Mythbusters Part 2: Public Support for the Affordable Care Act
The Claim: “The majority of Americans do not want ‘Obamacare'”
The Reality: Actually…. we do
As I promised in one of my latest posts here, I will be continuing with a series on the Affordable Care Act (ACA) with the goals of debunking common myths, clearing up misconceptions, and providing factual information about health care reform. To be honest, it was somewhat difficult to start writing this particular post because there is so much misinformation out there that it is a bit overwhelming to begin the task of identifying and debunking all of the myths. Rather than trying to cover them all in this one post, I am going to start by analyzing the veracity of a claim that we have heard quite a bit over the past several weeks- that Americans do not support the Affordable Care Act. Of course, there are certainly those who do not support the ACA and I do not intend to claim that all Americans support the law; however, the numbers have been greatly exaggerated through a combination of intentional and unintentional misinterpretation of data. There are other factors, such as the multi-million dollar ad campaigns funded by the Heritage Foundation, the Koch brothers and their conservative action group, ‘Americans for Prosperity,’ and other groups targeting the ACA with fear tactics and misinformation, as well as the general lack of personal experience with and understanding of the ACA among most Americans, which have contributed to the skepticism of the law, but my focus in the current post is to take a look at the statistics on Americans’ views about the ACA, and how these statistics have been misrepresented, distorted, and taken out of context. As I said, I don’t intend to imply that all Americans love the ACA. However, with over half of all Americans and over 2/3 of uninsured Americans stating just last month that they do not have enough information about the law to know how it will impact them, it is a bit troubling to hear politicians and members of the media citing claims that most Americans don’t want the ACA to be implemented. If most Americans say that they don’t have enough information to understand the law, then how would they have enough information to say that they don’t like it? In the following post, I will discuss some of these recent claims and then refer to the data on which these claims are founded. I will also go through some of the most common mistakes (intentional and unintentional) in survey/questionnaire design and data interpretation that contribute to these skewed reports. My goal is to provide a clear view of the most recent findings from several nationwide surveys, which do not support the claim that most Americans dislike the ACA. As we have seen with many other talking points used by opponents of the ACA, the truth is all too often pushed aside to make room for an ideological agenda.
Debunking the Myth
In recent weeks, the claim that Americans do not support the ACA has been repeated numerous times, often used as a strategy to legitimize shutting the government down in an effort to defund the ACA (which, in itself is a myth; most of the funding for the ACA is considered mandatory spending, so it would not be affected by the shutdown)* (see end of article for a brief aside on this matter). It is not quite as hard to understand the origins of this myth (compared to some others, such as the death panels mentioned in my previous article about ACA myths), as recent findings on favorability for the ACA are somewhat mixed and almost always difficult to interpret in a straightforward manner. Much of the confusion results from the survey designs and subsequent misuse or misinterpretation of survey data. The design of most of these surveys is such that individual items on the survey are not very informative when examined on their own; rather, they are designed to be examined as a whole. Unfortunately, when politicians and members of the media report the findings of public opinion surveys, they often choose to examine a particular question, which is usually chosen based on the goals of their particular agenda. So, if a certain question appears to provide support for the agenda that a political party or media outlet wants to promote, they will choose to report the results of that question while overlooking the rest of the survey. Although single-item surveys are not unheard of, it is much more common to use surveys with multiple items to obtain more reliable and valid results; when this is the case, it is not generally appropriate to interpret the results of a single question as an indicator of the overall results of the survey, and findings based on single-item measures are usually not nearly as reliable as those based on measures with multiple items. There are also a lot of issues with the wording of survey questions and response categories that can lead to skewed results when they are intentionally or unintentionally taken out of context or interpreted incorrectly. For example, in July 2012 the Doctor Patient Medical Association Foundation released the results of a survey given to physicians to investigate physician’s attitudes about the current medical system. One of the questions asked physicians how the current medical system affects their desire to continue practicing medicine. Responses to this question were very negative, with 83% of physicians reporting that the current system “makes [them] think about quitting.” The question did not ask about the Affordable Care Act or any of the provisions in it; it simply asked about “the current medical system,” which could include any number of issues. In July 2012, the impact of the ACA was almost non-existent because the vast majority of the provisions had not been implemented. However, politicians like Representative Jeff Duncan (R-S.C.) saw an opportunity to use these results to promote their negative views of the ACA, and in doing so, completely misrepresented the findings. In a twitter message posted on July 10, 2012, Rep. Duncan stated that, “83% of doctors have considered leaving the profession because of #Obamacare. #repealandreplace.” Obviously, this is not what the results of that question actually implied, but that did not stop those with an agenda from misrepresenting the findings to support their viewpoint.
