The Washington PostDemocracy Dies in Darkness

New anti-Obamacare ads conflate the exchanges with the entire health-care system

Supporters of the Affordable Care Act. (Brennan Linsley/AP)

“Obamacare has been a disaster for Ohio families. … We’re paying more for health care. A lot more. … It’s time to repeal and replace the health-care mess voted for by Senator Sherrod Brown. … Congress can start by eliminating Obamacare’s one trillion dollars in tax hikes.”

— voiceover in new radio ad by One Nation, a GOP nonprofit, released March 7

“Under Obamacare, our choices are limited and people have lost the coverage they liked.”
— voiceover in another One Nation ad

With the debate over the GOP replacement for the Affordable Care Act at full boil, a Republican nonprofit entity controlled by allies of Senate Majority Leader Mitch McConnell (R-Ky.) has launched a big ad buy to remind people what’s wrong with the ACA in the first place.

The 60-second spots target five Democrats running for reelection in 2018 and seeks to support six Republicans who face challenges or might be considered uncertain on how they would vote on a replacement bill.

But as is often the case, the language of the ads leaves a misleading impression that the problems that afflict the ACA exchanges extend to the entire insurance market. But that’s not the case. Health and Human Services Secretary Tom Price, briefing reporters in support of a House proposal on March 7, even noted: “For most Americans, they receive their health coverage through their employer. It’s about 175 million folks. Those individuals will see no significant change other than there won’t be a penalty for not purchasing coverage.” (Note: the Congressional Budget Office says the figure is 155 million.)

Let’s take a closer look.

The Facts

The ads repeatedly mix up “Obamacare” with the entire health-care system. They flatly state, “Obamacare has been a disaster for Ohio families,” or “Under Obamacare, our choices are limited and people have lost the coverage they liked.” The ads further claim: “We’re paying more for health care. A lot more.”

But premium increases mentioned in the ads have to do with the 22 million individual and small-business policies sold on the ACA exchanges or directly to consumers. That’s significantly smaller than the employment-based market — one-seventh the size.

Employers generally subsidize a large part of the monthly premium for their workers. The ACA was designed to replicate that system for poorer workers, with the government footing the bill, to encourage more people to seek health insurance. Advance payments of tax credits have helped shield many participants in the exchanges from sharp premium increases because the law establishes the share of income that households are expected to pay.

A 2016 Commonwealth Fund study found that for people with low and moderate incomes, the ACA’s tax credits have made premium costs roughly comparable to those paid by people with employment-based health insurance. About half of the adults in the marketplace said their premiums were affordable — and 4 in 5 people who joined the marketplace or Medicaid after the law was implemented said they were satisfied with their health insurance. (About half of the adults said that before they signed up, they had been without health insurance for more than two years.)

About half of the people in the individual market are getting subsidies — and the other half are being hit with increases, in some cases quite high. But, to put it in context, the number of people affected by premium increases is just one-fourteenth the size of the employment-based health-insurance market.

In some states, the ratio is even smaller. The impressive nine pages of backup material for the Ohio ad say that there were nearly 250,000 enrollees in the ACA, many of whom qualified for subsidies. Compare that number to 6 million Ohioans on employer-provided plans, 2.4 million on Medicaid and 1.7 million on Medicare, according to estimates by the Kaiser Family Foundation. Combined with an expansion of the Medicaid program contained in the Affordable Care Act, the number of people in Ohio who lacked health insurance dropped from 1.4 million in 2013 to 681,000 in 2015.

“Ohioans purchasing health care on the exchanges have seen premiums rise, choices shrink, and deductibles so high that it hardly feels like they have insurance at all,” said One Nation spokesman Ian Prior. “This is even worse for middle-class families that do not qualify for subsidies and must devote more resources to health care.”

It’s certainly correct that the ACA market has been under pressure because the mix of people signing up for health care under plans offered on the exchanges has been unhealthier than expected. The feared individual mandate — which Republicans say they will eliminate — did not have the expected result of persuading people to buy insurance. Younger and healthier Americans apparently were more willing to pay a $695-per-person fine than sign up for health care they think is too costly. So the people in the insurance pools have tended to be those who have chronic illnesses and thus require more care and frequent doctor or hospital visits. The makeup of the risk pools is also why insurance companies have sought higher premiums and the biggest deductibles.

But again, the problems in the ACA exchanges do not extend to the entire health-care market.

“Obamacare was marketed to the American people as health-care reform that would make health care more affordable for everyone. It has clearly not done that; that is why we are advocating that it be repealed and replaced with something that will,” Prior said.

In his 2008 campaign for president, Barack Obama certainly promised that his health-care plan would reduce health-care costs by $2,500 a year. He even earned Pinocchios for that statement.

But, at the same time, health costs for employer-provided plans have grown much slower than expected since the ACA was implemented. The average family premium is now almost $3,600 lower than if premium growth had kept pace with the rate in the decade before the law was passed, while all out-of-pocket costs would have been nearly $5,000 higher if they had continued on the previous inflationary path. However, there is little consensus among health-care experts about whether the ACA can be credited with the slower rise in health-care costs.

Finally, the Ohio ad highlights the law’s $1 trillion in tax hikes. The factual backup even lists a Washington Post fact check as a source. That’s a 10-year number, for the years 2013-2022. But it’s important to provide some context for that figure.

As we noted in the fact check, almost a third of those tax hikes were aimed at couples making more than $250,000 and individuals making more than $200,000. The Joint Committee on Taxation identified only about $130 billion in taxes with direct impact on the middle class, and $247 billion more in taxes with possible indirect effects. Most calculations show that middle-income Americans were expected to get more in tax relief, such as health-care subsidies, than in additional taxes. Indeed, the tax increases mostly were used to pay for the tax credits, which were estimated to total $1 trillion in the 10-year period.

The Pinocchio Test

If you were driving in your car, listening to the radio, these ads might get you rather worried about what a “mess” Obamacare has made of the health-care system. But it would be a misplaced concern.

These ads conflate “Obamacare” with the entire health-care system. The ACA was intended to provide additional options in the individual market for people who could not afford health insurance. Most people on the exchanges get tax credits that mitigate the cost of premiums, which has resulted in a substantial decrease in the number of Americans without health insurance. In the meantime, people who have employer-provided plans saw little or no change, except that the law may have added benefits, eliminated lifetime caps on coverage, and barred the denial of insurance for preexisting conditions.

The “mess” extends to people in the individual market who do not qualify for tax credits — and their premiums have increased because of mandates in the law, a sicker-than-expected pool of applicants and decreasing competition because insurance companies have found it too difficult to make money. Whether Republicans will find a solution to this problem — without creating more havoc — is open to question. But the ads need to make clear, as Price did, that the turmoil on the exchanges has not affected most Americans.

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"We’re paying more for health care. A lot more."
in a radio ad
Tuesday, March 7, 2017