Americans have always been a politically contentious lot. But one topic seems to produce more pure vitriol than any other: the
I posted an item on my Times blog, the Economy Hub, citing new statistics indicating that the act has materially reduced the ranks of the uninsured, kept premiums moderate and seemed likely to keep rate increases modest next year. I sought agreement that, given these developments, "Obamacare is working."
I didn't get it. What I got instead was an unexampled outpouring of angry, vulgar and bitter emails, almost none of them bearing even the slightest attempt to counter my statistics with alternative facts.
Here's one: The subject line advised me to perform an anatomical act on myself not physically plausible or suitable for repetition in print. The text read:
"Also, I hope you get cancer and die. Painfully."
This message may have been more extreme than others in my inbox, but not by much. All for suggesting that a government program is actually succeeding in improving access to healthcare for millions of Americans who didn't have it before. Plainly, something is at work here other than the wholesome give-and-take of political debate.
Healthcare reporters and bloggers I queried in an informal poll confirmed that the ACA elicits unusual fervor among their readers. One who writes for a progressive website says that "Obamacare is only in second place when it comes to hate tweets. No. 1 is Benghazi."
What accounts for the pungent rancor? Here's a rundown:
The campaign involves ceaseless repetition of the mantra that Obamacare is bad, accompanied by almost no explanation why. It's a canny approach, because polls have shown consistently that Americans favor the individual elements of the ACA by a wide margin — the ban on exclusions for preexisting conditions, the closing of the
Conservative talking points can live longer than redwoods. Remember the "death panel" lie wholesaled by
•The novelty of health insurance. Most Americans entered the ACA era without understanding how health insurance works — including what one pays for and what it covers. Before the open-enrollment period that started last Oct. 1, few Americans had any choice; they took what they could get. Annual premium increases averaged 10% or more a year. Was that a lot or a little? There was no way to know, because there was nothing to compare it to. The enrollment process introduced many people to the confusing realities of premiums, deductibles and out-of-pocket maximums, and the way they interrelate, for the first time.
Insurance in general is infuriating, because it entails a bet against yourself — if you insure your home, you "win" by collecting only if your house gets burgled or burns down. It's natural, perhaps, that people newly encountering this system will train their anger on the law that mandated the encounter. "It used to be, people got mad that their costs were going up," says Jost. "Now they're mad at Obamacare."
•Nature abhors a vacuum. The yawning vacuum in analysis of the Affordable Care Act has been hard information. Figuring out how many people have enrolled in qualified plans means compiling data from federal sources, two dozen states and scores of insurance companies. And that's only one of countless metrics by which the act will be judged.
Here's another measure: How many enrollees were previously uninsured? That depends on how you define "uninsured." The latest figures from the Kaiser Family Foundation indicate that 57% of enrollees in exchange plans say they were previously uninsured, that 71% of those say their period of uninsurance had lasted two years or more, and that 45% say they had gone without coverage for five years or more.
Then there's the question of how much premiums have risen from 2013 to 2014. This is an especially tough issue because health insurance has changed dramatically since last year, as has the nature of the buying public.
Health economist Mark Pauly of the Wharton School put his finger on the issue with two colleagues in a paper published this month by the National Bureau of Economic Research; he's a respected scholar and by no means a fan of the ACA. Pauly observes that comparing premiums in pre-ACA plans with premiums in 2014 is typically an "apples to oranges" exercise. Among the reasons: Health plans today must meet higher standards of minimal benefits than before, and the premiums typically cited for plans in the pre-ACA market were often illusory — conservative analysts crowing about "sticker shock" often cited premiums available only to consumers in the best of health.
"There is not much point in considering a premium (or a pattern of coverage) no one buys," Pauly warns. But that's how ACA opponents ginned up the sticker-shock story. Pauly's estimate, accounting for these variables, is that premiums increased by 14% to 24% from the pre-ACA, 2010-12 period to today. That's much lower than the typical scare story would have it, and doesn't even account for the premium subsidies available to 80% of all exchange plan buyers.
But these figures are almost all based on conjecture and deduction, not on empirical data. In a paranoid age, lack of information looks like the product of conspiracy, not complexity.
•Us vs. them. As Jonathan Chait of New York Magazine observes, the conservative critique of the ACA has been shifting "from the practical to the philosophical." The old talking points have gone down in flames: Through the exchanges and the expansion of Medicaid (in some states), the numbers of uninsured residents have been reduced materially; "rate shock" has been moderated by tax credits and is expected to be moderate by historical standards for next year.
So now their objection is that the ACA mainly benefits the poor. This is a recurrent theme in my emails: "The ACA TAKES from one to GIVE to another forcibly," one reader writes. (Emphasis in the original.) "That is socialism, cut thick thin or however you wish to shade the truth.... Taking money someone else earned is at best government theft, and at worst theft of property."
As Avik Roy of Forbes puts it, "Subsidies aren't free. They're financed by taxes: not just taxes on 'the rich,' whoever they are, but on average Americans."
That's an attack on the very concept of social insurance. Since the 1930s, the sharing of assistance to the poor, sick and elderly has been accepted by the majority of Americans as a fundamental value. The popularity of Social Security and Medicare attests to that. And Roy's analysis ignores that the millions of Americans who receive their health coverage from their employers are themselves heavily subsidized. Their premiums are tax-exempt, which means that the subsidy rises as one moves up in income.
Still, reasonable people could weigh all these knowns and unknowns and conduct a debate free from racism, vituperation and defamation. The reason that hasn't happened may boil down to this observation by one health economist who writes often about the ACA and asked to remain anonymous: "Healthcare is so intimate to our humanity," he says, "it makes people a little crazy."