In addition to survey and question design, there are several other issues with interpretation and reporting of survey findings that can result in misleading reports. First, some recent poll results appear, at first glance, to indicate that the majority of Americans do not like the ACA; however, upon closer analysis, the interpretation of the results actually changes significantly. Second, several polls have found substantial differences in favorability ratings simply by using different terminology (e.g., ACA vs. ‘Obamacare’). And third, other polls, in which the respondents are asked about the provisions of the ACA, yield completely different results compared with polls simply asking about the ACA as a whole, without any explanation of the law (and, as mentioned previously, the majority of Americans report that they do not understand the law or how it will impact them). In the following paragraphs I will discuss these three issues in more detail.
Misinterpretation of Findings: The Numbers Game
In the CNN/ORC poll that has been cited frequently in recent weeks, 57% of Americans say that they do not support the current health care reform law for some reason. Many have interpreted and reported these results as indicating that 57% of Americans simply do not like the ACA; however, further inspection of the data yields some revealing findings (this is where it gets interesting!). Among the 57% of Americans who oppose the law, 11% oppose it because they believe it is not liberal enough; thus, they want the law to include even more provisions than it already does. For this 11%, they apparently like the ACA so much that they want it to be even bigger; obviously, this is quite different than opposing the law simply because you don’t like it! Thus, there is actually a pretty even split (49% vs. 46%; the rest had no opinion), with a greater percentage (49%) of Americans reporting that they support the law/want the law to go further compared to the percentage (46%) who say they oppose the law/want to take away from it. The results from another survey, conducted by the Kaiser Foundation, were very similar. Findings from the Kaiser poll indicated that the majority of Americans (53%) either want to keep the ACA “as is” (25%) or expand the law (28%). However, Rep. Michele Bachman and several of her colleagues in Congress reported that, based on these findings, the majority of Americans do not want Congress to implement the ACA. Again, this seems to be an intentional misrepresentation of the results by politicians with an agenda.
Terminology: What’s in a Name?
In CNBC’s third-quarter All America Economic survey, half of respondents were asked if they support they support the Affordable Care Act while the other half were asked if they support ‘Obamacare.’ The first interesting finding was that 30% of respondents do not know what the Affordable Care Act is, while only 12% do not know what ‘Obamacare’ is. Further, among those asked about ‘Obamacare,’ 46% of respondents said they oppose the law, compared to just 37% among those asked about the Affordable Care Act. Thus, results from the exact same survey found an 11% difference in favorability ratings for health care reform simply by switching the wording from ‘Obamacare’ to the Affordable Care Act.
Breaking it Down: The Sum of All Parts
The final issue, and perhaps the most telling, is the overwhelming support for the ACA when it is explained to respondents before asking about their opinion. Although favorability hovers around 50% when no explanation is provided, support is significantly higher when respondents are asked about the core provisions of the ACA. Out of a total of 11 core provisions, favorability ratings are 57% or higher for 10 of the provisions; 65% or higher for 8 of the provisions; 71% or higher for 6 of the provisions; 76% or higher for 7 of provisions; and 80% or higher for 3 of the provisions. The three most popular provisions are the tax credits given to small businesses to buy insurance (88% support), closure of the Medicare ‘Doughnut Hole’ (81% support), and the creation of the insurance Marketplace (i.e., insurance exchanges) (80% support). The only provision with a favorability rating below 50% is the individual mandate, which is viewed favorably by 40% of Americans. Thus, when respondents are provided with basic information about the law, favorability ratings are much higher. Given these results, as well as findings from the same survey showing that the vast majority of Americans have one or more misconceptions when asked about what provisions are actually included in the Affordable Care Act, it is apparent that a significant proportion of respondents who report low favorability for the ACA likely do not understand the law well enough to make a decision about whether or not they support it. This finding is significant for several reasons. First, because it indicates a need to provide the public with more accessible, higher quality information about the ACA. As I discussed in my previous post on the ACA, there is an alarming amount of misinformation about health care reform being spread through various media outlets, political campaigns, social networks (digital and in-person), and even seemingly trustworthy sources. Many government and public health agencies have tried to counter this misinformation with ad campaigns providing truthful, accurate information about the law, but there is still a great deal of misunderstanding and a desire for more information among the majority of Americans. In fact, public awareness of the ACA has not seen significant improvements since October 2010, and for several provisions included in the law (4 out of the 6 included in this particular question), public awareness actually decreased between October 2010 and September 2013. The second, and even more significant implication of these findings, is that most Americans actually do support the most important, fundamental changes in our health care system made possible by the ACA. Although some people object to certain aspects of the law, the vast majority of Americans agree with the primary goals and functions of health care reform. There are many parallels between the implementation of the ACA and the passage of Medicare in the 1960’s, which was originally favored by only 28% of Americans and still had less than 50% support when Lyndon Johnson took over the Presidency. Today, Medicare is one of our most popular government programs (falling just behind education), with approximately 60% of the public in favor of current government spending levels for Medicare. Any big change is likely to face challenges and a certain degree of skepticism, but that is no reason to give up on something as promising and as necessary as the ACA. Lack of health insurance is a major concern for millions of Americans. A 2009 study published in the American Journal of Public Health estimates that 45,000 annual deaths in the U.S. are directly associated with being uninsured. In the same study, researchers found that working-age Americans without health insurance face a 40% higher risk of death compared to those with health insurance, even when accounting for socioeconomic status, health behaviors, and baseline health. According to these findings, one American dies every 12 minutes from lack of health insurance.
