Americans have agreed to disagree about the efficacy of the Patient Protection and Affordable Care Act (ACA). According to Kaiser Family Foundation President and CEO Drew Altman, Americans agree about this one thing: “It really does help the uninsured; 32 million uninsured people will get coverage.”  The foundation’s recent tracking poll found that only about 50 percent of uninsured people have any idea that help is on the way.  Fewer than one-third (31 percent) think the ACA means they will be able to purchase health insurance.

Those two misperceptions are unmistakably connected.  Among those who currently lack insurance, 41 percent incorrectly think the law has no provisions to help people with modest means buy health insurance coverage; (seven percent said they didn’t know); and 37 percent believe the law doesn’t include an expansion of the Medicaid program to low-income, able-bodied adults; and (16 percent were unsure). 

The logical conclusion, Altman says, is an apparent “communications failure” on the part of the law’s supporters to explain how the ACA will actually work.  “What’s going on here is people who are uninsured are busy just trying to make it through the week, paycheck to paycheck,” he said.  “They’re listening to a confusing political debate.”  But the bottom line, Altman says, is that the healthcare overhaul will eventually start to become clearer in 2014, “when there are benefits out there, real coverage out there that people can look at — and can get.”  That’s when people without insurance will really be able to decide whether they can afford insurance or they like the law or it helps them.  “Until then,” Altman says, “it’s just a political debate.” 

Writing in The Hill, Sam Baker says that “Only 29 percent knew that the law eliminates cost-sharing for some preventive services, and half said the law did not provide that benefit.  The poll was conducted just two weeks after the Health and Human Services Department (HHS) announced that it would require plans to waive cost-sharing for contraception and other women’s health services.  And strong majorities approved of that decision, despite not being aware that the healthcare law includes preventive benefits.  Eliminating cost-sharing for birth control garnered 66 percent support in the Kaiser poll.  Although support was higher among younger respondents than their older counterparts, partisanship was the sharpest fault line.  Fewer than half of Republican respondents approved of HHS’s decision, compared with 64 percent of independents and 82 percent of Democrats.” 

On the Politico website, Jennifer Haberkorn writes that “The coverage expansion isn’t due to go into effect until 2014, but Altman says people are unlikely to be truly aware of the benefits until up to two years later.  The figures reflect the struggle supporters of the law will have in getting the word out to consumers who can benefit from it.   President Barack Obama and congressional Democrats focused much of their ‘pitch’ for the health law on the benefits for the uninsured.  They frequently cited the Congressional Budget Office estimate that the law would insure 32 million Americans.  But since the law’s passage, some have criticized that pitch, insisting that they should have focused instead on the benefits for the middle class and those who already have coverage.  Altman said the figures do not reflect a communications failure.  He says busy people — particularly those struggling to afford insurance now — will only understand the law when it becomes tangible for them.  The law’s least popular provision — the requirement that nearly all Americans have to buy insurance — remains one of its most recognizable.  About 65 percent of Americans know about the provision, the poll found.” 

At the beginning of 2011, any Republican suggestion of “repeal” was nearly always followed by “Obamacare”.  Since then, the debate has drifted into the background, morphing into a new regulatory repeal push.  A memo outlining the strategy, issued by House Majority Leader Eric Cantor (R-VA), includes a single paragraph on a grandfathering rule for health insurance plans that will become a target in the winter.   While Republicans are moving away from a health repeal agenda, Democrats appear to be having a hard time explaining what exactly the ACA will do for Americans.

Despite their best efforts, both political parties see their bases moving away from them on health reform.  The number of Republicans who have a favorable opinion has gone up by nine points, while Democratic approval ratings fell by 10 points.  Independent voters held on to their original opinions, with nearly the same number favoring the ACA was as when it was passed.  Both parties are running up against the same two challenges here. First, the health reform law is really complicated.  Other than “repeal and replace,” the ACA doesn’t lend itself easily to slogans that explain how it works.  This hurdle has been especially thorny for Democrats, who have seen low support for the ACA, despite the fact its individual provisions are polling extremely well.  

Tim Hoff of the Albany Times-Union believes that “Offering health insurance at reasonable prices is a key component of making the reform law cost-effective and able to reach millions of uninsured people.  The logic of getting private insurance companies to participate in state health insurance exchanges and offer good coverage at those reasonable prices predicates itself on having a balanced ‘risk pool’ of individuals in the marketplace — who must purchase health insurance.  Through a mix of healthy and sick purchasers, some who overuse their insurance and some who underuse, private insurers can be assured of not losing money (and thus exiting the market) by signing up only high-risk individuals.

“Without a mandate, many healthy uninsured people, as they tend to do, will continue to roll the dice and go uninsured.  This is even truer for the increasing number of Americans who are out of work or who work for employers who do not provide insurance, but earn too much to qualify for Medicaid.  For them, paying for health insurance is lower on the priority list.  That is, until they get sick,” Hoff said.

“Our country faces what may be an extended economic slump, a severe and perhaps more permanent absence of good jobs, rapid downsizing of the middle class and continued abdication by employers from offering benefits such as health insurance.  Yet, we leave it to lawyers and politicians to engage in armchair debates about what might or might not be ‘constitutional’ instead of supporting our government to do something beneficial that furthers the nation’s long-term health and prosperity.  Insuring every citizen is beneficial for our country.  It would do as much for our long-term future as a just, democratic society as any jobs program or debt reduction strategy would.  We are an increasingly sicker, unequal and less productive country in part because of the declining health and well-being of our citizenry, especially our poorer citizens,” according to Hoff.

 “How do we think we can fix the problem of the uninsured without requiring people to carry health insurance?  In our broken, polarized political system that is devoid of bold ideas, this health reform law and its insurance mandate were the best we could do to get health insurance to more people.  Asking almost everyone — citizens and legal residents — to have health insurance is fair, and subsidizing the poor’s ability to do it sensible.  At some point, everyone uses the health care system.  When the uninsured do, they cost us a lot more than those who are insured.  But the insurance mandate issue also speaks to how those of us with good health insurance often think selfishly about the role of healthcare in our own lives.”