Details matter in discussion of health insurance

Now that Congress is on the road to repealing the Affordable Care Act — Obamacare — we’re reminded again how the country missed an opportunity to have an intelligent debate during the campaign on health care access.

Democrats, who are vocal now, didn’t do much to defend the health care law during the campaign because Republican attacks on the law worked perfectly, starting with calling it Obamacare.

So, how to explain this week’s poll from the Wall St. Journal and NBC News that showed for the first time since the law passed that more people like the law than don’t?

nbc_wsj_poll

To be sure, the reaction to the law still breaks down along party lines.

A poll from the Kaiser Family Foundation this month is a little more detailed in which Republicans and Democrats agree that lowering the cost of out-of-pocket spending on health care is a priority.

8955-figure-2

Kaiser’s finding in the poll, however, found more people still objected to the law than favored it.

8955-figure-6

Kaiser’s phrasing of the question was significant. It started with, “Given what you know about the health care law…”

That’s the missing ingredient in many of the polls, as this bit from Jimmy Kimmel Live attests. Many people don’t know much.

On Monday, President-elect Donald Trump told The Washington Post he is almost finished with a plan to replace the Affordable Care Act with a proposal that would provide “insurance for everybody.”

In her appearance on PBS NewsHour on Monday, Susan Page of USA Today noted why it’s important to pay attention to the details of a statement and phrase like that.

“We think that it’s possible that he is — we’re moving toward is health care access for all, not coverage for all,” she said.

“There’s a big difference between coverage for all and universal access,” NPR’s Tamara Keith pointed out.

Details matter in the debate over health care in the United States, even if the American public isn’t really big on them.

Related: With health insurance rebates on Capitol agenda, individual market customers hope for political compromise (Star Tribune)

  • MrE85

    It is sometimes said that we never really know what we’ve got until its gone. Perhaps this is one of those instances.

    • Maybe. And maybe we choose not to know what we’ve got.

      • MrE85

        We certainly did. In more ways than one.

      • chris

        Using the collective “we” when Trump and republicans in general, especially in the senate, received millions fewer votes, misses the mark.

        The ACA is far from perfect but if republicans could propose a better plan they would have in the past 7 years. ACA exchange premiums are going up because the cost of health care is going up. It’s actually going up less now than before the ACA, but controlling costs while expanding coverage is the issue. I think the GOP plan if they can even pass one, will be high deductible plans that seem cheaper, but if you get sick will end up bankrupting people, which is right up Trump’s alley.

        • MrE85

          The ACA, as the Congressional Budget Office now tells us, has an economic and social impact on all of us, regardless of who we voted for or where we get our health insurance. So the “we” is justified, IMHO.

          • chris

            More of the we voted to keep it than not, whatever the current opinion poll is saying.

          • MrE85

            “More of the we voted to keep it than not”
            As my wife keeps reminding me. 😉

        • KariBemidji

          I had a little cancer scare last year that resulted in 2 mammos, a biopsy and outpatient surgery. It nearly wiped out our HSA that we’ve had for 10+ years. The HSA is not the savior of our healthcare system.

          • MrE85

            HSAs are just a way to shift the costs back to us. I don’t even have one, even though my health has taken a turn for worse in past eight years. I suppose THAT’S Obama’s fault, too.

            PS: I’m so glad you’re okay.

  • wjc

    Trump appears to be driving Congressional GOPers nuts (not a long drive) with his pronouncements about “coverage for all” and “almost simultaneous repeal and replace”, but given all of the time spent by the GOP on symbolic repeal votes, we still haven’t actually seen a replacement plan that can be evaluated.

    Sad.

  • Rob

    It’s easy and justifiable to ding Americans generally for not knowing a lot about any given subject, but it doesn’t help when a bunch of attorneys – whoops, I mean Congress – gets together and produces overly complex, multi-layered legislation that’s hard to penetrate unless you devote most of your waking hours to it. And just look at the complexity the Republican leadership is building into its efforts to provide relief from premium costs. Under their plan, by the time any rebate money actually gets to people, it’ll be 2035.

    • True. But you can learn about what’s in the ACA without reading the legqalese of the bill.

      Surely, someone in coal mining country, for example, could have asked themselves, “I wonder why black lung disease is now considered the default cause of respiratory problems, allowing me to get benefits” at some point.

      It’s like the nation never heard of Google.

