Will “Repeal and Replace” Really Result in “Repeal and Confuse”?

The Republicans pledged to “repeal and replace” health reform, but some political observers are now concerned that the result could be little more than “repeal and confuse.”

The new Republican-controlled House is expected to easily vote to repeal the Patient Protection and Affordable Care Act. The vote, originally set for last week, was delayed as the House suspended business after the shooting of Rep. Giffords in Arizona. The outcome, however, is not expected to change because of the delay.

This initial quick vote is designed only to repeal the legislation, and Republican leaders will not immediately offer a replacement. Instead, House Republican leaders said they will hold hearings to consider their own health policy solutions before offering anything definitive on the floor. So for the moment, rather than “replace” President Barack Obama’s signature legislation, House Republicans will simply offer a two page  bill, called the “To repeal the job-killing health care law and health care-related provisions in the Health Care and Education Reconciliation Act of 2010.” Yes, that’s its name, about as euphonious as PPACA.

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This post is the first in the Health Policy Forum’s new series of original reporting. Published on Tuesdays, our News & Analysis features will cover topics in the politics of health policy and reform, health care innovation, and wellness and prevention. We will also feature occasional news stories from Kaiser Health News.

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The question is, or at least one big question is, do the American people remember enough about eighth grade civics to know that the House vote may have political resonance, but no immediate policy impact? The House on its own cannot repeal legislation, and repeal is almost certain to fail in the Democratic-controlled Senate. And even if it did get through the Senate—which no one can really envision—President Obama would veto it.

While the political victory for conservatives from this symbolic vote may be clear, the practical impacts on the rest of the population may actually be very confusing. Savvy fortune 500 companies will understand where policy still lies, but the less sophisticated or well informed may struggle to understand the real status quo. Tiny businesses may not understand what tax credits are available to them, and people who have been ill may not realize high-risk pools are still there if they need them. And will people who want to get their kids covered by insurance still understand they can do so?

This potential for confusion goes on and on. Mollyann Brodie, Ph.D., director of the Kaiser Family Foundation’s Public Opinion and Survey Research, puts the risk quite plainly. “The confusion factor,” she says, “is extreme.”

At the same time, the potential for confusion co-exists with an already generally poor understanding about the legislation’s actual provisions. According to KFF research, roughly four in ten Americans—depending on how the question is asked—admit to not understanding the bill. Other Americans may be equally confused, even if they won’t admit it to pollsters. Some may not even realize that they are confused.

Opinions of the legislation are equally clear and fixed. Survey data from Kaiser and other polls show that Republicans don’t like the law by significant margins. Democrats by-and-large do like the law, although they may not love it. Independents are split, according to the conventional wisdom, but Brodie suggests this is somewhat more complex in reality, as independents who lean Republican dislike it, not surprisingly, while those who lean Democratic tend to like it, and only the truly independent independents are split.

This state of play has been fairly steady for many months despite the millions of dollars and huge amounts of political energy both sides have used to sway public opinion. Real understanding and opinion shift may not come until people start to experience the bulk of health care changes when the law takes full effect, but that doesn’t start until 2014.

Some provisions kick in earlier, but it’s not clear whether people will really get it—or are only further confused by it. Or they may simply blame everything that goes wrong in the health care system or their own insurance on “ObamaCare”—even if their problems arise not from health reform but the status quo. But if between now and the 2012 elections people become convinced that reform is the cause of their medication price increase, or a crowded ER waiting room, or a doctor who tells them they don’t need an annual mammogram or PSA test quite yet, confusion could have very clear political consequences.

For instance, both polling data and all sorts of anecdotal media reports show that people blame rising insurance premiums on “ObamaCare.” Yet insurance premiums have gone up year after year, decade after decade (with a brief respite in the mid-1990s during the HMO heyday). Those relentless increases were a big part of why health reform was enacted in the first place.

Some confusion is of course inevitable. The new law is complicated, with numerous interlocking pieces. It is impossible with complete confidence to predict how everything is going to turn out—which logical-sounding innovations will fall flat, and which long-shot ideas will play out brilliantly. Half the time, as Kaiser’s Brodie points out, the debate isn’t really even about health care, but instead about government size, government spending, and government’s fundamental role in our lives.

Part of the challenge, of course, is the sheer magnitude of the complexity of health care issues themselves, which are impossible to explain in simple, easy-to-grasp sentences.

“There’s no one liner you can point to that will make all of health reform and health care economics make simple sense to the average person,” explains Brodie. Instead, those in the policy sphere have to try to connect the dots, she says. To most Americans, “bending the cost curve” is not an easy-to-grasp concept, and trying to persuade people that less care can often be higher quality care also sounds vaguely unAmerican.

“That’s the biggest communication challenge—how do you connect those dots? That has been the ongoing challenge,” she said.

On top of the confusion are a lot of internal contradictions about health reform and public opinion. In aggregate, large numbers of Americans say they want to repeal the law or parts of the law. But when the Kaiser pollsters delved into whether people like specific elements of the law, most components are extremely popular, even with some of the people who say they want to throw the whole thing out.

For example, more than 70 percent of the public wants to keep tax credits for small businesses, help low-income people buy insurance, gradually fill the Medicare doughnut hole, and require insurers to cover people with preexisting conditions. More than half also approve of having wealthier Americans pay higher Medicare payroll taxes. The exception to this love-the pieces, hate-the-whole contradiction is the individual mandate, which is unpopular and probably the major element of the Patient Protection and Affordable Care Act that is at most risk, politically as well as judicially.

Clearly, the political discourse at the moment is a collision between dug-in opinions, contradictions, and confusion. And the likely legislative outcome? In the short term, between now and 2012, probably not very much will change, according to most political analysts as well as health policy experts.

As former Medicare chief Gail Wilensky put it at a recent Washington panel discussion on health reform, with a divided government in a polarized capital, “[I]t’s going to be tough to get a sense of cooperation and we need to be realistic about that.” The most likely event is inaction, she noted.

And that bit of a legislative breather—time to get to work on the many tasks and initiatives within the legislation—may be just what the doctors ordered.

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Contributing Writer Joanne Kenen writes monthly news features for the Health Policy Forum discussing health policy innovation and “what works” in our health care system, as well as the politics of health policy and reform. As a leading nonprofit health care research and consulting institute dedicated to improving human health, Altarum encourages open discussion and debate about the many challenges in health care today. All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Altarum is a nonprofit, nonpartisan organization. No posting should be considered an endorsement by Altarum of individual candidates, political parties, opinions, or policy positions. Read more.