With implementation of the core provisions of the Affordable Care Act (ACA) finally upon us, pollsters have been busy soliciting current public opinion of the law, as the fanatical Republican Party continues its quixotic mission to destroy it. Ludicrous though it is to subject such a complex and multi-dimensional law to an up-or-down, binary referendum, the American people continue to "disapprove" of the ACA by a modest margin; this polling dynamic has been relatively consistent since 2010.
Far more interesting than the fatuous and oversimplified "approve or disapprove" question, though, is the more concrete polling data that reveals public perception of what is, and is not, actually contained in the reform package. Surely, before subjectivity even enters the equation, there must be a coherent, objective understanding of the law itself. Any negative - or positive - opinion about the ACA that is premised on a thorough lack of knowledge of the law's actual substance may, of course, be dismissed as essentially meaningless.
The genuinely shocking degree of public ignorance regarding the ACA that has been revealed by this slew of recent polls, more than three years after the law was signed by President Obama, should not be something to which we respond by simply shaking our heads and lamenting that the American people are so "disengaged." No, this ought to be viewed as a very serious political crisis and a grave threat to whatever semblance of health our badly disfigured democratic culture still maintains.
The public is dramatically uninformed, and misinformed, about the law. A recent Wall Street Journal/NBC News poll found that 76 percent of people currently lacking health insurance "didn't understand the law and how it would affect them." Just 51 percent of respondents were aware of the existence of the exchanges that launched; 49 percent were aware of the subsidies available for low-income people.
A Kaiser Family Foundation poll asked respondents about the exchanges and even provided several choices of launch dates: October 1; Other date in 2013; Date in 2014; Other; or Don't know/Refused.
Given the structure of the question, the results are astonishing: 64 percent of the public refused to even venture a guess, with just 15 percent answering correctly that the exchanges were set to launch on October 1. Among the uninsured, the bloc of people the new marketplaces are designed to help, it was even more striking: 74 percent did not know, and just 12 percent answered October 1. The poll was taken less than two weeks before the exchanges were set to go live.
As the years pass, there is virtually no evidence that accurate information about the ACA is successfully penetrating the public consciousness: Kaiser concluded "the public's level of awareness about exactly which provisions are - and are not - included in the health care law has generally not increased in the three and a half years since the law was passed."
If anything, the trend is going in the opposite direction, with the public having actually become less informed with time: Levels of awareness of other key provisions have either remained stable or declined over time.
For example, the shares who are aware of the law's subsidies, Medicaid expansion, and closing of the Medicare prescription drug "doughnut hole" have all decreased since right after the law's passage in 2010 (by 12 percentage points, 6 percentage points, and 7 percentage points, respectively). This leaves substantial shares unaware that the law includes each of these key provisions.
The public is not just uninformed, but also misinformed, about the most consequential social reform signed into law in many decades. More than half of Americans reported to Kaiser that a public option was, in fact, included in the ACA. More than 40 percent believe that the law provides subsidies to undocumented immigrants to purchase health insurance, establishes something very closely resembling a death panel, and cuts benefits for seniors currently enrolled in Medicare (43 percent, 42 percent and 42 percent, respectively).
These statistics simply preclude any kind of serious discussion about the law's "popularity" or lack thereof. It would be no more absurd to approach a group of 12-year-olds and inquire about their views of the conflict in Syria. And that analogy actually understates the case, because the 12-year-olds in question could at least respond honestly and instinctively, without having been helplessly subjected to four years of relentless and fantastically dishonest propaganda regarding the policy on which they are opining.
It's worth remembering that these are the central provisions of the ACA. If so many citizens are unaware of the core tenets of the law, including those which are specifically geared to benefit them and have generated an enormous amount of media attention, it stands to reason that the dozens of smaller-scale programs and reforms contained within the law are unknown to virtually everyone except the most dedicated policy wonks.
What percentage of the public, for example, is aware of the provisions that
- Prohibit insurance companies from imposing annual dollar limits on coverage, the cause of so many bankruptcies among American families?
- The 85 percent Medical Loss Ratio provision (requiring that percentage of premiums be spent on actual care rather than administration) that has already resulted in billions of dollars in rebates?