      • jon

        The nation doesn’t want to read anything that doesn’t support their pre-existing view of reality.

        • >>The nation doesn’t want to read anything that doesn’t support their pre-existing view of reality<<

          …and in a few weeks, that pre-existing view won't be covered anymore…

          😉

      • Rob

        Google?

      • Heb Ienek

        You’re right. Now that it’s been passed, everyone knows what’s in it.

        Maybe after repeal we can find out what’s been removed.

    • Jeff

      Maybe I’m boy genius, but there hasn’t been anything in the ACA that seemed complex to me as just a citizen. Maybe if you have a business or are in the insurance game it gets more dicey.

      • Kassie

        As someone who was a Project Manager on MNsure for over a year, who has a Master’s Degree in Public Policy, and has worked administering Medical Assistance in the past, I think it is very complex.

  • Mike Worcester

    My employer just changed insurance providers (yes, I know I’m fortunate in that regard). As we were trying to decide, we were given a report that outlined the basic details of the proposed package. That “report” was nearly ten pages long of charts and graphs and numbers and it still left us with many unanswered questions.

    Considering that precious few Americans who do have insurance read the entire packet that explains benefits (and non-benefits), should we be surprised that few folks really understood what was in the ACA, other than it was framed as some sort of government takeover of the health care industry? A framing that President Obama and Congressional Democrats did virtually nothing to counter?

    • I don’t read the privacy notices that companies send out either. That said, before I got on a soapbox about privacy, I think I’d do some research about why there isn’t any.

    • Veronica

      It’s complicated because we Americans like CHOICE– Doctors and APNs like to choose who they work for, mental health providers who go into private practice, we have for profit health care systems and non-profit health care systems because it’s the American way to make a ton of money off of patients who stay sick and need billable care as long as possible, and we think we should have a choice to where we go (when in reality we’re terrible at doing any homework to figure out who has better care), we want to choose our doctor, choose our plans….

      If we’re talking Medicare/Medicaid, there are 4 stakeholders: The patient, the health care system, and, if it’s like what we have in Minnesota with private insurers acting as plan administrators, the state and the insurance company are involved. All 4 are fighting for the lowest costs and highest profits.

      For Private Insurance, there are also 4 stakeholders: The patient, the health care system, the insurer, and the employer.

      • tboom

        Americans like choice, but Americans are unwilling to do the work of understanding their choices (as this post and discussion thread proves). Americans aren’t all heath care system experts and mostly don’t have the time or inclination to make themselves experts, that’s why health care should be single payer. In the same vein Social Security should never be privatized (keep your eye on Paul Ryan on both these subjects).

  • Will

    Can someone tell me who was paying for the subsidies for lower income and middle income people, you don’t get something for nothing…what taxes were created to pay for those large subsidies. Who paid those taxes?

      • wjc

        Heh!

      • Oh, well played Bob…well played.

      • Will

        Cute, just thought a journalist might want to do their job and report the facts…If you are determined to keep Obamacare you’d think answering a simple question about funding of massive subsidies would be quite easy to reply to.

        I’ll go ahead and give my canned response to “go look it up on Google”, you don’t care enough about this topic to research and and reply with a counterpoint in your own words.

        • Except you proved the point. I’m neither determined nor sanguine about the situation in Washington. What I would like is for people to invest time in gaining knowledge before forming an opinion.

          “Do it for me” isn’t a pathway to an informed discussion. It’s been six years since the law was enacted.

          // you’d think answering a simple question about funding of massive subsidies would be quite easy to reply to.

          Indeed, it was.

          • Will

            I was literally asking to be informed, I’m at work writing code…I can’t do in depth research on the ACA and how or if it was funded…Did the ACA simply increase our debt? Was it paid for? Are states forced to fund those subsidies? I’m curious about those things, asking me to Google is a bit patronizing since anyone could respond like that on every complex issue.

          • X.A. Smith

            You have time during work to complain, but not to research.

          • Will

            To ask questions, yes, to read 2700 pages of an arcane bill, no.

          • X.A. Smith

            There could be a few articles published on it in the last 6 years that might summarize the law.

          • Will

            Maybe a person defending the law should link to those stories then…

          • I’m not defending the law and not sure why you don’t understand that basic point. I’m criticizing people — on either side of any important issue — who dont’ bother to educate themselves about it.

            It’s a basic responsibility of civic engagement.

