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The JAMA Forum
March 10, 2015

Why Does the Affordable Care Act Remain So Unpopular?

Author Affiliations
  • 1economist and Senior Fellow at Project HOPE, Millwood, Virginia
JAMA. 2015;313(10):1002-1003. doi:10.1001/jama.2015.0542

In mid-November, just as the second enrollment period for health insurance under the Affordable Care Act (ACA) was starting, a Gallup poll indicated that only 37% of the US public approved of the ACA—a record low percentage (http://bit.ly/1xOiNj8).

Gail Wilensky, PhD

American Medical Association

Since the ACA was passed in 2010, its overall approval rating has never been high, generally hovering in the low-to-mid 40% range. Approval of the law took a conspicuous dip in November 2013 after several million people received notices that their current policies were being cancelled. Not surprisingly, approval varies sharply by party: 74% of Democrats approve of the ACA vs only 8% of Republicans. What is more noteworthy is that the approval rate among political independents is also low, only 33% as of November 2014. Enthusiasm for the ACA has decreased even among nonwhites, who disproportionately identify as Democrats, with only 56% favoring the law compared with the 76% who reported they liked it when it passed.

Popular ACA Provisions

The ACA’s supporters have pointed out that some of the law’s features are very popular, much more so than the legislation as a whole (http://bit.ly/1yBMOF6). This is particularly true for some of the insurance reforms, such as provisions that require insurers to allow young adults to stay on their parents’ health insurance policy until the age of 26 years, that prohibit insurance companies from denying coverage for preexisting conditions or charging enrollees higher rates because of preexisting conditions, and that limit the variations in premiums allowed for enrollees of different ages. Before the ACA’s passage, these changes were mentioned most frequently by President Obama in promoting the legislation’s passage and continue to be cited as important reforms associated with the law.

What is rarely mentioned is that these popular measures carry almost no governmental costs (the higher insurance costs they produce are spread across everyone who buys insurance). What’s more, these measures could have been enacted as part of a narrow package of insurance reforms, providing many of the protections already provided to people with group insurance to those who purchased insurance in the individual marketplace.

Why Is Support for the ACA so Tepid?

Before 2014, I had assumed that once the coverage expansions began, those who benefitted from the new subsidies for private insurance or expanded Medicaid coverage would be supportive of the legislation while most others would be neutral or indifferent. But that has clearly not been the case. So why does this legislation continue to receive such low enthusiasm from the American public?

It is possible that ACA’s low approval ratings are in some way related to President Obama’s relatively low job approval ratings Gallup’s daily polling (http://bit.ly/1s6d9Zm) indicated that the average approval rating for the President from December 1, 2014 through January 4, 2015 was 44%). If the 2 approval ratings are related, however, it’s not obvious whether one is causing the other or whether both reflect generalized dissatisfaction with the President and with the direction in which his leadership is taking the country. The large loss in the number of Senate and House seats held by Democrats is certainly consistent with a generalized mood of public disapproval.

There may, however, also be factors specifically associated with the ACA that contribute to its low approval rating. The ACA disapproval rate was almost as high in the fall of 2013 as it is currently; it presumably reflected dissatisfaction with the rollout of the dysfunctional insurance exchanges in most parts of the country and the anger reported by many individuals who were notified that their health insurance was being cancelled because their policies didn’t comply with the ACA’s requirements.

Because many of those cancelled insurance policies purchased in the individual market were very costly or provided limited coverage, they were not highly regarded either by their purchasers or by insurance experts. But not everyone who purchased insurance in the individual markets had been unhappy with their coverage and some were unhappy to lose those options.

For example, under the ACA, single individuals and middle-aged couples were being told they had to have policies that included maternity care, full dental coverage for children, and other coverage features of little use to them. Requiring the purchase of comprehensive benefits was probably not objectionable for those with incomes low enough to receive substantial subsidies. But many middle- or upper-middle-income couples or individuals who would receive small subsidies or no subsidies at all were unhappy at being forced to buy a product they didn’t want that was more expensive than their previous coverage. The cancelled policies also made a mockery of the President’s assurance that “if you like your coverage, you can keep your coverage.”

It remains a mystery why the President made that statement (repeatedly)—and the related claim that “if you like your doctor, you can keep your doctor.” I have been asked by reporters both on-camera and off-camera whether I thought the President knew that was a promise he couldn’t keep. I, of course, have no idea what the President knew, but his policy advisers had to know these were promises that weren’t the President’s to make. Maybe they thought that so few would be affected that it wouldn’t matter, or that people who had been without insurance would be so happy to have it available that these cases would seem unimportant. Whatever the gain at the time, I believe the repercussions have been significant and have contributed to a view held by some that the current leadership can't be trusted (http://bit.ly/1bIzuBy).

But pushback against the individual mandate (the ACA’s provision that requires most individuals to have a minimum level of heath insurance coverage) may be the strongest reason for the continued disapproval rates (http://bit.ly/1yBMOF6). This antipathy is likely to only get worse if the Internal Revenue Service begins to assess penalties to those who remain uninsured.

What I find frustrating is that the whole national trauma associated with the mandate might have been avoided if the administration had followed the lead of Medicare. Medicare doesn’t require seniors to buy Part B coverage (which covers physician payments) or Part D (which covers outpatient drugs). But if seniors choose to buy either coverage after the enrollment period ends a few months after their 65th birthday or after they stop being covered by group employment insurance, they are penalized for every month they delay their purchase. I realize seniors tend to be more risk-averse than younger individuals, but at some point, most people will want or need coverage. Assessing a penalty to people who delay buying health insurance until they need it is a way to compensate for the cost they impose on others. This strategy would surely have been worth a try.

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Article Information

Corresponding Author: Gail Wilensky, PhD (gwilensky@projecthope.org).

Published online January 7, 2015 at http://newsatjama.jama.com/category/the-jama-forum/.

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