- The expansion of free preventive care?
- The development of Accountable Care Organizations, Electronic Health Records, and bundled payments, to finally address the rampant structural dysfunction in health care?
- The myriad cost control mechanisms?
Our health care system has long been an unconscionable international scandal, with terribly high costs and tens of millions of citizens lacking access. Democratic control of the White House and both chambers of Congress presented a unique opportunity to finally address the problem. The long and often grotesque legislative process eventually produced a law that, while further postponing the country's eventual and inevitable embrace of some sort of single-payer system, contained a number of exceptionally propitious ideas and long overdue reforms. It's a clear and undeniable step forward for health care in this country. Indeed, it's virtually impossible to coherently argue - even for those of us who support single payer - that the ACA, in its totality, is not exceedingly preferable to what had been the status quo, at least from a utilitarian perspective.
How then, can the public be so consistently antipathetic about the law, given that it merely removes some of the most excessive brutality from the American system of health care, while making a multifaceted effort to both expand access and control costs?
It's been theorized that the broad aversion stems from the fact that around 85 percent of American adults already have health insurance, are reasonably satisfied with it, and are therefore anxious about any sweeping overhauls of a system that is, as they see it, working tolerably well for them.
To be sure, there is some truth to this. For all the systemic problems with health care in this country, most Americans families do have health insurance, and, within this group, many families are facing other, often quite dire economic challenges. Understandably, they might have wanted federal policymaking to be focused elsewhere in 2009 and 2010 (on the foreclosure crisis, for example).
Less Than Half Know About Closing "Doughnut Hole"
Of course, this explanation fails to account for the lack of support for the numerous cost-control mechanisms in the ACA, which, if effective, will benefit everyone, not just the currently uninsured; or, for example, the closing of the dreaded Medicare "doughnut hole," something that benefits all seniors - and something that, to this day, less than half of Americans know is included in the law.
Nevertheless, due to various social, political and economic realities, not everyone will support sweeping social legislation, and this is unavoidable. The one strain of opposition - or indifference - to the ACA that is not unavoidable, though, and on which the progressive movement should focus, is that which is based on pure lack of information.
Thomas Jefferson once said that, "though the people may acquiesce, they cannot approve what they do not understand." This is especially true when what they are being asked to approve is something as complicated and far-reaching as the ACA.
Widespread civic ignorance is intrinsically beneficial to reactionaries and anathema to progressive politics. The lack of basic, sensible policy knowledge among the general public is hardly limited to the arena of health care.
It's no great secret which political actors are responsible for this democratic crisis. Our national political media is led by people like Chuck Todd, who, in a moment of breathtaking honesty, openly confessed that he does not view the dissemination of accurate and factual information as part of his job description as a journalist.
The Republican Party, as well as what David Frum refers to as the "conservative entertainment complex," combine to operate an extremely powerful, 24/7 propaganda machine, specifically designed to misinform Americans and spread an inherent distrust of any progressive policy ideas.
Indeed, going down the line of policy realms on which the public is ignorant, in virtually every instance, it benefits the ultra-right-wing. Indifference to climate change is rampant. The public judges levels of income inequality in the United States to be much less dramatic than they are in reality. Support for the extraordinarily idiotic "balanced budget amendment" is overwhelming. In all of these cases, wildly uninformed public opinion serves to provide tactical support to Republicans and aid them in their vicious ideological crusades.
There is cause for optimism about the future of progressive politics in the US Demographic realities, seismic shifts in public attitudes on social issues and a lasting feeling of abomination at the unhinged lunacy of the Bush years are just some of the reasons to feel hopeful about our political direction over the long term.
The reality of a massively uninformed public, though, is simply incongruous with this vision of a progressive future. So long as colossal swaths of the population are in the dark about the major policy issues of our time, the political scene will be ripe for ultra-right-wing demagogues and faux-populists to thwart progress at every turn. Progressives have to confront the fact that, technically, Republicans are right when they say that the ACA is "unpopular" or that "the American people" want a balanced budget amendment. This has to change. The vibrancy and legitimacy of our democratic culture depend on it.