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Glenn D. Braunstein, M.D. Headshot

Donkeys, Elephants, Politics and Politicians: Is Logic and Self-Interest Lost Among the Foes of Health Care Law?

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The geographic and demographic disconnect between those who need health care reform and those who oppose it really is astounding. It seems that the people and places that most need better health care access and healthier outcomes are the very ones fighting tooth and nail to stop reform.

It's not a simple red state-blue state divide and most recent polling on health care reform delves into national opinions, not state-by-state attitudes. But some polling and surveys, along with the declarations of states' elected officials, provide a picture of a citizenry so confused about the nitty-gritty of the health reform law that many people may be rallying against their own best interests.

As the national political conventions get under way and the post-Labor Day push starts for the presidential race, Americans may be concerned about the need for health care reform — but probably not as much as they should be. Some 49 percent of Americans think the Democrats will do a better job of dealing with health care; only 35 percent believe Republicans will do a better job, according to a March 2012 poll by the Pew Research Center for the People and the Press. Regardless of which party people believe will do a better job, the same poll found that only 5 percent of Americans consider health care costs and accessibility the top problem the country faces, far behind those concerned about jobs, unemployment and the economy.

A Kaiser Family Foundation poll in July 2012, shortly after the Supreme Court upheld the law, found support of health care reform slipping but still close: 44 percent say they oppose the Affordable Care Act, while 38 percent support it.

But if interviewers get into the nuts and bolts of the reform law, respondents show higher levels of support. Nearly half, or 48 percent, of those asked think that those with pre-existing conditions will be better off under the new law.

In general, those surveyed seem to believe that the law will benefit others, not them. Again, about half, or 49 percent, believe that the uninsured will be better off under the law; but only 30 percent believe middle-class Americans will be better off. Only a quarter of those questioned expect to be better off themselves under the health reform law.

It Could Happen to You

So here is one disconnect. Half of Americans believe people with pre-existing conditions will be better off, but people seem to think those with such conditions (diabetes, high blood pressure, heart disease, asthma, arthritis) are some invisible group of "others." What they may not know is this: Up to half of all Americans are walking around with what insurers deem to be pre-existing conditions that could some day put them at risk of losing health coverage just when they most need it. That figure jumps to up to 86 percent of people between ages 55 and 64 — old enough to have developed chronic conditions but not yet old enough to qualify for the government program, Medicare. And let's not forget that any of the rest of us who are healthy now could one day be diagnosed with a disease or condition, putting us in the "pre-existing condition" no-man's land of present-day private health insurance. In fact, government figures estimate that 15 percent to 30 percent of those younger than 65 who are in good health now will develop a pre-existing condition within the next eight years.

Under the system we had — and which still is in effect until all the provisions of health reform take effect in 2014 — health insurers could deny coverage to individuals with asthma or high cholesterol or to a cancer survivor; or insurers could charge premiums unaffordable to all but the wealthy; or they could offer coverage that excludes the very care a person needs, such as denying anything cardiac related to those with high blood pressure.

Elected Officials Responses

When Families USA, an organization that works to promote health care for all, examined the effect that this part of the new law would have on a few states, researchers found that 1 million South Carolinians have pre-existing conditions.

Yet a Republican senator from South Carolina, Jim DeMint, joined two Republican representatives in sending a letter to all 50 governors urging them to oppose implementation of key components of the health reform law.

Some 3.8 million Floridians with pre-existing conditions now can expect protection from insurance denials in the future. Yet, Rick Scott, the governor of Florida, is one of 15 governors, 14 of them Republicans, who either say they oppose the plan or are likely to reject parts of the law.

Healthy vs. Unhealthy States

Health statistics vary widely by state, with Vermont residents rated as the healthiest in the nation, according to rankings by United Health Foundation, followed by New Hampshire, Connecticut, Hawaii and Massachusetts. (California ranks No. 24.) Mississippi has the poorest health in the nation, according to the survey, and barely above it, coming in at No. 49, is Louisiana. And yet Louisiana's governor, Bobby Jindal, is one of the governors answering with a resounding "no" to the health care law's offer of assistance through increased Medicaid funding to cover more uninsured people.

