A Final Response to Cato on Public Support for Reform: Opposition Based on Misinformation Fading, Though Seniors Remain “Confused”

Summary:  As regular readers know, not long ago Cato Institute senior fellow Michael Tanner published a 52-page critique of the new health care legislation titled Bad Medicine,  and I decided to write a series of posts, rebutting Tanner’s arguments about the  Real Costs and Consequences of the Law. In my first post,  I took on Tanner’s assertion that “ObamaCare remains deeply unpopular,” with the majority of Americans supporting repeal.  

Tanner’s colleague, Michael Cannon replied to my post, and I responded to his reply,   Since then, Cannon has written another post titled “ObamaCare Still Unpopular: Round Two of My Exchange with Maggie Mahar.”  Once again, he focuses on what the polls say about the public’s appetite for repeal.

I believe it’s time to move on to the next talking point in Bad Medicine–Tanner’s contention that the “individual mandate” requiring that all Americans have health insurance, or pay a penalty, is “unprecedented” and, perhaps, unconstitutional. He argues that the mandate “violates individual liberty” and that it just won’t work:  young healthy Americans will pay the penalty rather than join the insurance pool.

This is, I think, a meatier issue than what the public “thinks it thinks” about the legislation.  There is only so much one can say about polls. And if truth be told, most Americans really won’t know how they feel about reform until the legislation is enacted in 2014.

Nevertheless, Cannon has taken the time to make a serious argument, and it deserves a response.  So before moving on to consider what Tanner has to say about the “Individual Mandate” , (see “A Reply to the Cato Institute’s Report on Health Care, Reform Part 2– The Individual Mandate” –above)
 let me reply to the highlights of Cannon’s “Round Two  of My Exchange With Maggie Mahar”  

In my last post on public support for reform, I suggested that if you’re looking for a trend in how Americans view health care legislation, it’s only sensible to take March 23, 2010 (the day the bill was signed), as your beginning point. In my view, it is very hard to ask people whether or not they like legislation that doesn’t yet exist. It was only after the final bill was passed, that they could begin to offer opinions based on fact.

Cannon objects. He prefers to take January 2009 as his beginning point, explaining that “opposition to ObamaCare surged after Obama’s inauguration and surpassed support just as the debate began in earnest in July 2009. (That rising opposition fueled the angry town halls of August 2009.) In other words, from the moment the public began to focus on ObamaCare, they didn’t like what they saw, and opponents have out-numbered its supporters for 12 months now.”

The truth is that there was nothing to “see” at the beginning of 2009. At that point, legislation remained a gleam in Nancy Pelosi’s eye.  Many hoped (and others feared) that “reform” would mean single-payer health care. Even at the end of the 2009, it was far from clear whether reform legislation would include a public option; whether abortion would be covered; whether the states or the federal government would regulate insurers; whether people over 55 would be able to “buy in” to Medicare;  and whether Democrats would “go back to the drawing board” and try to hammer out a “bipartisan bill” that would draw Republican votes . . . As anyone following the process remembers, the legislation was in constant flux.

Even when President Obama signed the Patient Protection and Affordable Care Act (ACA) , many Americans had little idea as to what was actually in the bill.   The media had not done a very good job of spelling out the provisions of the legislation as it evolved, so the vast majority knew only what they had “heard” about the legislation, not what they had seen.

And what they heard was a disturbing mix of allegations and rumors  regarding “death panels,” (thanks Sarah Palin, for coining the phrase on Face Book )  “rationing” (“Women won’t be able to get mammograms,”  Carly Fiorina, December 5, 2009 )  and my personal favorite: “President Obama . . . wants to mandate circumcision.” (Rush Limbaugh, who else? August, 2009)  ) All lies, Big Lies. But as Hitler explained in Mein Kampf,  if the whopper is large enough, and repeated often enough, people will believe it.  After all, they will think, “Who would claim the legislation calls for ‘death panels’ if it wasn’t true?”

It was only after the Accountable Care ACt  was signed in March that reformers could challenge conservative fear-mongers by saying:  “Please point to the page where the bill says that woman cannot have mammograms.”  Gradually, specific provisions of the legislation made their way into the press, and as people read what was in the bill with their own eyes, they found that there was much to like. This is why I, like many pollsters, track the public’s changing response the Affordable Care Act since late March:  if you focus in on the past four months, the trend line suggests that as facts replaced myths about “ObamaCare,” opposition softened.

Which Polls Should You Use?

Nevertheless, Cannon claims that I highlight only “a few polls that support my narrative (‘the more people learn about the legislation, the better they like it’)” — including Gallup, NBC/Wall Street Journal, Kaiser Family Foundation, and Bloomberg. . Here,  he argues that these polls “probably paint a less accurate picture than looking at something like Pollster.com, which aggregates all polls and therefore (presumably) cancels out the quirkiness of individual polls.”

