Fluent Essays

The Patient Protection and Affordable Care Act (ACA, also known as ObamaCare) became law on May 23, 2010. It strives to reform the health insurance and health care industries in an effort to cut health care costs and provide Americans with affordable health insurance. The ACA also strives to expand Medicare and Medicaid to assist those Americans who cannot currently afford health insurance. As a result of the reforms, there may be a significant influx of patients into the health care system. In addition, there will be a greater focus on integrating health care services, particularly for individuals with physical and mental health conditions. It is expected that under the ACA, social workers will take a more active role in the coordination of care for existing and new members of the health care system. Social workers will also provide additional direct, frontline services to patients.To prepare for this Discussion, review this week’s resources. Consider the debate over the ACA and explore the reputable sources on the Internet for additional resources on the balanced debates over the ACA. Consider how the ACA might expand meaningful services to all Americans including children, young adults, uninsured minorities, and spouses of employed individuals. Consider one population.By Day 4Post a description of the findings of your research on the debate over ACA. Explain some of the misconceptions or misunderstandings the general population might have about the ACA. Explain how the ACA may or may not increase affordability, health insurance coverage, and access to health care services for the population you selected. Explain the potential or documented influence of the ACA on medical social work practice. Describe the medical social worker’s role in clarifying the ACA to patients and families. health_care_2012___knowledge_and_favorability.pdf Unformatted Attachment Preview AMERICANS’ ATTITUDES TOWARD THE AFFORDABLE CARE ACT: WOULD BETTER PUBLIC UNDERSTANDING INCREASE OR DECREASE FAVORABILITY? WENDY GROSS1 TOBIAS H. STARK2 JON KROSNICK3 JOSH PASEK4 GAURAV SOOD5 TREVOR TOMPSON6 JENNIFER AGIESTA7 DENNIS JUNIUS8 This research was conducted with support from the Robert Wood Johnson Foundation, GfK, Stanford University, and the Associated Press. The authors thank Arthur Lupia and Michael Tomz for helpful comments on this manuscript. GfK. wendy.gross@gfk.com Stanford University and Utrecht University. t.h.stark@uu.nl 3 Stanford University. krosnick@stanford.edu 4 University of Michigan. jpasek@umich.edu 5 Princeton University, gsood@princeton.edu 6 Associated Press‐NORC Center for Public Affairs Research. tompson‐ trevor@norc.org 7 Associated Press. jagiesta@ap.org 8 Associated Press. djunius@ap.org 1 2 Abstract National surveys conducted in 2010 and 2012 suggest the following conclusions: ‐ American understanding of what is and is not in the ACA has been far from perfect. ‐ Correct understanding of the elements of the bill we examined varied with party identification: Democrats understood the most, independents less, and Republicans still less. ‐ Older people and more educated people have understood the elements of the bill we examined better than have younger and less educated people. ‐ Between 2010 and 2012, public understanding of the elements of the bill we examined did not change notably. ‐ Most people have favored most of the elements of the ACA that we examined, but not everyone recognized that these elements were all in the plan. ‐ Most people opposed policies that were sometimes falsely thought to be parts of the ACA. . ‐ If the public had perfect understanding of the elements that we examined, the proportion of Americans who favor the bill might increase from the current level of 32\% to 70\%. Taken together, all this suggests that if education efforts were to correct public misunderstanding of the bill, public favorability might increase considerably. 1 Introduction The Patient Protection and Affordable Care Act of 2010 (ACA) enacted a series of significant changes to the American health care system. The 900‐page‐long bill, which elicited an extremely partisan reaction and substantial news media interest, amended the U.S. code to prevent insurance companies from denying coverage for pre‐existing conditions, provide for health care exchanges where individuals could purchase care directly, require all individuals to have health insurance or pay a fine, and more. In June, 2012, the U.S. Supreme Court upheld a central element of this law. Public debate about the bill called attention to many aspects of the law that were included in the version that Congress approved. But during the course of public debate, a number of inaccurate claims were made, asserting that the bill included provisions that were not included in the final version. Some of the widely discussed components were part of the legislation, such as the plan to allow children to stay on their parents’ health plan through age 26. But other widely discussed notions were never considered for inclusion, such as the claim that a panel of bureaucrats could decide when coverage would be given (the so‐called “death panels”). The legislation included a variety of less‐often discussed provisions, such as charging a fee to insurance companies that offered particular types of insurance. Many surveys were conducted both before the bill’s passage and after its enactment to gauge the American public’s reaction to it. In early 2010, public opinion was fairly evenly split. For example, according to a Kaiser Family Foundation (KFF) survey in April of that year, 46\% of Americans said they had a favorable opinion of the bill, and 40\% said they had an unfavorable opinion. A year later, in April 2011, KFF reported these two statistics to be 41\% and 41\%, respectively. And in January 2012, the figures were 37\% and 44\%, respectively, perhaps suggesting a slight shift in the unfavorable direction as time has passed. In May 2012, the figures were identical: 37\% and 44\%, solidifying evidence of that slight shift. And in August 2012, these figures were 38\% and 43\%, respectively. A similar portrait was painted by AP‐GfK polls. In