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RealClearPolitics HorseRaceBlog

By Jay Cost

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Why Does the Public Oppose ObamaCare?

As the Senate debate drags on, public support for the Democratic health care reforms remains very weak. The latest RealClearPolitics average shows just 40% in favor with nearly 49% opposed.

These figures remain a bit puzzling because individual items within the bills still poll strongly. Even if the question wording of the public option tilts the playing field, the fact remains that proposals like guaranteed issue are popular.

How to explain the divergence? Why does the public oppose ObamaCare overall while supporting items within it? Let's approach it by imagining how a (stylized) voter would make up his mind. We'll assume that he is not a strong partisan, and so does not simply accept the rhetoric of one side over the other. This is the sort of middle-of-the-road person who is going to swing a poll such as this one way or another. We'll also assume that this voter is rational. He intends to add up all the expected benefits and the costs. If the sum is positive, the voter supports. If negative, the voter opposes.

First, we must recognize that public knowledge about these bills is very minimal. From the perspective of an average voter, these bills are hopelessly indecipherable. They are so complicated that the experts literally need weeks to figure out what they'll mean for the country. And even then, they cannot give certain answers to the big questions. For instance, many of the Medicare savings in the House bill come from "productivity improvements." Richard Foster, Chief Actuary of Medicare and Medicaid Services, said that these could make it difficult for providers "to remain profitable and end their participation in the program." He suggests that this could "possibly jeopardiz[e] access to care for beneficiaries)." [Emphasis Mine]

Sometimes, the experts offer more confident claims about what these bills will mean, but those clarifications are still terribly complicated. Consider, for instance, the recent scoring from the Congressional Budget Office on how the Senate bill will affect insurance premiums. Question: will premiums go up, down, or stay the same? Answer: yes, yes, and yes! It all depends on where you fit into the scheme. But unless you are a policy wonk, it is extremely difficult to know how it all applies to you.

The impenetrability of these hyper-technical bills is a very important factor for this analysis. It means that voters must weigh their perceived costs and benefits under conditions of severe uncertainty. This point is going to affect every calculation they make.

With this in mind, let's begin the analysis by talking about the potential benefits. The main focus of the bills is expanding coverage to those who lack it. If somebody does not have health insurance, that's a big expected benefit, which should be pretty obvious even with little information. Of course, most people already have health insurance, so they will not enjoy this benefit. Still, they will gain something because the bills make it easier to acquire insurance. Everybody has a non-zero probability of losing coverage in the future, so expanding access to coverage gives everybody at least a little more security.

Another important benefit: insurance premiums are expected to go down for those who buy a policy on the exchanges and who qualify for federal subsidies. For lower income individuals who already have insurance, this is a major benefit.

Yet here the uncertainty kicks in. Some people currently without insurance will still be unable to afford it, and will pay a tax penalty for their lack of coverage. Can average voters evaluate whether they will wind up in this group? Probably not, which means that this has to factor negatively into the analysis. Another item to consider: do average voters know whether they will qualify for a subsidy? If they do not, their premiums could go up. Once again, that's a difficult piece of information to acquire, so this has to enter the equation as potential cost, too.

Uncertainty is a key factor in tallying up the other costs, most notably potential reductions in Medicare benefits, tax increases, and ballooning deficits. If any of these things occur, they would be bad for average voters. But will they actually happen? The Democrats say they won't. The Republicans say they will. That puts moderates, Independents, and soft partisans in a difficult position. Staunch Republicans wholly accept the GOP argument. So, they price in bigger deficits with almost 100% certainty. Staunch Democrats do the opposite. President Obama says no deficits; they say no deficits. But people in the middle without strong partisan affiliations have to acknowledge both arguments. They need to assign each claim a probability of accuracy between 0% and 100%. Thus, GOP warnings about Medicare cuts, tax increases, and out-of-control deficits should thus be priced in as expected costs - perhaps not to the same extent that staunch Republicans are factoring them in, but they are still included.

Another problem for the bills is the Congress. It's heavy involvement has to be acknowledged as a cost, again because of the uncertainty inherent to the bills. RealClearPolitics currently shows congressional job approval at just 27%. That matters for these bills. If voters cannot evaluate the bills for themselves, they have to trust that Congress has written them well. Polls indicate clearly that most people do not trust Congress to do that. If they suspect that the bills are tailored to the special interests rather than their own, they have to factor congressional authorship into the analysis.

The final factor is risk aversion. Recent polling has shown that most people are satisfied with the health care system. Rasmussen recently found that 49% rate it as "good or excellent" while just 27% rate it as "poor." Gallup's numbers are not as positive, but still suggest that most Americans are generally all right with the system as it is.

This might make them especially nervous about the risks inherent to the reforms. If somebody has a 50-50 shot at winning $5,000 or can take $2,500 for certain, what will he do? A risk neutral person will be indifferent between the options. But a risk averse person is acutely uncomfortable with the uncertainty, so will instead take the sure thing. A similar psychological phenomenon might be in place here. If somebody really abhors the uncertainty inherent to a comprehensive overhaul of a system that he thinks is generally all right - he might count it as one of the costs.

Importantly, risk aversion can vary according to the stakes. If somebody has a 50/50 shot at winning $1 million or can take $500,000 for certain, what will he do? A risk neutral person would be indifferent. But most people's risk aversion will make them eager to take the sure thing. People are extremely risk averse when it comes to health care precisely because the stakes are so high. This might make them especially squeamish about the possibility that the bills will have negative side effects.

All in all, this is how I see a rough support/oppose calculation for a middle-of-the-road voter who already has health insurance:

Possible Benefits
(1) Reduction in premiums.
(2) More security in retaining health coverage.

Possible Costs
(1) Increase in premiums.
(2) Medicare cuts.
(3) Tax increases.
(4) Deficit increases.
(5) Congressional particularism.
(6) Intolerable risk.

I think this takes us a long way in explaining the opposition to these bills, even if people support particular items within them. On balance, many people who already have health insurance are going to feel skittish, given the large number of possible costs and their potential severity. They might be all right with provisions that help others acquire insurance - and thus give them a little more security - but their holistic evaluation has to take into account every relevant factor. According to many polls, the bills do badly with Independents and soft partisans, suggesting that this cost-benefit analysis is typically yielding a negative result.

And note that we have not discussed the public option. The more I reflect on it, the more I think it is a red herring - at least as far as public opinion is concerned. It is an issue that has activated the party bases because it signifies a major expansion of social welfare. Americans who are deeply invested in a vision of the proper role of government have focused intensely on it. But what about middle-of-the-road people who do not have such strong feelings? My guess is that it doesn't register nearly as much.

If I'm correct about this, it would mean that the health care debate is perhaps similar to the dynamic laid out by Morris Fiorina in Culture War? The Myth of a Polarized America. Political elites and party activists have focused relentlessly on the public option because it is part of a symbolic battle over the appropriate scope of federal power. Yet the vast, moderate middle is not invested in such symbolism. They don't like the bills because of old standbys like Medicare, taxes, and deficits - not the public option.

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-Jay Cost