A poll shows that two years after the law’s passage, most Americans still don’t understand what the Affordable Care Act entails.
As the exchanges open nationwide for applications for the Patient Protection and Affordable Care Act’s subsidized health insurance program — informally known as Obamacare or the ACA — confusion and contention about the controversial bill continues to ring more than two years after the bill’s passage. An unprecedented repeal effort from congressional Republicans, which has resulted in a failure to pass a continuing resolution and the current federal government shutdown, has dogged the bill since the Republican takeover of the House in early 2011.
It may be, however, that the confusion fueling the continuing public dissent toward the program may be in part the administration’s fault. A recent Kaiser Family Foundation report found that two-thirds of all Americans — which includes three-quarters of all uninsured Americans — did not know that the exchanges opened Tuesday. Half of all respondents did not know how the ACA affected them or their families, nor understood their financial obligations under the law. Some 56 percent of all respondents found that media coverage of the ACA focused more on the politics of the law instead of how the law worked.
“While policy watchers have been counting down the days until open enrollment in the ACA’s new health insurance marketplaces, just one in eight of the uninsured know that the exchanges open for business on October 1,” wrote the Kaiser Foundation in its poll finding. “Public awareness of many of the law’s key provisions has not increased since 2010, and some stubborn misperceptions persist. Finally, as rollout of many of the ACA’s major provisions begins, eight in ten of the uninsured, as well as over half of those with insurance, say they have skipped or postponed some type of health care in the past year due to cost. About half of those with insurance also report experiencing a variety of problems with their current insurance, such as misunderstandings about coverage, problems with billing, and delays or denial of treatment.”
As glitches in this complicated, highly interagency-connected enrollment system — such a crash on the Maryland website Tuesday morning — are expected and are being dealt with optimistically, the biggest glitch — the problem with public understanding about the program — has been acknowledged as having been wholly avoidable.
“I think it still isn’t real for a lot of people. And there is a lot of confusion,” U.S. Health and Human Services Secretary Kathleen Sebelius told NBC Nightly News in an interview. “But for the 15 percent in and out of the market, not insured at all, this will be a new chance, a new choice for health security. But they need to see it and make it real. And that will happen starting tomorrow.
“I think we bear part of the responsibility of not being able to get through a lot of the noise,” she said.
A campaign of misinformation, competing punditry and a litany of judicial actions — including a poorly reported Supreme Court decision that partially changed the implementation of the law — have made the ACA one of the least understood laws in modern history. To alleviate this, let’s break down the legislation.
The ACA and you
The Patient Protection and Affordable Care Act of 2010 has been called the “Dodd-Frank Act of healthcare” due to the number of direct challenges the act introduce to health insurance companies. Created under the same Congress as Dodd-Frank, the bill was designed not only to address the issue of rampant individual health uninsurance in America — which is ultimately manifested as an additional burden to taxpayers, as hospitals are required by law to treat all critically ill or injured individuals and the nonpayment is reported as a tax write-off — but to also address key complaints about insurance provider malfeasance.
— Codified guarantees on equal insurance coverage on all members of an age- or location-based demographic without consideration of race, most pre-existing condition (with the exception of tobacco use) or gender;
— Established minimum standards for health insurance policies;
— Expanded Medicaid eligibility for all individuals and families up to 133 percent of the federal poverty level (it should be noted that the Supreme Court case National Federation of Independent Business v. Sebelius made the provision optional and made it possible for states to opt out of expanded coverage. Many states did opt out, leaving many impoverished Americans with no means to pay for the ACA-offered insurance);
— Reformed the Medicare payment system, addressing the Medicare Part D coverage gap, which made a patient responsible for payment for his or her prescription-drug plan after initial coverage has been exceeded, and changing health provider payments from individual payments to bundled payments for whole procedures or “episodes of care”;
— Mandated that employers of 50 or more individuals that do not provide employer-paid health insurance coverage to all of their employees must pay a fine for each uninsured full-time employee, and
— Mandated that all Americans must have health insurance. The federal government would run exchanges where private insurance companies can sell standardized insurance plans to the public conveniently and will subsidize the cost of the insurance policy — in part or fully — for individuals and families earning between 133 and 400 percent of the federal poverty level. Individuals who choose to remain uninsured after the implementation of the exchanges’ insurance program will be fined, unless religious association or financial hardship is the reason for opting out of insurance.
Most of the provisions of the ACA have already been put into effect. For Americans who already have health insurance — either through their employers or through the government via Medicare, Medicaid or TriCare — the immediate effects of the ACA will probably not be immediately noticeable. Dependent children up to the age of 27 can now stay on their parents’ insurance, pre-existing conditions cannot be factored in decisions to grant or honor health insurance policies and — due to the ACA’s Medical Loss Ratio, which dictates that 80 percent of premiums collected from small-group or individual plans and 85 percent of large-business plans go to actual medical care — many insurance recipients, about 12.8 million Americans, ended up getting a rebate on their paid premiums: on average, $151. Individuals that make more than $200,000 and married couples that make more than $250,000 in a calendar year in income will be subject to a 0.9 percent Additional Medicare Tax, and manufacturers and importers of certain medical devices must pay a 2.3 percent medical device excise tax.
