The Takeaway: More Please

  ·  Health Policy Hub   ·   Michael Miller

The most significant development of the week at the intersection of health care policy and politics was the Obama administration’s crackdown on insurers for evading the rules about free preventive services as they apply to contraception. "Free means free" – the carriers were admonished.

In addition to its intrinsic importance, the action this week is a reminder that the consumer protections in the ACA are not self-executing. I don't want to cast aspersions on all insurers, but there has been too much flouting of both the letter and spirit of the ACA so far. In addition to failing to fully cover contraception, we have seen insurers fail to abide by mental health parity rules, and market plans with discriminatory benefit designs and discriminatory networks.

Why No Replace?

There is still no clear replacement strategy from Republicans even as the clock ticks down on the King v. Burwell decision. And guess what? There isn't going to be one. Why not, you may ask? Put yourself in Boehner and McConnell's position. Getting their respective caucuses to agree on anything is a big headache that requires a lot of arm-twisting. Anything they put out immediately becomes a target for Democrats. Plus, its political relevance is entirely hypothetical since without a decision for King, they have virtually no leverage with the President who will almost certainly veto whatever they send up. With all that weighing against them, it really is no wonder that "replace" remains a hypothetical idea five years after passage. Still, lack of a clear strategy has left the anti-ACA crowd open to jibes like this.

More on ACA and Public Opinion

ACA proponents have long been frustrated by the public's reluctance to embrace the law despite growing evidence of its success (though the public opinion needle finally seems to be moving a bit). At the same time, despite massively outspending proponents, the opposition has also been unable to gain much ground. The debate has been more or less a standoff. A new poll sheds some additional light on why. The poll found that the majority of Republicans think ACA has increased the number of uninsured, despite all the evidence showing the opposite.

The bottom line is people's view of the ACA is largely a matter of party identification. (If you like Obama, you like Obamacare; if you don't, you don't.) This is not so much about people placing different interpretations on the facts so much as people simply ignoring the facts that don't fit into their preconceived notion. People aren't making a rational judgment about the ACA, they are making a judgment based on emotion and personal identity and then ignoring facts that conflict with that world view. But proponents should not despair. Hardly anyone wants to actually repeal the main pillars of the ACA, which remains a dilemma for the repeal and replace crowd. We just have to come to terms with the fact that the public is not internally consistent with respect to health policy and understand that full acceptance of the law will take more time as well as a shift in the current hyper-partisan political dynamics.