May, 2010, 39\% of respondents said they supported the ACA, and 46\% said they opposed it. In June, 2012, those numbers were 33\% and 47\%, respectively. Thus, a small decrease in the proportion supporting, and a small increase in the proportion opposing. Surveys done by other organizations provided similar, though not identical, portraits of the balance and trajectory of opinions. For example, a NBC News/Wall Street Journal poll done in May, 2010, found 38\% of respondents saying they thought the ACA was a good idea, and 44\% said it was a bad idea. As of June, 2012, that organization found these figures to be 35\% and 41\%. Thus, the proportion expressing a positive opinion dropped slightly, like the KFF polls. But the proportion expressing a negative opinion also dropped slightly. Only one prominent national survey research organization, The Pew Research Center, reported results suggesting movement in the opposite direction. In January, 2011, 41\% of their respondents approved of the ACA, and 48\% opposed. Their most recent survey, in June‐July, 2012, found that 47\% approved, and 43\% opposed. 2 Put together, most national surveys during the last two years support two principal conclusions: (1) public opinion has not manifested a sizable and consistent leaning toward being favorable or unfavorable toward the ACA, and (2) a slight shift in the negative direction may have occurred since the law was passed. It would be understandable to look at such evidence as an indication that the American public does not strongly support this piece of legislation. After all, if about as many people favor it as oppose it, and if we have never seen a majority favoring it, that hardly sends a strong signal of support. Furthermore, it is easy to imagine that since passage of the bill, Americans have had time to consider the bill and its implications in more and more depth, and if such consideration leads to a shift in the negative direction, that certainly signals quite the opposite of enthusiasm. Thus, such data could be taken as a signal that Republican efforts to repeal the bill would be warmly welcomed by a growing group of Americans. At the same time, the very same polling evidence can be viewed from the opposite viewpoint. Although a majority of Americans have not favored the bill, it is also true that a majority have never opposed it, either. And even after the recent small increase in opposition, the proportion opposing it does not exceed 50\%. So direct questions asking about positive vs. negative evaluations of the plan have not documented a mandate from the public to repeal the bill.9 Taken together, all this evidence portrays the American public in what might seem a typical way: split about evenly, and not providing a clear mandate to elected representatives one way or another. It would therefore not be unreasonable for those representatives to look at this polling evidence, reach that conclusion, and proceed to take actions in keeping with the guardianship view of democracy: deciding what they feel is best for the country and taking action (or doing nothing) accordingly, regardless of public opinion. Such ignoring of public opinion might also be justified from another perspective as well. In so many survey‐based investigations of the American public for many decades, people have been found to perform quite poorly on quizzes assessing factual knowledge about domains in which significant legislation has been considered or passed. If most people lack the facts needed to truly understand the problems to be solved by a piece of legislation and the solutions offered by that legislation, why should public evaluations of the legislation be taken seriously? That is, the public might feel very differently if they truly understood a bill, so opinions based on partial information or substantial misconceptions can certainly not be described as “wise” and should perhaps therefore be ignored by legislators. Of course, ignoring public opinion, even uninformed public opinion, may place legislators at risk come election‐time. Even when the public does not understand a piece of legislation, members of the electorate may nonetheless hold strong opinions about it, either favorable or unfavorable, and those opinions may shape their voting down the road. Indeed, a great deal of research suggests that public opinion on policy issues does sometimes shape vote choices (see Anand & Krosnick, 2003; Krosnick, 1988). So a legislator who votes against a piece of legislation that voters favor may 9Questions asking whether the bill should be repealed have sometimes shown a majority of Americans answering affirmatively. 3 find himself or herself later paying an electoral price if that vote becomes well publicized by the legislator’s opponent during a campaign, even if public understanding of the legislation is seriously wanting. In a situation such as this, legislators who wish to see a piece of legislation passed (or avoid its repeal) always have the option of informing the American public about what the legislation would truly do, in the hope that better understanding would lead the public to offer a stronger signal of support to their elected representatives. But would such education indeed lead to more support? This presumably depends on the nature of the public’s misunderstandings and on the public’s evaluations of the elements they believe compose the legislation and of the elements that in fact compose it. In this paper, we report an investigation of exactly these issues with regard to the ACA. Using data from two surveys (one conducted in 2010 and the other in 2012), we explored: 1) How accurately Americans have understood what is in the ACA and what is not. 2) How the accuracy of people’s understanding has changed during the two years since the bill was passed. 