An unhappy birthday for the ACA
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As the Affordable Care Act (ACA) celebrated its fifth birthday on March 23, supporters had a lot to crow about: According to the Obama administration, 16.4 million uninsured people gained health insurance coverage since October 2013, resulting in a 35 percent reduction in the number of uninsured — the largest drop since Medicare and Medicaid were enacted in 1965. As a result, fewer adults delayed getting needed care and almost 10 million fewer Americans reported having difficulties paying their medical bills. In addition, the Congressional Budget Office reported that the projected costs of the president's signature health reform legislation had dropped one-third from initial estimates in 2010. To top off the good news, hospitals that incur uncompensated costs for treating the uninsured saw their losses fall by over 20 percent last year, with over $1 billion saved in bad debt. With all these glad tidings, why does ObamaCare remain so unpopular?

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Public sentiment about the ACA is stagnant: Eighty-three percent of Americans still hold the same opinion since the law's passage five years ago, and generally, that view is more negative than positive. More recently, however, poll numbers have improved slightly, and favorable versus unfavorable views are running neck and neck. The Kaiser Family Foundation's March 2015 Health Tracking Poll reported that 41 percent of Americans now favor the law and 43 percent oppose it. In a convoluted way of thinking, that is good news for ObamaCare since 57 percent of Americans found it to be distasteful as recently as last July. Fewer now disfavor the ACA, but a plurality of Americans still do not support it, even as almost three in five Americans say they have not been affected by the law at all, and over 50 percent are unaware of the current Supreme Court challenge that would disqualify tax credits for 7 million people purchasing health insurance in the federal marketplace.

What does all this mean? At the most basic level, it means that the Obama administration needs to do a better job of communicating the value of the ACA if it hopes to garner more support from the public. Simply proclaiming how many more Americans now have health coverage doesn't bring around support from the majority of Americans who already have health insurance. For them, it needs to be more personal. The cost and availability of their own health coverage is more important than facts about the bigger societal picture, and the disjuncture between the two leads to suspicion and misperceptions. For example, more than four in 10 Americans think that the overall cost of the ACA has increased when, as mentioned above, it has actually decreased, and insurance premiums have for the most part been stable since the implementation of the ACA. However, for some individuals, the cost of their own health insurance has gone up or has become less comprehensive as a result of employer decisions to reduce the generosity of employer-sponsored coverage so as to avoid the upcoming 2018 "Cadillac tax" assessment on high-end insurance plans. Although it is unclear how many plans may be subject to the tax, some suggest it may be as few as 20 percent of workers. Nevertheless, the specter of a future tax sparks fear in many employers, and by extension, their workers, as they are asked to have a little more financial "skin in the game." It is little solace that these and other ACA-enabled actions may slow national health spending over time or that millions of Americans can now purchase insurance without regard for health status, gender or where they work. Understandably, most Americans see larger policy decisions in terms of how they play out in their personal lives. Is it any wonder then that public opinion continues to be tepid about ObamaCare?

Six out of 10 Americans do not understand how the ACA affects them and most get overwhelmed trying to understand the law. The real and perceived effects of the ACA are fraught with confusing half-truths: Yes, some employers are cutting back on employees' hours so they can avoid the employer mandate, but this is not happening overall; and no, the ACA is not a cure-all, despite offering many Americans health coverage, as too many still struggle with high deductibles and out-of-pocket spending. While this variability in outcome is not unexpected from a large piece of social policy, it nevertheless subjects it to exquisite ideological partisanship and politicization from those who both support it as well as oppose it. Overly simplistic media sound bites heralding the success or failure of ObamaCare just increase mistrust of the law. Until the Obama administration is better able to communicate the value of the ACA in the lives of most Americans, the uncertain prospect for smoothing the law's future makes for a very bittersweet half-decade commemoration of its passage.

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