What Cannon ignores is the title of my most recent post: “Pollster.com Shows Disapproval Fading As Americans Learn More about Health Care Reform.” In other words, while I mentioned the other polls, I rested my case on the very same pollster.com chart that Cannon prefers. (See the chart below.)  Take a close look at the chart you will find that on March 23 close to 51% of respondents disapproved of the legislation. Today, that number has fallen to 46.8%. As I pointed out in my last post,  while  “the red line indicating disapproval has been moving down quite smoothly since March . . .   the black line, indicating approval, has been wriggling around. This indicates that a great many people still don’t know whether they like the bill. They won’t know what effect it will have on them and their families until it is implemented.”

But Cannon disagrees with my interpretation of  the trend; “If the trend line showing declining opposition to ObamaCare supports Mahar’s narrative . . .  the trend line showing declining support for ObamaCare supports the opposite narrative (‘the more voters learn, the less they like it’). When we look at the trend in public opinion on ObamaCare since the signing ceremony, we see that opposition and support are declining .” 

I am afraid that Cannon is mistaken. The black line, indicating approval, is not falling; it remains solid. Click on the beginning of the line—March 23— and you’ll find 42% of respondents approve of the legislation; at the end of July,  41.7%  supported it. Meanwhile, opposition (illustrated by the red line) has fallen from roughly 51% to 45.4%.  

Those Targeted by Fear-Mongers  (Seniors) Are Most Likely to Be Opposed

Finally, Cannon turns to my argument that as Gallup polls show, “the largest well of opposition” to reform “is found among seniors, 60% of whom call passage of the bill a ‘bad thing.’” (This explains why polls limited to “registered voters” show less support for reform; a disproportionate share of seniors are registered.)  By contrast, among young and middle-aged adults, only 40% to 44% call ACA a “bad thing,” with support strongest among younger Americans. (See table below.) Note that, since April, opposition has fallen in every age group except “65 and older.”


In other words, opposition is largely confined to the one group that already has universal coverage–seniors. Here I quoted Ezra Klein: “seniors, of course, aren’t opposed to government-run health care. They love their Medicare, and insofar as they have a policy concern here, it’s that the Affordable Care Act will interfere with the single-payer system they rely on.”  Responding to this point, Cannon writes: “Finally, Mahar channels Marion Barry, who (in)famously claimed that if you don’t count murders, the crime rate in Washington, D.C., is really quite low. She cites a poll that ‘suggests that opposition is largely confined to the one group that already has universal coverage–seniors,’ and then invokes Ezra Klein’s rationale for dismissing their opinions . . . .

“It is nonsense,” Cannon adds, “to say that ObamaCare is popular if we just ignore the views of people who will suffer.”

I think it’s fair to say that Cannon sounds a tad upset. This is understandable.  In his mind, seniors will become the “victims of reform. (It’s something of a stretch to compare them to murder victims, but then it’s something of a leap to compare me to Marion Barry.)  

Let me be clear: Nowhere does the legislation propose cutting Medicare benefits. To the contrary, the law specifically prohibits Medicare’s Independent Payment Advisory Board “from submitting proposals that would ration care, increase taxes, change Medicare benefits or eligibility, increase beneficiary premiums [or]-sharing requirements.” 

In fact, the ACA increases benefits for seniors by;

  • beginning to close  the “donut hole” so that seniors pay less for drugs
  • eliminating co-pays and deductibles for preventive care,
  • providing bonuses to doctors who offer preventive care to Medicare patients
  • offering free annual wellness visits

The ACA does call for pilot projects that aim to squeeze some of the waste out of Medicare spending by a) reducing hospital errors, and b)rewarding providers who achieve better outcomes without exposing patients to unnecessary risks. The goal is to keep seniors out of hospitals by managing chronic conditions. Pilot projects would pay doctors more to talk to and listen to patients, before a chronic disease turns into a condition that requires hospitalization.

It is crucial to realize that the Accountable Care Act would not reduce total Medicare spending; it would simply rein in runaway growth in Medicare’s outlays.  Over the next 10 years, the new law would trim Medicare inflation— from 6.8% per year to 5.5%. This, along with tax hikes for the wealthiest Americans, will put Medicare on the road to fiscal health.

Nevertheless, Medicare beneficiaries are scared because those who hope to stop reform –and “break Obama”– have told them that they should be scared, targeting seniors with a carefully crafted message.

A poll of Americans over the age of 65 conducted by Harris Interactive for the National Council on Aging (NCOA), and released just last week, reveals that seniors have swallowed the misinformation.

  • only 22 percent of seniors polled knew that the law will not cut their basic Medicare benefits, compared with 42 percent who thought it will cut them, and 37 percent who said they don’t know if they will lose benefits;
  • only 34% knew that Medicare spending  will continue to grow under the new law, just more slowly.
  • and 45% thought that the new law cuts Medicare payments to doctors; only 14% knew that this isn’t true. 41% said that they didn’t know.

