Coverage of the Affordable Care Act's fifth anniversary Monday -- it was signed into law March 23, 2010--will undoubtedly focus on the gains in coverage and reductions in healthcare costs that have followed its rollout. To get the raw figures out of the way first, 16.4 million previously uninsured people now have insurance, the uncompensated care expenses of hospitals have fallen by more than 20%, and the rate of medical inflation is at a historic low.
But a less-noticed trend also may be unfolding: Americans are beginning to appreciate that Obamacare has improved the nation's healthcare system, and their lives.
Evidence for that comes from the Kaiser Family Foundation's health tracking poll, the latest results of which were released Thursday. According to the poll, Americans' favorable opinion of the ACA has been rising almost steadily since November 2013, when the botched launch of the federal enrollment website, Healthcare.gov, brought the favorable/unfavorable split to its worst showing, 33%/49%. (See graphic above.)
The latest survey shows that the "favorable" camp has risen to 41%, vs. 43% unfavorable. An additional 16% say they have no opinion or refused to give it; that figure has declined modestly since November 2013, when it was 18%. If you factor out that group, then among those who expressed an opinion, 49% are favorable.
Another statistic in the Kaiser survey reinforces the trend. The public's opinion of how the ACA has affected them personally also has been improving steadily. Of those who say the ACA has had some effect, 47% say it's been positive; in November 2013 that figure was only 34%.
Well more than half of all respondents, 57%, say the ACA has had no effect on them personally. That's not surprising for a couple of reasons. One is that some 85% of all Americans get their insurance from their employer or a government program such as Medicare, where the effects of the ACA are hard to perceive. Another is that most people typically don't have an interaction with the healthcare system in any given year; that's where the availability of coverage and its cost would be felt most acutely.
Yet as we enter year six of the ACA era, some flaws in the rollout persist. One is that too many people don't understand how the law works--indeed, how health insurance works. In part, that reflects the situation in the pre-ACA days, when fewer people had an insurance choice. They were either given a limited menu of selections by their employer, or took whatever they could get in the individual insurance market, often an overpriced, low-benefit plan.
Now millions of people have to figure out how to balance premiums, co-pays and deductibles, and plainly they're not getting much help. Just last week, in a piece asserting that "many" uninsureds are opting to pay a tax penalty for going without coverage rather than buying a plan, the Wall Street Journal interviewed Florida retiree Richard Gonzalez, 59, who chose to pay a $250 penalty for going without insurance because insurance would cost him $400 a month for a plan with a $6,000 deductible. The penalty, he said, "beats paying more than $10,000 a year."
Of course, he's not paying $10,000, but $4,800. For that he would have access to a raft of benefits not subject to the deductible, including preventive care and diagnostic tests. His out-of-pocket expenses would be capped, and he'd likely gain from paying his doctors, pharmacists, and hospitals negotiated fees rather than the uninsureds' rack rates for services.
Who deserves blame for Americans' continuing difficulty understanding the basics of health insurance? Republicans and Democrats alike. President Obama accurately stated Sunday that the ACA has been the target of "more rumor, more attempts to dismantle and undermine it than just about any law in recent history."
That's a Republican campaign, and it has been unrelenting for five years. The Democrats, for their part, have let them do it. Starting with the election of 2010, they did everything possible to run away from their signature social insurance achievement.
The litany of ACA benefits in Obama's statement this weekend--"Parents who can finally afford to take their kids to the doctor...families who no longer risk losing their home or savings just because someone gets sick...young people free to pursue their dreams and start their own business without worrying about losing access to healthcare...Americans who, without this law, would not be alive today"--should have been on his lips every day from day one.
Instead, he and congressional Democrats let the opposition define the law for public consumption. They're still at it. In a fundraising email pegged to the ACA anniversary, Wisconsin Gov. Scott Walker, an aspirant for the GOP nomination for president, repeated the party's shibboleth that the ACA is a "debacle" driving up costs and risks, when the raw figures show the opposite.
"The only thing going down will be Americans' health," the email says. That's contradicted by the facts, too. Just Monday, researchers from the clinical lab Quest Diagnostics and Tulane University reported that the ACA contributed to a surge in people getting tested for and diagnosed with diabetes, one of America's most preventable and costly medical conditions.
A key factor, they said, was expanded enrollment in Medicaid, as permitted by the ACA and almost entirely funded by the federal government. In the 26 states and District of Columbia that expanded Medicaid, they found, diabetes diagnoses increased by 23% in 2014 compared with the previous year. "I cannot think of any other explanation except these people have now got health insurance," Vivian Fonseca of Tulane, one of the researchers, told the Washington Post.
That will produce a long-term gain, they said, because catching and managing diabetes earlier leads to better "long-term outcomes"--that is, healthier and longer lives.
In the 24 states that hadn't expanded the program, mostly Republican-led states in the South and Midwest, the increase in diagnoses was only 0.4%. One of those states is Walker's Wisconsin.
As the post-ACA era unfolds, we should expect to see more readings like this. The GOP's campaign to "repeal Obamacare" depends on voters thinking of the law as merely a mandate to buy insurance, without thinking too much about all the other ways the law has remade healthcare delivery and practice. For example, hospital readmissions are down significantly, in part because higher Medicare penalties have prompted hospitals to pay more attention to the post-discharge health of their patients. That's a big gain in healthcare efficiency.
Obamacare has worked its way into the fabric of American medicine, which was on an unsustainable path to ever higher costs and less access. Assuming that the law isn't short-circuited by the Supreme Court with a big ruling due this summer, the positive trend should continue.