The ACA: Good policy, tough politics
Three charts may explain in part why the ACA is working as designed, improving life in America, and hurting Democrats politically.
First, Gallup's latest on the uninsured rate:
Next, an assessment of the redistributive effects of the ACA by Henry Aaron and Gary Burtless (via Bill Gardner) :
And finally, some data from Pew about white voter preferences in the last election:
See that? Democrats got the bottom segment only -- the group that benefits most immediately and directly from the ACA. Gallup's latest poll bears this out -- along with the politically charged ethnic corollaries :
While the uninsured rate has declined across nearly all key demographic groups since the Affordable Care Act went into effect a year ago, it has plunged most among blacks and lower-income Americans. The uninsured rate among blacks dropped seven points over the past year, while the rate among Americans earning less than $36,000 in annual household income dropped 6.9 points.
The Hispanic population remains a key target of the healthcare law's marketing efforts, as it continues to be the subgroup with the highest uninsured rate, at 32.4%. Still, the percentage of uninsured Hispanics is down 6.3 points since the end of 2013.
Over the long term, if Republicans don't destroy it, the ACA as it evolves will help far more than the lowest quintile of Americans -- or rather, by helping primarily the poorest at any given time, it has the potential to foster shared economic growth and improved security for all but the wealthiest.
First, if the ACA really is contributing to a long-term slowdown in the growth of US healthcare spending -- admittedly a big 'if' though the data is promising -- it could secure the nation's fiscal future. Second, in recent decades both low income and lack of health insurance are conditions that huge swaths of the U.S. population cycle through. According to the Census Bureau's Survey on Income and Program Participation (SIPP), from 2003-2007, 71% of Americans 18-64 had continuous health insurance, 6% had no coverage at all, and 23% were uninsured for part of that time (Stephen J. Rose, Rebound, 189-90). In an even shorter time frame, as John Graves and Rick Curtis noted in a Nov. 2013 Health Affairs blog post, "a study by Mathematica Policy Research found that 7.7 percent of non-elderly persons were uninsured for the entire year, while on average 15.9 percent were uninsured in a given month, and 27 percent were ever uninsured at some point during the year. That study further found that as of January 2001:
17.6 percent of this population lacked health insurance coverage. Over the 36-month reference period of the 2001 SIPP panel, roughly twice that fraction (35.0 percent) had some amount of time in which they were not covered by health insurance. How much time? Nearly 60 percent were without coverage for 12 months or more, and more than a third were uninsured for at least two of the three years. These include 4.5 percent who were uninsured the entire time.
Extend the time frame further, and an even larger percentage of the population has surely experienced periods of uninsurance.
In the short term, though, more Americans continue to tell the Kaiser Family Foundation that the ACA has hurt them than that the law has helped them:
Obviously "helped or hurt?" is viewed through a strong partisan lens, but the perception of harm is high among independents as well as Republicans (though as Dana Houle reminds me, those who self-identify as independents have shifted right in the last 10 years or so). That may be due in part to a successful five-year smear campaign, but also probably reflects the fact that employers regularly cite the ACA when announcing new or raised deductibles and co-insurance and new restrictions on coverage.
Addressing a dominant social problem with a comprehensive program that is so far meeting its ambitious goals is not helping Democrats politically. That's a harsh political reality -- but one that I think Democrats will be willing to accept... if the Supreme Court doesn't nuke the whole massive edifice.
UPDATE, 3/16/15: Last week, HHS released ACA private plan enrollment data that provided more information than previously on the income levels of ACA enrollees. In the 37 states using healthcare.gov, 68% had household income under 200% of the Federal Poverty Level (FPL). The numbers are lower in the 13 states operating their own exchanges -- both because their median household incomes are higher on average than those of the hc.gov states and because they all expanded Medicaid, which means that their QHP pool starts at 138% FPL, rather than the 100% threshold that applies in non-expansion states. In any case, the very high concentration below 200% FPL seems in sync with Aaron and Burtless' projections.