When it comes to ObamaCare, fear is the great equalizer
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During the seven years since the passage of the Affordable Care Act (ACA), or ObamaCare, Republicans have maintained total agreement in their hatred of the legislation. In their view, the federal takeover of the insurance industry alongside taxpayer-funded subsidies to purchase health coverage is particularly egregious.

Following its passage in 2010, House Republicans repealed the ACA over 60 times.

Likewise, public opinion polls consistently rated the ACA unfavorably, with approval ratings rarely exceeding 50 percent. Although it is not clear that many Americans fully comprehended the law, they understood quite well the high deductibles, surprise medical bills and cost of prescription medications that accompanied the implementation of ObamaCare.

In spite of its problems, the ACA has had successes, most notably in extending health coverage to about 20 million previously uninsured Americans. This expansion in coverage was due in no small part to federal subsidies that made insurance more affordable and through consumer protections that ensured, for the first time, that insurers could no longer deny coverage to anyone based on health status — a valued safeguard for the 133 million Americans with chronic illnesses.

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But for those 10 million or so higher-income, healthy individuals purchasing coverage on the individual market without a subsidy, the very attributes of the law that made access easier for sicker Americans made insurance much more expensive for those less ill. The days of having available relatively cheap "bare bones" plans based on health status were over for healthy young adults beginning Jan. 1, 2014.

 

Instead, the law required all insurance plans to provide comprehensive benefits within a premium structure that could not be based on utilization or health status.

Although unpopular with many, this requirement was essential to meet the accessibility and affordability goals of the ACA. In order to honor the law's promise to provide reasonably priced coverage for Americans with preexisting conditions, healthy people had to subsidize coverage for those who used more care. The math of insurance, which relies on spreading risk over a large pool of enrollees, just won’t work otherwise.

If you were eligible for an ACA subsidy to help defray the cost of health coverage, though, the economic reality of this explicit cross-subsidization was less painful.

In the hopes of making health coverage cheaper for some, Republicans have proposed bringing back the "good old days" of risk-based health insurance through state waivers. These state-based initiatives would allow governors and legislators to cast aside many of the ACA's protections like the ban on preexisting condition exclusions and/or affordable premiums using community rating.

The rationale is understandable: Many Americans remain uninsured because health insurance is too expensive. Carving out the sickest from state health insurance pools would lower premiums for its healthier members, a very attractive notion.

There's only one problem: Most Americans do not support that change.

Post-election public opinion polls continue to trend upward regarding the growing support for the ACA. According to a McClatchy-Marist poll last month, 65 percent of registered voters want to see the ACA maintained or strengthened. In April, for the first time since the ACA rollout, Gallup found that more than half of Americans approve of ObamaCare, and the Kaiser tracking poll found overwhelming support for fixing the law: 75 percent of respondents believe the Trump administration should try and fix the law compared to just 19 percent who support its demise.

Why the public about-face regarding ObamaCare?

I suggest two reasons: the lackluster components of the "replace" efforts in Congress that do not align with Americans' desires for decent health coverage, and the generalized fear about losing what has been gained under the ACA.

Americans continue to want and need health coverage. Low-income Americans, many of whom voted for President Trump, fear losing their coverage under ObamaCare. Focus groups of ACA-enrolled Trump supporters in America's Rust Belt in late December reported consistent views on Trump and health care. The respondents trusted the president to "do the right thing" when he promised to fix the problems they experienced firsthand under the law, problems such as having to switch plans, losing trusted providers, and paying more out of pocket.

However, surpassing the frustration over the deficiencies of their health coverage was the palpable fear that future health coverage would be unavailable or too costly for themselves and their families. This fear outweighed any anger they had about ObamaCare.

It is human nature to want to hold on to what we have. Economist Robert Frank wrote about the power of the principle of "loss aversion" last December in The New York Times. Repealing the ACA would unleash, according to Frank, "the awesome power of loss aversion," where the natural tendency is to expend much more effort resisting the loss of a possession than to mount the energy to acquire something new.

Loss aversion helps to explain the cognitive dissonance on the part of many Americans who jointly hold the incongruent views that on the one hand reject ObamaCare and on the other hand fear the loss of coverage within it.

The combination of recognizing the personal need for affordable, government-subsidized health coverage alongside the abject fear of losing the coverage one currently holds may explain the recent shift in public opinion surrounding the ACA. Importantly, the swing in national sentiment may signal a fundamental shift in the nature of the healthcare debate in this country.

With presidents and politicians, even conservative ones, now defending consumer protections like affordable coverage for people with preexisting conditions, healthcare is more and more viewed as a right not just for the elderly and the desperately poor in this country, but for all Americans.

In short, in seven years, the core elements of the ACA have become the new normal. Although ObamaCare may still divide Americans, more now worry about scaling back its benefits or losing coverage altogether than repealing the law and replacing it with an unknown.

For Republicans, the challenge of "repealing and replacing" the ACA is how to structure and decide who is going to pay for a plan that maintains the promises of the ACA and yet moves away from a top-down government program paid for by taxpayers.

Trying to accomplish this economic and ideological feat without increasing the federal deficit or eliciting public backlash is proving very complicated.

The president's core supporters still believe in him and his promises to fix the problems in our healthcare system. However, the clock is ticking: Factions in the Republican Party refuse to give up trying to gain internecine agreement as to how best to come up with a "leaner and meaner" ACA, and insurers are ready to let the individual health insurance market implode if not given assurances that generous ACA subsidies remain into 2018 and beyond.

Perhaps it is time to listen to the people.

Carolyn Long Engelhard is the director of the Health Policy Program at the University of Virginia School of Medicine's Department of Public Health Sciences.


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