HEALTH CARE

How Obamacare became a political football

Guy Boulton

Milwaukee Journal Sentinel

A woman looks at the Healthcare.gov website in Washington, D.C.

If you get health insurance through your employer, can you list one or two ways that the Affordable Care Act has affected your coverage?

A bit more money probably is coming out of your paycheck for health benefits now. You may have higher deductibles. But for most people, premiums and deductibles had been rising for the previous decade or longer, well before the law took effect.

If you're covered by Medicare, can you point to any change, other than having better coverage for prescription drugs?

Yet even though Obamacare significantly affected only a small percentage of Americans — those who buy health insurance on their own rather than getting it through their employer, and those who could not afford insurance — it has remained a major political issue for almost seven years. And today, repealing the law is one of the top priorities of President Donald Trump and the Republican-controlled Congress.

How did this happen?

“The Republicans have done a great job in making this an issue for political gain, and the Democrats have done a horrible job in explaining how people benefit,” said Simon Haeder, a professor of political science at West Virginia University. “That’s really the remarkable story behind this.”

The successes and failures of the Affordable Care Act hold important lessons for health-policy wonks. But the law ultimately may be of more interest to political scientists than health economists.

It also may hold important lessons for lawmakers as they try to craft a replacement plan.

One of the biggest: Don’t over-promise.

Former President Barack Obama's now infamous promise that people could keep their health plan shows what can happen. So, too, does his promise that the law would lower premiums, when health care costs have declined only once — in the mid-to-late 1990s — in almost 60 years.

That cautionary advice may be too late, though, given Trump's promise that a replacement plan will be “much less expensive and much better.”

“They are committing some of the same sins that the Obama administration committed in the run-up to the ACA,” said Daniel Ehlke, an assistant professor of health policy and management at the State University of New York Downstate Medical Center.

Promising too much, with little mention of the trade-offs required by Obamacare, was just one of many factors in the law's remaining at the forefront of the political divide.

For one thing, there were valid ideological reasons for people to oppose a law that raised taxes, particularly on those with high incomes and on insurance companies.

The law’s implementation also was bungled, and it proved to have serious flaws. As a result:

Millions of people — almost 10 million people by some estimates — who bought health insurance on their own saw their premiums soar, particularly this year, and their choice of plans limited.
In many states, the market for insurance sold directly to individuals and families is in shambles.
Provisions in the law raised the cost of insurance sharply for people who are young and healthy. As a result, many chose not to sign up for coverage, and they were needed to offset the cost of covering people with health problems.

On the other hand, many of the most dire predictions about the law proved wrong. Employers didn't stop offering health benefits, and health care spending overall has risen at a historically slow pace since 2010. In addition:

An estimated 20 million people gained health insurance, about half of them through Medicaid, bringing the percentage of the population without coverage to a historic low.
People with pre-existing health conditions could get coverage that wouldn't have been available to them before.
Young people could stay on their parents' health insurance until age 26.
The gap, or “doughnut hole,” in prescription drug coverage for people eligible for Medicare was closed.
Limits on lifetime benefits were prohibited, and out-of-pocket expenses were capped.

One of the paradoxes of the law is that a majority of people support many of its specific provisions, according to a tracking poll by the Kaiser Family Foundation.

“What’s in the law is quite popular, and popular across party lines,” said Lawrence Jacobs, a professor of political science at the University of Minnesota.

Yet even people who have benefited often are unaware of just how the law has helped them.

“It’s really hard for people to get an assessment of whether this is working or not working,” said Charles Franklin, a professor of law and public policy at Marquette University and director of the Marquette Law School Poll, “and their assessment depends on who is telling them whether it is working or not working.”

Instead, many Americans attribute longstanding problems in the U.S. health care system, such as its high costs, to the Affordable Care Act.

The frequent references by Republicans, such as House Speaker Paul Ryan, to soaring health care costs — without the qualifying reference to the market for insurance sold directly to individuals — only reinforced that.

The attacks on the law were unrelenting — and effective. The law at one point led to a shutdown of the federal government. It also was the subject of two cases before the U.S. Supreme Court.

“It is nearly unprecedented, at least in our recent political history,” said Ehlke, co-editor of “Health Politics and Policy.”

The contention that the law was a government takeover of health care in particular resonated with many people.

“A lot of the rhetoric surrounding it is actually premised on the idea of the ACA as being this absolute government takeover of health care that is serving to stand between the doctor and patient,” Ehlke said. “And of course that is not what it was at all.”

Fact-checking news organization PolitiFact rated the contention its lie of the year in 2010.

Three years later, though, PolitFact’s lie of the year was Obama’s promise that people could keep their existing health plans. That also came during the botched roll-out of the government website for the marketplaces — which only solidified many people's take on the law.

“That was sort of a stunning failure by the administration,” Franklin said. “It didn’t produce the clear success at a time when a clear success would have been helpful.”

The Obama administration and Democrats expected the law to gain support over time, he said.

It didn’t happen.

"It’s been six or seven years, and people still don’t know what the ACA is," said Haeder, the professor at West Virginia University. “That’s just shocking.”

For certain, the law is complex, but that may have been inescapable.

“We have a very messy, fragmented health care system," Ehlke said, "so any reform that’s designed to lie on top of that messy, fragmented system, by its very nature, is going to be, if anything, even more messy and fragmented."

A replacement plan ideally would be simple. The question is whether that’s possible.

“That’s where we run into trouble,” Ehlke said. “Nothing in our health care system is particularly simple, and it’s very hard to reduce it to anything that can be very easily explained.”

Now that the Affordable Care Act is almost certain to be effectively repealed, people are becoming more familiar with it — and in many cases alarmed by what could be lost.

A Wall Street Journal/NBC News poll last month found that for the first time since 2009 more Americans supported the law than opposed it — 45% to 41%. On Friday, a poll released by the Associated Press-NORC Center for Public Affairs Research found that 56% of adults are “extremely” or “very” concerned that many will lose health insurance if the Affordable Care Act is repealed.

And the most recent Kaiser Health Tracking Poll found that three-quarters of Americans either oppose repeal or want to wait until the details of a replacement plan are known.

“People are starting to take the time to see, ‘OK, how does this affect me?’ ” Ehlke said.

That will add to the challenges that the Republican-controlled Congress will face in coming up with a replacement plan.

There will be others.

“Everything we do in policy has trade-offs,” Haeder said. “And health care policy has lots of trade-offs.”

Reach Guy Boulton at guy.boulton@jrn.com.