Health Reform – Many Americans Don’t Know What It Means

He finally said it.

“Obama cares,” President Barack Obama told a town hall over the summer, turning the Republican “Obamacare” phrase on its head.

I was wondering what took him so long (and yes, I have wondered in public why he didn’t use that phrase before–and can prove it!)

As the Congressional “supercommittee” gets to work this month, with health care and just about everything else under the sun potentially on the chopping block, and with the Republican presidential nominating contest heating up with talk of repeal, will we hear “Obama cares” again?

As Brown University political scientist James Morone, co-author of “The Heart of Power: Health and Politics in the Oval Office, said in a recent interview, the Democratic voices publicly defending reform are not exactly breaking the sound barrier. But the Republicans, from center-right to far- right, are pounding at the repeal message. ”

“If you watch the (Republican) fund-raising letters, there’s a lot about Obama health care in it,” Morone said. “But the Obama ones never mention health care. They are trying to walk away from it.”

Meanwhile numerous polls have shown that the public remains divided about health reform – and remarkably ill-informed about it. An August Kaiser Family Foundation tracking poll found that even people who would most benefit – the uninsured – were remarkably clueless. Only about half of the uninsured said they are familiar with the main provision of the law, and only three in 10 thought it would help them get health care. Nearly half thought it would have no effect on them, and 14 percent thought they would be hurt by the law, possibly because they understand there is a mandate requiring them to get insurance, but don’t understand there are subsidies to help them afford that insurance.

“People who are busy in their everyday lives (and who are being bombarded by a highly spun, confusing political debate about the ACA), will only understand what a complex law like this does when it is tangible for them – when they either get the benefits themselves, see family members and friends benefiting, or see news reports about how the law is working after it is implemented,” commented Kaiser Foundation CEO Drew Altman.

“When there is real insurance coverage available for people who don’t have it, they will be more aware of it, and they will be able to render a judgment about whether coverage is affordable for them. These benefits will technically be available in 2014, but outreach and enrollment takes time. It will be 2015 or 2016 before there is a real test of awareness and affordability,” he added.

Politically, though the fate of the reform legislation may be decided long before that – to some degree, in the congressional budget process and the “supercommittee” and certainly between now and the elections in November 2012.

“If the Democrats on the campaign trail don’t make on argument about health reform, about why they did it and why it matters, it leaves it incredibly vulnerable should Republicans win,” Morone noted.

The campaign dynamic is one factor casting a shadow on health reform. The deficit-cutting about to begin in Washington could be another. Yet while we can’t predict how exactly that will play out, the debt deal may not be as dangerous to health reform as some fear. The administration may not be shouting health care’s benefits from the rooftops, but inside the Washington, DC Beltway they drew a sharp and clear line in the sand protecting key parts of the Affordable Care Act, one of the few “victories” that the White House got in that hard-fought deal. That priority-setting exercise has not gotten a lot of attention.

There are actually two, separate but parallel, budget-cutting processes. The appropriators will be cutting more than $1 trillion from annual spending – and various funds and programs and implementation budgets, etc., the discretionary spending annual appropriations part of the ACA, may well face cuts. Even so, Democrats aren’t going to let them be zeroed out, anymore than Senate Democrats let House Republicans dismantle health reform during this year’s earlier budget and legislative fights.

The “supercommittee” will seek more than $1.2 trillion in further savings, from mandatory spending and entitlements (and perhaps something on the revenue side, loophole closures or the like, although obviously Republicans have drawn their own big bright lines in their sand opposing tax increases). If the panel fails to find agreement, a trigger goes into effect, automatically cutting all sorts of defense and domestic programs, including Medicare (providers, not directly beneficiaries).

But a few things are exempt from the trigger—including programs that serve low-income people. Medicaid, and the subsidies and tax credits to help people and small businesses afford health insurance, are among those few trigger exemptions. As political analyst Nate Silver of the FiveThirtyEight blog wrote, “If Democrats read the fine print on the debt deal struck by President Obama and Congressional leaders, they’ll find that it’s a little better than it appears at first glance.”

The cost-sharing subsidies in the ACA for low-income people could be subjected to automatic cuts. This isn’t the money to subsidize buying insurance; this is the money for helping with the co-pays when people do get care. Those payments are made to health plans, not directly to beneficiaries so it won’t have the direct impact of discouraging care. It may affect how health plans decide what markets to participate in. (Gary Claxton and Larry Levitt at Kaiser Family Foundation explain the cost-sharing here.)

The CLASS Act (the voluntary long-term care program created under health reform) is also quite vulnerable to a budget axe or repeal as it’s widely seen as fiscally out of balance.

One further twist – some Republicans have urged that health reform be delayed for a year or two to save money. “Delay” may sound better than “repeal” to an ambivalent public. What’s delayed (if anything), how it’s delayed, how long it’s delayed, and what stopgaps are created in the meantime could have an impact on how many of the uninsured get coverage in 2014.

So once again, we’re back to an “inside game” and an “outside game.” Inside, ACA may face some cuts (along with all sorts of other public health programs) but it’s hard to envision Democrats allowing evisceration. Outside, it’s going to be “Obamacare” versus “Obama Cares.” And as Morone noted, one side is being a lot more focused, and a lot more audible, than the other.


Contributing Writer Joanne Kenen writes monthly news features for the Health Policy Forum discussing health policy innovation and “what works” in our health care system, as well as the politics of health policy and reform. As a leading nonprofit health care research and consulting institute dedicated to improving human health, Altarum encourages open discussion and debate about the many challenges in health care today. All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Altarum is a nonprofit, nonpartisan organization. No posting should be considered an endorsement by Altarum of individual candidates, political parties, opinions, or policy positions. Read more.

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