The ACA will be most noticeable for the nation’s uninsured. To facilitate the individual mandate of health insurance coverage, the Centers for Medicaid and Medicare Services (CMS) — the ACA’s governmental administrator — have established exchanges or online “marketplaces” that allow the customer to quickly compare different insurers side-by-side, determine his or her eligibility for tax subsidies and apply quickly. For those needing assistance in filling out their applications, coordinators are available at CMS sites during the open enrollment period.
The ACA mandates five levels of coverage for its insurance program. Bronze is a 60-40 split, in which the individual is responsible for 40 percent of all medical expenses. Silver is a 70-30 split, gold is an 80-20 split and platinum is a 90-10 split. There is also catastrophe coverage that only covers emergency room visits. While actual pricing of these plans are expected to be on par or below employer-plan rates, the notion that employers will be forced to pay for their full-time employees’ health insurance is raising speculation that labor costs will rise at an unsustainable rate — especially for smaller and mid-level companies.
Due to the nature of the CMS’s funding, the exchanges will remain open despite the federal government shutdown.
The employer mandate and unintentional consequences
According to the Orlando Sentinel, Seaworld has capped hours for part-time workers to 28, in anticipation of the ACA’s definition of full-time work being 30 hours worked per week or more. Trader Joe’s and Home Depot have ceased offering health insurance coverage to part-time employees in an attempt to dodge the $2,000-per-uninsured-eligible-employee fine. Forever 21, in a leaked company memo, indicated that it will cut hours and reclassify some full-time employees as part-time. Some 15 percent of large employers and 20 percent of smaller employers indicated that they will adjust hours to reduce the number of full-time employees they have, according to a survey by the International Foundation of Employee Benefit Plans.
This creates a double whammy in which employers are cutting hours to avoid the employer mandate. It produces a situation wherein employees must pay for their own insurance premiums with less money. The penalty for individual non-coverage is a fine of $95 per person and 100 percent of all incurred health care costs.
“My husband is debating getting insurance which scares me as the job is physical so there is always a risk of on site injuries that require medical attention. We are expecting to pay more out of pocket. We are working on putting aside some now so we can afford coverage next year,” said a mother of two and part-time Trader Joe’s worker who spoke confidentially to the Guardian. “I am worried there will be months when we will have to choose paying health insurance or paying a bill. Neither is a good option with two children to think of.”
“We are hearing from our members who are concerned about what is happening with their companies,” said Janna Pea, deputy communications director of the Retail Wholesale and Department Stores Union. “Not only are they looking at having their healthcare coverage cut they are also looking at less hours. You have a trend where employers are saying they have no obligation to do anything for anybody who works less than 30 hours a week. Part of the act created incentives for employers to take away benefits from employees. It is an unfortunate side effect. The act ignores part time workers.”
The never-ending fight
From all sides, this unconventional solution to a very real problem is posed to become a political lightning rod for years to come. From the left, the failure to cover the impoverished and the unintentional incentive this bill creates for businesses to not cover part-time employees are major failures that must ultimately be addressed. For the right, the forcing of additional labor costs on businesses, the establishment of a new social program and the mandating that individuals must buy a government product fuel the seemingly endless march to push back the legislation. It’s already being predicted that an unimaginable amount of money will be spent in 2014 lobbying for and against the ACA.
“It’s really unprecedented what we’re going to see,” said Dhavan Shah, director of the Mass Communication Research Center at the University of Wisconsin. “It’s going to be vast amounts of spending to get people inside [the exchanges] … but you’ve got tremendous political opposition on the right. It cuts both ways.”
Spending on ACA media buys is estimated to be at $1 billion by 2015, according to Kantar Media.
As the nation engages in this new experiment, few can argue that this undertaking is perfect. But even fewer can argue that what is being done is not important. While there are questions that are yet to be answered about ACA — and some that are currently unanswerable — the focus on the politics of the bill has hidden both the benefits and flaws in the law. As the ACA and the exchanges become a daily reality, the confusion will likely lessen, but in all of this is the reminder of how the media drives political conversation and the call for the news to inform and not simply entertain.
“Even though there’s been a lot of press about political influence around the law, consumers just hear a lot of noise, and they care about what value it can add to their lives,” said Cynthia Rolfe, vice president of consumer brand strategy for the Blue Cross and Blue Shield Association.
“What we’re finding is the most important thing is to help them understand, ‘How do I access health insurance?’” she added. “What does health reform mean for you personally — that’s where it has to start. Once they start to hear that, they’re opened up to it. They start to see it as real.”