The Battle for Public Opinion and the Future of the Affordable Care Act

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Karen Roach /
December 12, 2016

The battle for public opinion on the ACA is still ongoing. To fully understand the intense emotions surrounding the ACA, it is helpful to review some polling data and implementation problems.  

Two popular provisions have been noted in previous posts (extending coverage for children up to age 26 and banning denial of coverage due to pre-existing conditions), but other features are also popular. Women approve of charging equal insurance rates for men and women, and 69% of Americans approve of full coverage for birth control. For many supporters, the primary achievement of the ACA is the fact that a net total of 16.9 million people had gained health care coverage as of May 2015.

According to a 2015 Harris poll:

 “[A]n overwhelming 84 percent to 16 percent majority believes that having a system that ensures that sick people get the care they need is a moral issue. That includes 75 percent of Republicans and 91 percent of Democrats.

But, 52 percent of Americans think it's an individual's personal responsibility to figure out how to obtain health insurance. And exactly half -- 50 percent -- say that providing a system of universal coverage so everyone has health insurance would cost too much.”

The most recent polls before the election suggested that a thin majority approved of repealing the health care laws. However, these results should be interpreted cautiously. A 2013 survey revealed that only 37% of those surveyed were opposed to the ACA, but 46% were opposed when it was referred to as ‘Obamacare’.

Public trust was damaged by a broken promise. Obama assured people that they could keep their previous plan if they chose. Insurance plans that had been continuously maintained since 2010 were grandfathered into the ACA, even if the plans did not meet the ACA’s minimum standards. However, many insurance companies chose to modify their plans, forcing enrollees to lose these grandfathered plans. The available alternative plans offered better benefits than the substandard grandfathered plans, but they also charged higher premiums and/or higher deductibles and co-pays. The affordability of the new plans and the availability of options remain valid concerns.

Opponents of the ACA pounced once the first round of cancellation letters were sent and claimed “Millions of people have lost their health insurance. Millions of people can’t see their doctors.” The opponents overstated their case - evidence strongly suggests more people gained insurance coverage than lost it, and that those who lost coverage just switched to a different plan, usually a better one. Patients switching between HMOs and PPOs often do have to change doctors, but as noted in Lori Robertson’s informative post on, requirements to change doctors reflect market forces in the health insurance industry, not ACA rules.

The Future of the ACA

Health care in the United States is a complicated system of interconnected parts - so that fixing one problem (too many people without insurance) causes others (increasing costs and too few doctors). Followers of the school of systems thinking would argue that implementing successful health care reform requires a comprehensive plan that accounts for feedback between parts. In practice, aiming for a comprehensive solution can bog down complicated negotiations and end in an impasse.

Obama adopted a pragmatic, incrementalist approach for reforming health care. His failure to convincingly win the battle for public support prevented him from transforming the ACA into a comprehensive solution. While Obama’s bold determination to ram the ACA through Congress caused a backlash, it may have been the only way to change the rules of the game at the time.

Republicans now have the opportunity to change the rules of the game again. Optimistically speaking, perhaps an outsider such as Trump can negotiate a revision that will move the game forward permanently. If Trump does not, then Republicans need to be wary of generating anger directed at their party for pulling a fast one on their opposition – especially given Republicans did not win the majority of the popular vote.

Both supporters and detractors of the ACA would benefit by following time-tested negotiating advice: listen to opponents’ concerns and take them seriously, establish objective criteria for evaluation of outcomes, communicate motives clearly, identify common goals, manage public expectations, generate alternative solutions, and seek solutions that both sides view as fair. The Republican Party now holds the presidency and majorities in both houses of Congress; if it repeals the ACA, it bears the responsibility of delivering health care reform. If Trump wants to secure his legacy, then he needs to switch gears from the art of making the deal (other side be damned) to the art of implementing a lasting solution.

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