          • Matt

            Of, FFS. Here:

            “MIT economist Jonathan Gruber, who helped develop the law, says about half the costs are offset by projected savings in Medicare payments to insurers and hospitals. Another quarter is offset by added taxes on medical-device makers and drug companies.

            ‘The other source of revenue is a tax increase on the wealthiest Americans,’ he says. ‘Those families with incomes above $250,000 a year will now have to pay more in Medicare payroll taxes.'”

            That took 2 mins.

          • // ..I can’t do in depth research on the ACA and how or if it was funded

            It’s been six years.

          • Will

            So why are you unable to answer that basic question?

          • Jeff C.

            My guess is that Bob isn’t unable to answer that basic question. He *is* able to, but he doesn’t want to do your work for you.

          • tboom

            Whoever pays you to write code and instead gets an employee generating your volume of comments is getting robbed.

          • Will

            You’re reinforcing my point the ACA was so complicated, so arcane, so filled with give aways that asking a common sense question like “how are we paying for these subsidies?”, is met with such resistance and dancing around the question that it convinces me blowing up the whole thing and starting over is the best path forward. No one is even willing to defend it by clearly explaining the funding mechanisms. Fine then, get rid of it then.

          • The issue is knowing what you’re talking about and not knowing what you’re talking about. Americans, these days, are not that interested in knowing what they’re talking about. If that means blowing up a system, that’s up to you and them. People choose to be uneducated and uninformed but nobody should misconstrue that approach as good public policy.

            You have a job as a citizen.

          • Will

            Jesus, I asked an honest question about funding, of course I know of some funding mechanisms but they don’t add up to the subsidies and many of taxes were delayed and even Dems want to remove them. I was asking a serious question about both sides of this law, how much it costs us vs the subsidies (which sound great, but someone is paying for them).

            Ask yourself if you would have treated a liberal poster with the same animosity for asking a question about Trump.

          • Well, show us your math of subsidies vs. inflow and maybe we can help.

          • KTFoley

            No, you’re baiting people and it shows.

          • KTFoley

            What, you won’t even click on the NPR article that displays topmost in the search results from Bob’s link?

            You’re reinforcing the point that people reveal how set they are in their own preconceptions via their response to information that might not align to that viewpoint.

          • Jay T. Berken

            “No one is even willing to defend it by clearly explaining the funding mechanisms. Fine then, get rid of it then.”

            Feels good to say that, aye Will. Hey btw, what is the Republican plan to replace the ACA? You’re so hell bend of repeal and replace, explain to us why you think it should go forward?

    • jon

      ACA had a number of revenue sources… off the top of my head there was a tax on medical device manufactures, and a tax on the cadillac of health care plans, sure there was probably more as well.

      • Will

        The Cadillac tax was never enacted, it was continually pushed back. From what I remember even the senators from MN want the medical device tax repealed.

        • // even the senators from MN want the medical device tax repealed.

          You know why that is, right?

          • Will

            Yes, it’s what we do here in MN, I think the senators let us down by not fighting for that removal BEFORE it was law… another example of not understanding the ACA before voting on it.

          • X.A. Smith

            You’re complaining about them not understanding it, but you won’t read up on it before you hurl complaints.

          • Will

            You’re being disengenuous, so liberals can’t ask questions about Trump’s business holdings without fully understanding the tax legalities of every business he owns? Stop with having a double standard, I asked a question, answer it if believe in Obamacare.

          • You’ve totally missed the point of the post. It’s neither pro Obamacare or anti-Obamacare.

            It’s about the laziness of the American people to educate themselves BEFORE having an opinion.

            Do your job as a citizen. You’ve had six years to gain a basic understanding of the ACA — not complex, BASIC. If you’ve punted the last six years, don’t whine to me.

    • Kassie

      And who was paying for the uncompensated care hospitals and clinics were being stuck with before the ACA and the subsidies? We can’t pretend that people not being insured was actually a cost saving for average Americans.

      • Veronica

        Well. And then the hospitals have ALL taken that increased revenue and used it to build new additions, new clinics…and then lay off staff.

        • KariBemidji

          Hospitals are building new additions to add providers such as orthopedics because they are reimbursed 100%. Look around, do you see a lot of new family med additions?

          • Veronica

            Well, no, there is no such thing as a “family med” unit in a hospital. Med/Surg, yes, but not family med.

            They ARE however, pouring big bucks into maternity care floors. Do NOT get me started on THAT.

