It’s Groundhog Day all over again. Yet another president is preparing to tackle America’s most frustrating domestic public policy challenge. Healthcare is going to be a long hard slog for Republicans and every bit as unpleasant as it has been for Bill and Hillary Clinton and Barack Obama. At the end of a long and frustrating road, Republicans will wish they took an early deal with a few small tinkers and a declaration of victory.
There should be a presidential transition corollary to the Pottery Barn rule, “you break it you buy it,” that explains how ownership of a thorny problem transfers to the new president even if he campaigned for a year criticizing current policies. Perhaps, “To the victor goes the spoiled.” Trump and all of the rest of the Republican Party have made it clear they plan to repeal the Affordable Care Act (ACA aka Obamacare). When they do, whether they replace it or not, they will own the American health care system and all of its bureaucracy, frustrations, errors, denials, and rising prices.
But first, there will be a legislative process that will feel worse to Republican lawmakers than a visit to the proctologist. We have lived through this before with the roles reversed. Two Democratic Presidents have entered office with congressional majorities in both houses, believing there was broad popular support for reform. Bill and Hillary Clinton saw public support fade as the process dragged on and opposition mounted. Barack Obama was successful in passing his reform law but he too saw public opinion turn negative, and now, Republicans in full control of the White House and Congress believe they have a popular mandate to rip out Obamacare “root and branch.”
Here is a summary of public opinion on health care issues for all of 2017:
First pollsters will tell us America strongly favors reform of Obamacare.
Then we will learn there are some reforms that are particularly popular, while other specific reforms will be opposed by most voters.
Eventually the pattern will be clear – everyone wants more for less for their family, their business, or their industry. No one wants to see others lose the coverage they now have, but no one is willing to pay meaningfully more for someone else’s coverage.
As the opposition bores in on the proposals’ weaknesses support for reform will decline.
Whether Obamacare is repealed or not, and whether it is replaced or not, Republicans will own the American health care system and all of its frustrations.
How do we know this will play out in this way? It’s easy because we have seen this movie twice before. At the start, everyone wants reform that lowers costs or offers more coverage. By the end majorities will oppose reform that involves trade-offs.
Back when the Obama Administration was pondering introducing legislation in March of 2009 we wrote an article urging them to think twice. The article compared polling in 2009 to similar questions asked in 1993 and earlier, before the Clinton team began its efforts. The polling appeared to show strong support for reform in the months leading up to the introduction of the ACA in early 2009, but it was actually not quite as strong as the apparent support for reform at the start of the 1993 undertaking that eventually failed.
For example, in August of 2008 a Harris Interactive Survey found 82% of American voters favored “fundamental changes” or “a complete overhaul” to the health care system. But this was not quite as high as the 92% of American voters who favored “fundamental changes” or “a complete overhaul” to the health care system in 1991 in a survey by the same research company (then called Lou Harris and Associates) as Bill Clinton was preparing to run for President.
Both reform efforts faced the same structural challenges that were clearly visible in these early polls. As the nation reached near consensus that there was a problem, there was never any such agreement on the specific solution – and this is certainly the case today. This is why some Republicans have laughably been floating a strategy of “repeal and delay,” voting immediately to repeal Obamacare in three years’ time. This would be giving themselves until after the mid-term election to reach agreement on an alternative – a clear admission that they do not now have one.
We would not be at all surprised to see the White House threaten a veto of any Repeal and Delay bill. It would be very Trumpian to refuse to go along with a Congress that does not get its work done. If Trump can push health care reform back on Congress it is definitely in his interest to do so.
If it Ain’t Broke…
While in both the Clinton and Obama reform time periods, majorities agreed it is wrong that so many Americans are either uninsured or underinsured, their priority was on finding ways to lower their own health insurance cost. But the biggest obstacle to reform in the Clinton era and then again in the Obama era, was that most people already had health insurance that they judged to be pretty good. Even though many people told pollsters they believed there was a health care problem in America, large majorities said they were satisfied with their own coverage.
In 1993 a 77% majority told pollsters Martilla and Kiley that they were at least somewhat satisfied with their own health care coverage and in 2007 an even larger 82% expressed a similar level of satisfaction with their own insurance in a Greenberg Quinlan Rosner Poll. Despite all of the criticisms of Obamacare, any effort to change it would again be taking place in an environment where most people are satisfied with their own coverage. A November 2015 Gallup survey found 76% of the total populations rating the health care they receive as excellent or good. To the degree people are not satisfied, it is almost entirely people who feel the cost is too high.
Here we go again:
Despite the high satisfaction with health insurance coverage in their own poll, Riley Brands and Frank Newport of The Gallup Survey wrote in a November 28, 2016 Gallup Blog post, “Whatever the exact course of action that ensues once Trump and the new Congress take office, it is clear that about eight in 10 Americans favor changing the ACA significantly (43%) or replacing it altogether (37%).”
Don’t sweat the small stuff
The current story about support for health care reform reform is complicated by a lot of factors. For example, many people want to see changes because they believe Obamacare did not go far enough. But we will count on others to obsess about the details of the level of support today for repealing or reforming Obamacare. Our point is whatever the level is, we can be certain it will decline as the debate heats up. Support for reform declined for Clinton and again for Obama – and this is for structural reasons. Everyone supports reform if it will mean more care for a lower cost. As the debate goes on there will be increased emphasis on people who face higher costs or less care.
This vantage point will also save you a lot of time wading through the public opinion on the specific elements both of Obamacare and its potential replacement. Pollsters will ask scores of questions about each plank of the Affordable Care Act and each potential reform. Don’t get bogged down in the details. All of the results will follow the simple rule that vast majorities will support more care or a lower cost and vast majorities will oppose limits on care or higher costs.
So it is true that every specific element of the Affordable Care Act – including covering young adults up to 26 on their parents’ plan, setting up exchanges, and eliminating out of pocket costs for preventative services -- gets strong popular support (even from Republicans) except the mandate requiring individuals to purchase a plan or pay a fine. During the campaign, Donald J. Trump, appealed to this realization when he suggested he could retain some elements of the ACA but repeal others.
Specifically, he mentioned maintaining the popular requirement that insurance plans cover people with pre-existing conditions, while dropping the individual mandate to sign-up. This is a politically popular suggestion until everyone realizes it is (to use a Trumpism) a stupid suggestion. If insurance companies are required to cover pre-existing conditions but people are not required to have care, everyone will wait until they get sick to start paying for coverage.
Imagine if you could skip buying car insurance but insurers were required to fix a car that had crashed without insurance to anyone who offered to start paying the same premium as a safe driver. Most people would cancel their car insurance plan tomorrow, planning to buy insurance only if they get in a wreck.
Poll readers should be especially cautious in interpreting survey questions that offer a benefit without a cost (always popular) or a cost without a benefit (always unpopular). Any serious discussion of reform involves trade-offs. Health care is expensive and the costs are rising. Premiums, co-pays, drug costs, and mandates on individuals and businesses are never going to be popular, but neither can they be eliminated through reforms. All of these -- and you can add excessive paperwork, denials of benefit letters, and a host of other frustrations -- were Obama’s problems before November 8th. Now they are all the problems owned by Trump and the Republicans.
Vermont Senator Bernie Sanders wanted to take on health care if he was elected with a plan that would have replaced the health care coverage a majority of Americans currently have and like with a taxpayer-funded and government-controlled system. “National health insurance” or “Medicare for all” always test very well in polling, unless emphasis is placed on the taxes to fund it. After this is over, many Democrats may be glad the Republicans now own the voters’ frustrations with the health care system and their frustrations with health care reform politics.