To Know the ACA Isn't to Love It

Fareed Zakaria writes,

Many liberals believe that the Affordable Care Act — Obamacare — is unpopular only because most Americans don’t understand it. There is some truth to this: Studies show that the core provisions of the bill are more popular than the bill itself. But there’s also a reason, rooted in reality, why many Americans worry about Obamacare — its cost.

Starting with the opening two words (How many liberals? Do you care to name one?) Zakari's thesis is problematic. I think it would be fair to say that "many liberals believe that the ACA is unpopular because the Republicans have targeted public opinion on the individual mandate, which they know is its least popular aspect, and the media has largely been pliant or ineffective when responding to that position. But while it's true that on the whole, were they to in fact look, people would find a lot of elements of the ACA that they like, and that a better understanding of the bill might have made Republican demagoguery less effective, the best you're likely to do is convince people that on the whole the ACA is better than doing nothing. That it may turn out to be a starting point for serious reform, but that the process of reform is far from over.

But really, while I will grant that the issue of cost is occasionally raised, you can track public opinion through the resonant elements of Republican demagoguery: "Death panels", "Government bureaucrats choosing your doctor", "The government taking away your insurance," "Your employer may stop offering insurance", "You'll have to buy insurance you can't afford..." When you hear details on cost, you get stuff like this:

Former Massachusetts Gov. Mitt Romney's campaign and a like-minded conservative group launched seemingly uncoordinated but highly telling attacks Monday morning, both accusing President Barack Obama of trying to change Medicare dramatically, if not end the program outright.

And this:

"There's only one president in history who's cut $500 billion out of Medicare, and that's your guy, Barack Obama," Romney said recently. "And if I'm president, I'm going to preserve Medicare. I'm not going to cut $500 billion out of the Medicare that we have."

Yes, it's true that the Republicans have played a very good game of suggesting that "they" will be paying for health insurance for an undeserving other, never mind that many of the people targeted by that message will receive substantial benefit and subsidy from the ACA, but please - let's not pretend that cost control is a serious factor in the opposition to the ACA. For goodness sake, I saw a poll this morning that showed that far more people have an opinion on the validity of the Supreme Court's ruling than actually know what the Supreme Court did - when did this debate become rational?

I agree with Zakaria's larger point about the importance of having players in the game who take the long view on health, who in a market-based model of insurance may forego short-term profits in favor of achieving more substantial long-term savings that result from an insured person's improved health. I agree with him that consumers are poor consumers in a healthcare market due to asymmetry of information - and let's also mention undisclosed incentives held by the people recommending care, the difficulty of comparison shopping, and the lack of opportunity to comparison shop for sudden illness or traumatic injury.

But let's recall: flawed though it is, the ACA did include some serious steps to try to determine what treatments work and to compare the cost-effectiveness of different treatments. Those provisions were weakened in response to right-wing demagoguery, but some serious efforts remain. What's going on right now? Are the Republicans suddenly shifting gears and embracing a sensible, data-driven approach to determining the best, most cost-effective treatments that deliver the best options? Hardly.

Let's also be honest, if the public were concerned with all of the issues Zakaria raises, the Ryan "plan", voucherization of Medicare, transforming Medicaid into block grants, a Gingrichian assumption (or is it a pretense) that putting more of the cost of healthcare onto the backs of consumers will make them more informed consumers as opposed to less able to afford needed care, would be laughed out of the room. Yet it's their "serious" alternative to the ACA, as pushed by "serious" columnists like David Brooks.

So why don't we start again with the facts: Much of the ideological opposition to the ACA results from deliberate misinformation injected into the debate by the Republican Party and, but for that demagoguery, it would not necessarily be popular but it would be relatively non-controversial, would include additional measures to improve care and lower costs, and could be approached as a starting point for the additional reforms that we need to try to create a sustainable system of health care in this nation.