          • KariBemidji

            Again, because 100% reimbursement.

          • Veronica

            Ok, I can’t figure out what you mean by “100% reimbursement”. Nobody gets 100% reimbursement—not on the provider side at least. The clinic or hospital decides if you have x done, their “USusal and customary” charge is $y for everyone who has x done. Then, depending on the contract with the provider, the insurance company will only allow x to actually $z. Y never equals Z.

            Some things, the patient can’t be charged for as outlined in ACA, like preventative care. But that doesn’t mean the clinic is automatically paid whatever it wants by the insurance company for that preventative care.

            Prenatal care is considered preventative care. Birth costs, however, fall under the plan terms and are subject to all deductibles and co-pays. Not 100% reimbursed by anyone, whatever that means.

      • Will

        Sure, what were the costs before and what are the costs today?

      • kevins

        The issue of uncompensated care is the elephant the no one sees….those costs are never accounted for by critics of ACA. Does anyone remember hospitals closing because they cared for patients, and got no reimbursement. I do, because I worked at one of them. ACA was built on the principle of dealing with uncompensated care, but few understand that.

  • Will

    I’m sorry but I need to point this out, we can’t even have a serious discussion on this issue. First, I want to say I’m a right leaning moderate, I enjoy MPR and I speak up about the bias I see because I care and I think MPR can do better but dispite that bias I see from time to time I think MPR does good work…better than right wing talk radio (which is more joking propaganda, which some take as gospel). There are many who don’t believe in facts, who are much further right than me and yes, sometimes those things go together. But if I can’t even get through to people here to have a meaningful conversation here on MPR without being belittled and attacked as a more moderate individual then we have a problem. I didn’t even vote for Trump, I couldn’t stand him and he’s a snakeoil salesman…I voted for Johnson in hopes he would get 5% of the vote and provide us with a serious 3rd option in 2020. Since the election I have accepted the fact that Trump will be our president and I’ll support him as much can on issues I agree with him on and I’ll speak up if he violates our rights..but those on the left have claimed he’s not even legitimate and every single thing Trump has done has created freak-out in the media, constant outrage is what I see now. If everything is an outrage then nothing is…time to grow up and accept what happened. Now to have an actual conversation, just because I have different perspective doesn’t mean you get to gang up and attack, instead it should be the opposite, let’s talk if I ask then don’t offer some insulting retort in order to please other liberals; instead let’s engage and discuss. It’s amazing how closed minded people can be in their groups, even so-called open minded liberals can gang up against those who disagree. Anyway, I hope the level of discourse can be brought up a notch and that we can treat one another, even those with differing views, with more respect…if we can’t have a civil discourse here in a public forum then where can we? It shouldn’t be a public forum only for those with liberal ideas, we should welcome all people of all ideologies (as long as it doesn’t devolve into insults) to discuss issues like the ACA aka Obamacare.

    • You’re not being belittled here because you voted for Trump, are right wing, or have a name at the end of the alphabet.

      You’ve been belittled because you had the misfortune of representing everything that’s wrong with discourse on public policy currently, which was the point of the post. A disinterest in learning basic facts of an issue before engaging. That’s not a Republican thing. It’s not a Democratic thing (as the Onion link pointed out, if you clicked on it). It’s a lazy thing. And it’s without question the greatest threat to democracy. A discussion about public policy without basic knowledge about the public policy in question is not a serious discussion. That’s why you’re not getting a lot of sympathy. And THAT’S the point of today’s post and conflicting polls.

      There’s nothing wrong with having an informed position that differs from someone else’s informed opinion. There is somethign wrong with having an uninformed opinion, more so when the ignorance is willful .

      So, it’s not a question of disagreeing with you because you didn’t state a position with which to disagree. A serious discussion by definition is an informed one and it’s illogical to assert knowledge while at the same time asserting — let alone defending — a lack of knowledge.

      You’re not a victim, try as you might to portray yourself as one. You’re also not alone. The country is full of people who aren’t interested in anything other than what people are telling them to think.

      Take personal responsibility for your plight. You went six years without, apparently, putting any work in to a relatively simply question that you’ve spent most of the afternoon demanding others’ find for you.

      Think critically. And ask yourself why you waited so long to try to get the answer to your question. If your conclusion is, “because people wouldn’t do the work for me,” then think some more.