Rick Perry, the Texas governor and former presidential candidate, is on record as calling for repeal of the health care law — though his state ranks No. 44 in the overall health of its population; the Lone Star state has the highest number of uninsured residents; and it has among the most premature deaths due to lack of health insurance in the country.

Pink Slips

It seems that Americans who are employed and have health insurance have a hard time imagining that their circumstance could change. They may not be considering that the 44.6 percent of Americans (down from 45.8 percent in 2010) who now have employer-based health insurance — while safe from pre-existing condition exclusion as long as they hold their jobs — are a mere pink slip away from becoming uninsured themselves, without the protection of the new health care law.

And the number of people who have employer-based health insurance has been slipping since 2008. The recession and the increase in unemployment may be partly to blame. But even people who have held onto their jobs increasingly are less likely to be covered by their employer. That's no doubt due to the rising cost of health insurance. Some workers can no longer afford their share of the cost; some employers no longer can afford to offer health insurance to their workforce.

Seniors and Medicare

There is a long-standing joke among health policy wonks: An audience made up of people older than 65 listens to a presentation on health reform. One senior stands up and says, "I don't want the government messing with my Medicare." Well, the government is their Medicare — and without it, many older Americans would be in a world of hurt.

Maybe some older Americans don't understand that their beloved Medicare is a government program and that health reform seeks to provide at least some of its same health protections to younger people. Again, it makes me scratch my head and wonder when I see that the largest well of opposition to the health care law comes from seniors. In June 2010, the Gallup organization asked people whether the new health reform law was good or bad. Among those aged 18 to 29, 57 percent thought the new law was good. Among those aged 30 to 64, about half thought the law was good. But only 36 percent of those 65 and older thought the law — which seeks to cover almost all Americans — was good.



It could be that young people like the law because they were among the first affected by a much-supported provision: It allows adult children to stay on their parents' health insurance policies until age 26.

But what of the seniors who don't like the health care law? Surely, it can't be that those older than 65, safely and for the rest of their lives covered by Medicare, don't want the same health care protections for their children and grandchildren? Can it be that seniors have an "I've got mine, now pull up the ladder" attitude? Naw, not gamma and gampa, bubby and zadie. When the National Council on Aging explored the attitudes of seniors on health reform, they didn't find the selfishness that the Gallup poll numbers might indicate. Rather, they found ignorance and fear of a complicated law.

Researchers with the council found that only 9 percent of those 65 and older said they were very familiar with the law. When interviewers probed further, they found that seniors know less than they think they do about it. Even those who described themselves as familiar or very familiar with the law answered correctly on just 65 percent of answers when asked 12 factual questions about the law (in my high school days, a correct percentage answer like that earned you a D or maybe an F).

Some of seniors' misconceptions could, indeed, account for their fear about the law. Only 22 percent of them understood that the new law would not cut their Medicare benefits; only 14 percent knew the law is projected to reduce the deficit; only a quarter of them knew that the law is expected to extend the solvency of Medicare; only a third knew the law, for the first time, entitled them to a yearly wellness visit; and less than half knew that the law gradually closes the Medicare prescription drug gap.

Seniors may be absolved of selfishness — though we need as a country to work on educating them about the Medicare entitlement they love so well. But we can't let politicians off the hook so readily. Gov. Perry — who talks so zealously about slashing "entitlements" and reducing government spending, even as so many in his state go uninsured and have such poor health outcomes — collects a pension of more than $92,000, even as he continues to collect his salary of $150,000. He has government-paid health insurance and will continue to be covered even when he really retires.

And what about those senators and representatives so reluctant to ensure that all of us have good health insurance that won't be yanked when we really need it? They have never once voted to reduce their own health benefits, and they, too, will be covered for life.

So, my plea to the politicians is to accept that the Accountable Care Act is law and its major provisions have been found to be constitutional. Therefore, let's stop bickering over it. Let's work together to get it implemented for the benefit of the citizens whom they were elected to represent and help.