enough.  Seems like a fairly convenient lapse.

Having said that, I would like to review the current state of the public support for the law's reforms with the help of the most recent Kaiser Family Foundation tracking poll (pdf).  The overall public view of the law still trends unfavorable, but this seems to reflect in large part the public's unhappiness with the current state of politics in Washington, DC.  The chart on page 3 shows that half the poll's respondents would like the law expanded (32%) or kept in place (18%).  Only 24% would like the law repealed, and only 15% favor repeal and replacement with a Republican alternative.  This suggests that Republican alternatives to the PPACA have not gained traction, and that although many Americans prefer stronger reforms there is a willingness to work with the law as it stands. 

The chart on page 4 shows some reason for the public's confused approach to the law (unfavorable overall view, but support to keep the PPACA in place or strengthen the law): the public is still very confused about the law's reforms, but in terms of what is included in the law, and what isn't.  More than half of those polled believe the law includes a public option (it doesn't), while only slightly more than one-third are aware of the law's reforms to the medical loss ratio (requiring insurance companies to spend money paid in premiums on providing care, as opposed to executive pay, administrative costs, etc) or the law's requirement that screening tests such as mammograms and colonoscopies be provided without any patient co-pays.  This lack of understanding is no thanks to the Republican leadership in Washington or conservative pundits, who are so opposed to the law that they are willing to distort and misinform Americans about the law in their efforts to demonize it.

The reasons for the public's opposition to repeal/replace efforts are likely the law's actual reforms: as shown on page 5, the individual elements of the PPACA's reforms remain broadly popular across the political spectrum.  Republicans polled supported major elements of the PPACA, including closing the Medicare Part D donut hole, providing tax credits to small businesses who provide health insurance for their employees, providing subsidy assistance for individuals unable to afford insurance on their own, providing preventive care without any co-pays or patient cost-sharing, and guaranteeing coverage despite preexisting medical conditions.  In fact, of all the reforms Kaiser polled on, only the individual mandate was viewed unfavorably by the public. 

I suspect that the fact that the individual mandate has been the focus of so much discussion around the PPACA also helps explain why the public is ambivalent about the law: if bulk of the media attention is on the only reform viewed unfavorably, then it is natural that the law will be seen unfavorably.  It would be interesting to see what would happen if politicians and media discussed the law's other (positively-viewed) reforms: would this move public opinion more firmly in favor of the PPACA?  The charts on page 6 reinforce this suspicion: few Americans report hearing  any positive coverage.  Much of the negative coverage appears to come from Congressional and Republican Presidential candidates' debates, reinforcing the perception that the law's political opponents are choosing to attack it as opposed to assessing it fairly.

On page 7, the top chart shows that most Americans see that the greatest benefit from the PPACA's reforms will accrue to low-income Americans, those with preexisting conditions, and those who lack insurance.  This is a good thing, as these are the individuals who have been marginalized by our current system and who are most in need of help.

So: more Americans support the law or wish it were strengthened than support repealing/replacing it, the PPACA's reforms are broadly popular, the law's benefits will largely impact those most in need, and the law's opponents and the media are not discussing the law's reforms and benefits honestly.

I think this information leads to two important conclusions:
  1. The law is a net positive, its reforms are popular, and we need to continue discussing its benefits, protections and reforms and ensure that all Americans understand how it will protect us.
  2. We cannot rely on the media or political leaders to make this information available.  We must continue to be resources to our peers, our patients, and our communities.  We must do this, because otherwise we risk losing these important reforms.


MightyCaseyMedia said...

My question about healthcare payment reform - and healthcare full-stop - is this: why is healthcare insurance tied to employment?

I know why, actually. It all started in WWII as a short-term fix for stiff wage controls. Then it became a mandate. Which now, four generations later, has led to our "I wanna use other people's money" view of paying for healthcare.

If patients actually were encouraged to be customers of the healthcare system, rather than the passive-consumer meat puppets currently in vogue, much positive change would occur.

If we were allowed to buy health insurance the way we buy any other kind of insurance, and all citizens started out in a group - the group of all-of-us - that would let employers turn insurance benefits into true benefits, rather than what essentially amounts to a penalty for having employees.

I don't think the law went far enough. I think all people have the right to healthcare access. I think most of us would be happy to buy our own insurance - like we do for cars/houses/whatever - and throw some chedda in the kitty to make sure there was a safety net for people who need help.

mark said...

You're correct in how we came to have employer-provided health insurance: it's an artifact of the needs of World War 2 employment.

However, it never formally became a mandate. There are currently plenty of employers that choose not to offer health insurance...and many large employers cover employees very poorly, with Wal-Mart being a prime example.

The major issues I see with your suggestion to make insurance an individually-purchased product are:

--the cost would be ridiculous, barring major government price controls. This has been the case in the individual insirance market up up until enactment of the PPACA.

--with ever-increasing health care costs, private individual plans will become expensive to the point that they would be unaffordable for nearly all of us. Companies can negotiate on behalf of a larger pool of people, sharing the risk and lowering costs. However, as you suggest, this results employers paying a large portion of the premiums.

--I disagree that as individuals purchase insurance for themselves they will have enough to help others. Ask free clinics how well-funded they are. The answer is probably, "Barely.". If the non-profit, non-government safety net is barely funded in a system where many of the costs are hidden feo the individual, how can we expect it to be funded if we're all paying for all of our insurance?

I would have loved the law to have enacted deeper and more fundamental reform, but politically it wasn't in the cards. This is a critical first start, and we need to protect what we have even as we work to improve it.

Eve said...

Thank you, thank you, thank you, for taking time to write out a very reasonable, logical argument for giving a the PPACA a fair look. I'm new to trying to understand all this...yours was the most sensible, understandable source on the subject I've come across on the net so far!