      • Will

        I asked a serious question, hoping someone would provide a serious answer.

        I was belittled because of my views, you’ve answered plenty of questions for liberals without a second thought…with a person who holds more moderate views you attacked.

        Think critically, if people only think about the benefits and can’t even imagine the costs then we’re not having an open discussion.

        It was a more rhetorical question to see if anyone even thinks about the who pays for those subsidies…If they can imagine where they come from and that higher premiums, higher drug prices and higher medical device costs might be the price we are paying for the subsidies.

        • Jerry

          It’s not your politics that are the problem. It’s your tone and the way you act on this forum.

          • Will

            I’ll be sure to turn the tone down on my keyboard.

        • //It was a more rhetorical question to see if anyone even thinks about the who pays for those subsidies.

          Downthread:

          // I was literally asking to be informed, I’m at work writing code…I can’t do in depth research on the ACA and how or if it was funded..

        • KTFoley

          If you intend to have a respectful conversation, then enter it as a respectful participant: share the information you have absorbed so far, and pose a question from that.

          If instead you ask rhetorical questions to “see if anyone even thinks …”, then take a lesson from how quickly that disingenuous behavior got noticed.

          You simultaneously insisted that the topic was too complex to understand AND that people here should present it so you can understand it. Own it.

          You tried to say that it’s Bob’s job to synthesize the information for you, and then refused to engage with what he did pull up. Own it.

          You introduced the notion that a position on the political spectrum explains how you’re being treated and also what’s wrong with everyone else on this thread. Own it.

          That’s not ideology, it’s plain old disrespectful behavior on your part. Occam’s razor is in effect here: you’re getting dismissive responses because you strove to elicit them, not because of your political views.

          • Will

            Yep, that’s due to your political bias right there…I’m not going to sugar coat things because I’m speaking to a liberal echo chamber where anything is offensive if it challenges your worldview. THIS is the liberal bubble where people all speak to each other not understanding or hearing anything outside of their own like minded group.

          • Now you’re just trolling andu spraying the room. Don’t do that. It doesn’t fool anyone.

          • Will

            Truth is hard to hear sometimes, outside of Gary F this is a liberal echo chamber…that’s extremely hard to deny. But that’s fine I can stop. No one is able to take one moment for self-reflection so at this point it’s more of a direct attack on me because I have different political opinion from everyone else here.

          • Alright , Will. why don’t you take a little time out and when you’re ready to respect the room and offer some value to discourse, come back to us.

            You’re on hour #10 of your campaign and you’ve still not offered a single comment related to the point of the post, preferring instead to troll the discussion.

            Take 24 hours to think about way you can offer value and perspective to topics.

  • kevins

    Will. I for one value your opinions and ideas because you are articulate and thoughtful. I do dislike it however when you imply bias when someone disagrees with you, and use the term “liberal” generously but indiscriminately to set one against another, assuming that bias only goes one way. If, for example, I asserted that Mr. Trump is a liar, you could counter argue easily, noting times when he has told the truth or stated fact. I would agree with you, but would you agree with me?

  • dukepowell

    Details do matter when it comes to discussion of our health care programs. That is why it was so disappointing to hear that the then Speaker of the House quip, “You have to pass the bill to see what’s in it,” during the passage of the ACA.

    Another detail that mattered then but got little discussion was the definition of who the uninsured really were. U.S. Census data and a Minnesota Dept of Health 2006 report both came to the same conclusion – 75% of the uninsured nationally and in Minnesota fell into one of three categories:

    1. Illegal aliens who are ineligible for enrollment in our government plans
    2. Those who could afford insurance but refused to buy it.
    3. Those eligible to sign up for a government program like Medicaid but neglected to
    do so.

    Wouldn’t it have been a lot cheaper (and much less disruptive today) to have just given the remaining 25% a gold-plated “Cadillac” health plan?

    • Just to be clear, she didn’t say that to lawmakers during the debate/discussion.

      • dukepowell

        Frankly, while enjoying the proponent’s discomfiture after this was said, I always thought I understood why she said it.

        Health care policy and programs are very, very deep weeds. It is not surprising that Pelosi, when pressed, couldn’t get into details. Very few people can or be expected to.

    • king harvest

      Details do matter!
      82% of the uninsured at that time were citizens.
      87% were unable to afford it/not offered at work.
      71 million on Medicaid, 6 million eligible but not enrolled.
      Cheaper just to do single payer