Conclusion and Final Thoughts
The human right to health, defined as the “right to the highest attainable standard of physical and mental health, which includes access to all medical services, sanitation, adequate food, decent housing, healthy working conditions, and a clean environment,”, is protected in Article 25 of the Universal Declaration of Human Rights, Article 12 of the International Covenant on Economic, Social, and Cultural Rights, Article 24 of the Convention on the Rights of the Child, Article 5 of the Convention on the Elimination of All Forms of Racial Discrimination, Articles 12 & 14 of the Convention of the Elimination of All Forms of Discrimination Against Women, Article 11 of the American Declaration on Rights and Duties of Man, and Article 25 of the Convention on the Rights of Persons with Disabilities. The United Nations, in General Comment 14 in Article 12 of the International Covenant on Economic, Social, and Cultural Rights, provides a thorough explanation of the right to the highest attainable standard of health, which includes access to timely and appropriate medical care and necessary social services (as well as food, clothing, and housing). Further, the Right to Health includes: A) Availability of functioning public health and healthcare facilities, goods, services, and programs such as hospitals, clinics, other health-related buildings, essential drugs, and trained medical and professional personnel; B) Accessibility of health facilities, goods, and services to everyone without discrimination (including physical accessibility, information accessibility, non-discriminatory accessibility, and economic accessibility [i.e., “health facilities, goods, and services must be affordable for all. Payment for healthcare services as well as services related to the underlying determinants of health, has to be based on the principle of equity, ensuring that these services, whether privately or publicly provided, are affordable for all, including socially disadvantaged groups. Equity demands that poorer households should not be disproportionately burdened with health expenses as compared to richer households.]); C) Acceptability of health facilities with respect to medical ethics and culturally appropriate standards; and D) Quality of healthcare facilities, goods, and services must be scientifically and medically appropriate. The same document also addresses the right to maternal, child, and reproductive health/healthcare, the right to healthy workplace environments, the right to prevention, treatment and control of disease, and the right to health facilities, goods and services including the provision of equal and timely access to: a) basic preventive, curative, rehabilitative health services, and education; b) regular screening programs; c) appropriate treatment of prevalent diseases, illnesses, injuries, and disabilities; d) essential drugs; and e) appropriate mental health treatment and care. The U.N. also outlines the legal obligations of nations to uphold the Right to Health, recognizing the financial constraints faced by developing nations but also emphasizing the “specific and continuing obligation to move as expeditiously and effectively as possible towards the full realization of Article 12.” As Americans, we are fortunate enough to live in a country that does have the means to fully implement each and every statute underlying the universal Right to Health. In the United States, the Right to Health is inextricably linked with having health insurance; it is impossible, given the design of our healthcare system, to provide equitable access to healthcare without providing equitable access to health insurance. The purpose and goals of the Affordable Care Act are not a matter of politics, partisan ideals, or even good public policy; this is a matter of fundamental human rights. As a nation that takes pride in being one of the world’s leaders in human rights advancements, the U.S. is the only developed capitalist nation whose government does not provide guaranteed access to healthcare for its citizens. We can do better this, and the Affordable Care Act is a huge step in the right direction. There is no political agenda that is more important than the lives of our fellow citizens, and for the 45,000 Americans who die each year due to lack of health insurance, as well as the 48.6 million additional uninsured Americans, the Affordable Care Act may very well be a life-saving opportunity.
*A Side Note: As I noted above, the primary argument that many Republicans have made for defunding the Affordable Care Act is that the majority of Americans supposedly do not like it. I hope this article provided a different perspective on the actual findings regarding Americans’ views on the ACA; however, I also want to briefly mention one other reason that this argument is so fundamentally flawed (well, besides the fact that the ACA has already been passed through Congress, upheld by the Supreme Court, signed into law, and supported by the American people in the 2012 election). If we were to abide by the logic that our government should always go with what the majority of Americans support, then the Republicans would not be in control of the House of Representatives. In the 2012 election cycle, House Democrats actually won the popular vote by 1.17 million votes. Although Democratic candidates for the House won the popular vote, they did not get the majority of House Seats; this was the a result of the redistricting strategy (also known as “gerrymandering”) employed by House Republicans. I wonder if the politicians arguing to defund the Affordable Care Act under the premise of ‘majority rules’ would be willing to give up control of the House of Representatives based on this same principle? I think we all know the answer to that one.