What Does One Year Mean?

March 28, 2011

Well, the polling data are in! And, the results: people are just as confused about health reform today as they were when it passed a year ago; maybe, more so. In fact, 22 percent of those polled by the Kaiser Family Foundation believe health care reform has already been repealed and another 26 percent aren’t sure.

How could it be that one year after health reform was passed and dozens of provisions have already gone into effect that 48 percent aren’t sure if it has been repealed and 53 percent are still confused about what it is (the exact same percentage as the day the Affordable Care Act was passed)?

Democrats believed that once they had passed health reform, people would like it. They knew there would be some difficulty protecting the law from attack (since the big provisions don’t go into effect until 2014), so they front-loaded the Act with provisions they thought would be very popular: beginning to close the “donut hole” in Medicare drug coverage (including $250 checks for seniors, summer 2010); eliminating pre-existing condition clauses for children; allowing young adults to stay on their parent’s health plans even if they are not dependents or in school; ending lifetime limits on benefits, and establishing high risk pools for those who have had a hard time finding coverage.

And, indeed, people like all these things. But, polling data also show that even though people like these things, they don’t associate them with health reform.

How could this be and what does it portend for the future?

One theory is that the administration and the health reform advocates have done a poor job of communicating about the ACA, and that is certainly true.

But, another theory might be that the very attributes that enabled health reform to be passed in the first place made it a challenge to communicate and embrace.

The reality is that the Affordable Care Act is a complex piece of legislation and a compromise from the beginning: it embraces all sorts of ideas without fundamentally altering the existing, confusing, confounding structure of health care in this country.

While there are some things about American health care that will simplify over time, the truth is that the ACA keeps intact the public/private mix of health insurance, the many different health plans, and the multiplicity of avenues into the system.

Indeed, diagrams put forward by various opponents of health reform look like Rube Goldberg designs precisely because the ACA builds on the current non-system, filling in gaps rather than creating something entirely new. The political watchword in the 2008 campaign was to fix health care with a “uniquely American approach,” and the American approach to health care was already as complicated – and sometimes, convoluted – as anything Rube Goldberg could have imagined.

So, yes, communication about the Act has been poor. But when it is the goal of some to confuse and mislead about something that is already complex, it is not surprising that most Americans are as confused today as they were when health reform was passed.

Does the confusion mean that health reform has been ineffective or is doomed to be repealed?

No, and perhaps at least in part, for the same reasons that it is so confusing to so many. That is, undoing something as fragmented and decentralized as the American approach to health care is hard to do! Much has been put in motion over the past year, and more will be done in the year ahead. And with each change made by providers and states and health plans and consumers to implement provisions of the Act, forward momentum builds and becomes harder and harder to stop.

So, what is so significant about the one year anniversary? Maybe, nothing. But just maybe, the passage of time – in and of itself – is what’s significant.

Of course…only time will tell.