The ACA: Where You Sit Defines Your View

Whether attributed to Nelson Mandela, George Schultz or simply an old adage, the quote "Where you stand depends on where you sit" has powerful meaning when it comes to the Affordable Care Act (ACA) and the affordability of health care.

This sentiment was brought home in a recent survey of health care opinion leaders and health care providers conducted by APCO Insight.

Support for the Affordable Care Act

It is well known that public support for the ACA is split, particularly among Republicans and Democrats. As a recent survey pointed out, this same split holds when you ask health care policymakers and providers about their thoughts on the ACA.

While mean support for the law is just above average on a scale of 0-10 (5.6), where 10 indicates the highest level, ACA support among opinion leaders reflects public sentiment when party affiliation is taken into account. Democrats (7.9) and Independents (6.1) express levels of support above the mean and Republicans (4.1) are well below.

Interestingly, in the category of strongly support (8-10), Democrats express a level of 67%, while Republicans who strongly oppose (0-2) are only 51% of the sample. Perhaps, at least among opinion leaders, this indicates Democrats more strongly support the law than Republicans oppose it.

Besides party affiliation, age, gender and profession indicates level of support or opposition to the law. Of those who gave the highest level (8-10) of support to the law, women outpaced men 44% to 31%; and among age, those 18-34 led with 62%, well ahead of all other age categories (35-49: 46%, 50-64: 35%, 65+: 44%).

And when looking at professions, nurses have a higher level of support (6.5) versus doctors (4.7) and pharmacists (4.4). There is also a distinct difference among practice - those in general practice are much more supportive (5.9) than those in specialty fields (4.3).

While this study was done on only a small sample of the population, these results point to a simple hypothesis that because nurses and general practitioners come in contact more often with under and uninsured, their level of support can be understood, as they have the best understanding of the value of insurance in gaining access to health care.

The gender differential is also interesting based on a similar hypothesis; women make most of the health decisions in a family. Therefore, their higher support than men is understood - women have much more practical interactions with the health care system and thus a greater appreciation of the ability to access care that the ACA provides.

And thinking about accessing care, support differs little among those with private insurance (6.5) versus those with government insurance (6.2). This also supports the hypothesis that interaction with a health care system is better than no interaction at all.

The gender and age gap is also a strong determinant of support for the law. When asked how they would like to change the law, 88% of men said repeal the law while only 41% of women answered as such. Among age groups, results show older Americans are much more in favor of repealing the law than their younger counterparts. With lower premiums, low out-of-pocket costs, low prescription costs and good health, it is no surprise that the younger generation is the only group not to support repeal, especially compared to those over 50, who have the highest premiums and out-of-pockets, and have the most health issues.

Affordability

Questions surrounding affordability are also important to the current public discussion about our health insurance system. While affordability is a priority among all respondents, there is no specific cost identified as most important to address to make insurance more affordable. When asked what affordability means to them, they responded fairly evenly. Sixty-seven percent (67%) responded that lower out-of-pocket health care costs were important, while 70% responded lower prescription costs were and 73% said lower insurance premiums.

This sentiment was relatively unchanged across stakeholders. Seventy-four percent (74%) of health care providers (HCPs) responded that lower out-of-pocket health care costs were important to affordability while 60% of opinion leaders (OLs) also identified lower out-of-pocket health care costs (this differential may be due to provider's closer proximity to billing issues). On the question of lower prescription drug costs 70% of HCPs responded they were important while nearly the identical percentage of opinion leaders agreed at 71%. On the importance of insurance premiums to affordability the percentage of health care providers who agreed was 76% while 70% of opinion leaders also identified lower insurance premiums.

However, when you break down respondents according to age, a significant gap is revealed. The younger the group the less lower out-of-pocket costs are a priority. Among those 18-34 it was 38%; among the 35-49 age group it was 54%, and then it jumps considerably among older age groups. For those 50-64 it is 85% and for those Medicare eligible (65+) it is 80%.

However, when it comes to lower prescription costs and lower premiums, the 18-34 age group has similar responses as the other groups. For those 18 to 34, 72% thought lower prescription costs was a key to affordability. Sixty-eight percent also thought lower premiums were important. The numbers were nearly identical for the other age groups: 35-49; 67% and 70%; 50-64; 88% and 81% and 64 plus the numbers were 64% and 67%.

Again, a simple observation may explain this: younger people, while they do pay premiums and get the occasional prescription, they are less likely to face serious out-of-pocket costs like hospital stays, tests etc. All of these costs increase as you age, but when you hit 65, Medicare kicks in and your worry over them drops as these issues are less of a problem (though if you have traditional Medicare, your out-of-pockets can still be high, which may explain why they also score high on lower out-of-pocket costs).

Conclusion

When describing their opposition to the Affordable Care Act, Republican politicians make fuzzy and unproven claims about its impact on the economy. But they are very clear that their ideas will lower costs - though they do resort to vagueness in describing details over exactly how they would accomplish this goal. In fact, Republicans have yet to produce legislation or even a detailed plan given the challenge of matching their rhetoric to reality. So at first glance, given the result of this survey, this strategy makes sense.

However, when you get beyond the surface, the survey results paint more nuanced and complicated feelings about the law; feelings that the GOP positioning may run into if they find themselves in a position to make major changes to or even repeal the ACA. With support among young people and women higher than the average and the GOP's existing issues with losing younger and minority voters from the electorate, repealing the ACA may prove at best a short-term victory but a long-term loss. For Democrats the takeaway points to a stronger hand in the future as the results suggest a strategy of taking steps to "fix" the law. Now all we have to do is wait to see who's in charge come this November.

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This piece originally was published in The Morning Consult on May 12, 2016.