The Affordable Care Act turned five years old yesterday. As any honest parent knows, that’s a common occasion for saying, “thank goodness: we survived.” And it’s as good an occasion as any for me to write a post I’ve been considering for some time but never got around to because I lacked the time for proper research on public opinion. Rather than delay longer, I’m writing it now as a thought piece. My confidence that I’m right is, for the moment, strong but fragile. It relies on the evidence of things not cited.

The basic point is this: the ACA is set up to mimic private insurance coverage for those who previously lacked it. I claimed that would and should make it, over time, acceptable and routine. That claim tacitly assumed, though, that everyone had experience with private insurance coverage and thought it worked OK. The uninsured in fact lacked that experience, and that more-or-less automatic judgment.

Right after the ACA passed, I wrote a post saying the proper (and accurate) framing was not “mandate” plus “subsidies” but this:

If you or your family aren’t getting health insurance through your job, the government will pay to get you private insurance coverage, just as an employer would.  You’ll have to contribute something—but the law guarantees, with specific numbers, that it will be no more than you can afford. It’ll be less than three percent of your paycheck if your family makes $33,000 a year, less than ten percent if you make as much as $88,000.  Pre-existing conditions won’t matter.  The government will still pay for your insurance, with the same affordable contribution from you.”

(There was more, but that’s the kernel.)

When I wrote that, what I didn’t realize was that my analogy wasn’t so much wrong as unfamiliar. That is: the marketplace for private health insurance is regulated; as Krugman wrote in a column long ago, that’s the only reason it works. Employers can’t charge employees with preexisting conditions more than those who lack them. They can’t, normally, let healthy employees opt out of the health plan in return for higher wages. And of course there’s a government “subsidy”—before the ACA, a non-progressive one—in the form of tax deductions for employer-provided coverage. Those of us with private insurance often, though not always, have to pay a sum of money—sometimes invisibly, as a payroll deduction—as our share of the monthly premiums. And, especially for plans allowing a lot of doctor choice, we often must pay a certain proportion of our health costs because our insurance only pays for 80 percent or whatever. (The 20 percent is called “coinsurance,” not that the average intelligent person needs to know that.)

Those of us with employer-provided health insurance are used to all that. And because I’ve had such insurance pretty much my whole adult life I assumed that pretty much everyone was used to the idea of all that, and wanted it. But I assumed wrong.

There are lots of working poor and moderate-income people who have never been able to afford health insurance and had little experience with how it works. (That more and more people were working for employers who provide no insurance was of course a reason for the ACA in the first place.) In some rural areas, especially where public employment with good benefits is nonexistent or uncommon, lots of people before the ACA didn’t even know much of anyone with health insurance. From their perspective, pre-ACA, visits to an emergency room were the source of great financial anxiety, even bankruptcy, when they got sick but financially costless until then. Paying even fairly low premiums up front seemed a burden, not the price of a benefit they were used to. Many self-employed people with substantially higher incomes also lacked health insurance and reasoned similarly. Because they weren’t used to having health insurance as a routine part of their pay package, they didn’t think of health insurance as a standard part of what everyone got as compensation (before money income and, in a psychic sense, separate from it). They thought of its actual cost and, if healthy for the moment, often didn’t like the cost. When conservative economists want to end the tax deductibility of health insurance so that we perceive its “real cost,” they want us employer-insured people to think as the well-off uninsured always have.

These categories of people don’t find comfort in the fact that the ACA treats everyone as insured employees have always been treated. That fact is, as community organizers would say, “outside their experience”: irrelevant to the context of choice that they’re used to. (This isn’t even to mention people on the serious Left who know about other countries and don’t think health insurance should be provided by employers, through private insurance companies, in the first place. That’s a separate issue, a matter not of experience but of principle—a principle that I sympathize with but that lacks wide support in the US.) By the way, the argument that the ACA prevents people from “choosing their own doctor” often blindsides ACA opponents because it’s outside our experience. Most of us have for decades had plans that place certain doctors “in-network” and others “out-of-network.” We’re used to having the latter covered only partially, or not at all. That’s the only way to hold costs down: your insurer will only cover doctors willing to accept its fee. But if you’ve never had insurance, all the doctors you might want to see are, in a sense, equal. If you’re working poor, all the doctors you know, at the emergency room or health clinic, will equally have to write off the cost of your treatment (or badger you with bills you can’t pay). If you’re wealthier but self-employed, all doctors—your choice of which—will bill you for the full cost of treatment. In neither case will doctors normally compete explicitly with patients on price. They do so only when dealing with large insurance companies.

This lack of experience explains, I think, lots of the continued opposition to the ACA. For most of those for whom the system of doing business with private insurers is familiar, it stands to reason that the ACA does a good thing by bringing as many people as possible into it. But for those to whom the system, with its annoyances and burdens, is unfamiliar, being brought into it on pain of tax penalties seems a pure imposition of costs. The benefit—the peace of mind that comes with not having to worry about serious illness rendering you destitute or consumed with worry about bills—seems abstract and notional because it’s never been felt. And to the extent that ACA implementation has responded to complaints about plan costs by letting some plans be mostly or exclusively catastrophic-only—contrary to its initial intentions—it has guaranteed all the more that the benefits will, for most, remain abstract and notional. Only those who experience serious injury or disease will ever feel them.

For the same reason, though, another post I wrote remains, I think, valid. Once experience with the ACA has built up, over many years, the system won’t grate anymore. It won’t even seem like government. It will just seem like the way people get health care—just as a little paper or online brochure from our employer has been the “way we get health care” for those of us with employer insurance all along.

Update: the original version of the post said that employers providing group health insurance weren’t allowed to let employees opt out of the health plan. What I meant, of course, was that they couldn’t let employees opt out in return for higher wages. One may always turn down health coverage, but those with group insurance have no reason to (unless they have better coverage through another means, e.g. through a spouse). The current text reflects the change.

[Cross-posted at The Reality-Based Community]

Andrew Sabl

Andrew Sabl is a Visiting Professor in the Program on Ethics, Politics, and Economics and in Political Science at Yale University.