As Sam Wainwright explains over at the New America Foundation’s “New Health Dialogue: “Seniors constantly hear that health reform will ‘cut’ Medicare, so it’s logical they would assume it would also “cut” payment to doctors. It seems like simple math: less money for Medicare, less money for Medicare doctors. That argument is easy to understand, and repeat, and shout. The truth about cutting waste, and bending the curve, and improving care coordination, and reforming delivery systems to get more value-based care, all get drowned out in the din.” 

Overall, the Harris poll revealed that only 17% of seniors knew the correct answers to more than half  of the 12 factual questions posed about  key aspects of new law, and only 9% knew the correct answers to at least two-thirds of the questions.

The level of ignorance and misinformation is sort of astounding,” says Humphrey Taylor, chairman of The Harris Poll. “We’ve had an incredibly heated debate about this for a long time. And what people were reacting to was the rhetoric, not the substance of what was in the bill, because they didn’t actually know what was or was not in the bill.”

A Kaiser poll released last week confirms widespread confusion, with  half of seniors (50%) saying  the law will cut benefits that were previously provided to all people on Medicare, and more than a third (36%) incorrectly believing the law will “allow a government panel to make decisions about end-of-life care for people on Medicare.”

Since the beginning of the year rhetoric designed to spread fear and confusion has been extremely effective, especially among seniors. But in the months ahead, they, like other Americans will have an opportunity to learn more about the substance”of the Accountable Care Act. .  . The National Council on Aging has just announced a $100,000 campaign to educate 10 to 15 million seniors on the new health reform law. “Considering how important this issue is for seniors, we’re kind of just appalled at how little they know,” observes NCOA president James Firman.

6 thoughts on “A Final Response to Cato on Public Support for Reform: Opposition Based on Misinformation Fading, Though Seniors Remain “Confused”

  1. Maggie:
    It’s obvious that seniors don’t want their Medicare benefits cut.
    The same could probably be said for Social Security and Medicaid.
    In the CBO report entitled “The Long-Term Budget Outlook,” published in June, states “spending on the major mandatory health care programs and Social Security will grow from 10% of GDP today to 16% of GDP 25 years from now if current laws are not changed.”
    Our tax revenues have averaged 18% of GDP for the past 65 years. In effect, the CBO is telling us that Social Security and health care will use virtually our entire budget within 25 years.
    And you stll believe that Medicare will be on the road to fiscal health with your 2 recommendations?
    Don Levit

  2. Don–
    I guess you didn’t read the post. Nothing in the bill cuts Medicare benefits–it cuts Medicare waste, putting Medicare on the road to fiscal health.

  3. Maggie:
    Cutting waste has been done for years in various programs.
    And, we are still adding to our debt each year.
    Parts B and D of Medicare are very expensive. Only 25% of the premiums are paid by bneficiaries. The other 75% come from general revenues, and have an immediate impact on our budget.
    In addition, neither program has a trust fund of any significance (as if that really made a difference, since the trust fund dollars have been loaned to the Treasury to use for current expenses).
    From the Trust Fund Perspective, Parts B and D are fully funded, for there is no limit on general revenue funding.
    However, from the Budget perspective, the real dollar perspective, these programs add tremendously to our debt.
    From a paper entitled “Analytical Perspectives, Budget of the U.S. Government, Fiscal Year 2009,” on page 194 “SMI’s funding structure (Parts B and D) creates an enormous financing gap for the program and is the largest contributor to the total Mediacre program shortfall over the next 75 years of $34.1 trillion. Extending the horizon to perpetuity increases the total shortfall to $74.4 trillion. SMI’s financing gap is covered by an unlimited tap on general revenues. According to the Medicare Trustees’ 2007 report, ‘Within the next 10 years, general revenue transfers are expected to constitute the largest single source of income to the Medicare program as a whole – and would add significantly to the federal budget pressures.’ ”
    Go to: http://www.gpoaccess.gov/USbudget/fy09/pdf/spec.pdf.
    Don Levit

  4. Don–
    In the past, Congress has had control over the purse strongs. Medicare could not try to cut waste without going through Congress and one man’s waste was always somebody’s income stream.
    Under the new legislation, Medicare has great latitude to cut waste by rolling out succcessful pilot programs nationwide. Medicare will not need permission from Congress.
    The legislation gives the Centers for Medicare and Medicaid and the Secretary of Health and Human Services the freedom to make some major changes.
    Many conservatives will be surprised, just as they were surprised when reform passed without a major “bipartisan compromise.”
    This is a whole new ball game, starring a very different cast of characters.

  5. Reform is so popular, that the first time voters get to vote on the subject 75% are voting it down in Missouri.