3) How knowledge accuracy is related to favoring the ACA – that is, whether people who know more about what’s in the ACA like it more or like it less, 4) How the public would feel about the ACA if everyone understood that a series of its central elements are indeed included in the ACA and that a series of frequently discussed but ultimately omitted elements are not in it. Along the way, we investigated two other issues: 1) The predictors of accurate understanding of the plan ‐ that is, which types of people are more and less likely to score well on a quiz. 2) The popularity of various specific elements that were included in the plan, and how popular are elements that were not included but were sometimes claimed to be. In carrying out this investigation, we implemented a new approach to measuring public understanding of a public policy issue. In surveys done during the last 80 years, it has been routine to test knowledge by asking people factual questions and grading people as either correct or incorrect based upon whether their answer matched the facts or not. But this approach ignores a simple and unavoidable fact: that a respondent saying to a survey interviewer that members of the Republican Party outnumber members of the Democratic Party in the U.S. House of Representatives does not necessarily mean that the respondent believes this to be true. When asked which party holds more seats, a respondent might simply guess and end up giving the correct answer by chance alone. This response would not reveal a belief that the respondent genuinely holds, nor would that purported belief have any impact on his or her thinking, because he or she does not truly hold that perception of the world. Guessing seems likely to especially distort answers to quiz questions that offer only two response choices, as we used here (is this included in the ACA or not included in the ACA?). 4 One might imagine that this problem can be overcome by explicitly offering survey respondents the opportunity to decline to answer a survey question by saying they “don’t know” the answer and encouraging them to do so. But a great deal of research suggests that this strategy is unwise. Instead of attracting only and all of the people who truly do not hold a belief on an issue. “don’t know” response options attract many respondents who truly hold opinions and fail to attract respondents who hold opinions with little or no certainty (for a review, see Krosnick, 2002). The solution to this problem is suggested instead by a literature in psychology on certainty. The intended purpose of offering a “don’t know” option is typically expressed as filtering out people who would express a judgment with no certainty at all. That is, a person might say “I think that the Democrats hold more seats, but I’m not at all confident about that guess.” Thus, the preferable solution is to first ask people to make their best guess and then to ask them to rate the certainty with which they express that belief. This allows researchers to filter out people who offer opinions with little or no certainty. A collateral benefit of this approach is that certainty strongly correlates with use of beliefs during decision‐making. People who hold a belief with confidence are inclined to use it when making highly relevant decisions. In contrast, people who hold a belief with minimal confidence are unlikely to use it (for a review, see Petty & Krosnick, 1995). Thus, giving survey respondents “credit” for accurately possessing a belief only when they express high certainty allows us to identify those beliefs that are also likely to have shaped people’s overall evaluations of the ACA. Therefore, in keeping with this perspective, when we administered quiz questions assessing public understanding of the ACA, each question was followed by a question asking respondents how sure they were about their answer to the prior question. People who expressed high degrees of confidence when giving a correct answer were treated as holding an accurate belief, and people who gave a correct answer while expressed low degrees of confidence were not credited as having an accurate belief, nor were people who answered the quiz questions incorrectly. The elements of the ACA that were addressed by the quiz questions were selected carefully to cover most of the central elements of the plan. In their document entitled “Focus on Health Reform: Summary of New Health Reform Law” (Publication #8061; www.kff.org), the Kaiser Family Foundation provided what they called a “summary of the law and changes made to the law by subsequent legislation.” We relied on this summary to select the elements of the ACA to ask about in our survey. We also asked about an additional set of policies that were not ultimately included in the ACA but were discussed during the public debate of it. Data and Methods The data for this study come from two cross‐sectional surveys of nationally representative samples of American adults conducted via the Internet by GfK (formerly Knowledge Networks). Respondents were drawn from the KnowledgePanel® ‐ a nationally representative panel recruited via random digit dialing and by address‐based sampling. The sampling design covers 97\% of the American population, including households that do not have Internet access or a land line telephone. All panelists were remunerated for their participation; people who did not already have 5 either a computer or Internet access were provided them. Upon joining the panel, panelists first completed a core profile questionnaire that captured information about their race, gender, age, income, education, and more. For each subsequent survey, panel members were selected using a probability proportional to size (PPS) weighted sampling design, producing a sample that is representative of the American population. The first survey for this project was conducted between August 31 and September 7, 2010. A random sample of 1,815 adults was invited to participate, and 1,271 completed the survey (completion rate = 70\%). The median time spent completing the questionnaire was 26 minutes. The second survey was conducted between August 3 and 13, 2012. GfK invited 2,344 American adults to participate, and 1,334 completed the questionnaire, a completion rate of 57\%. The median time spent completing the questionnaire (which was much shorter than the questionnaire used in 2010) was 17 minutes. All analyses reported below were conducted using weights to adjust for unequal probability of selection and post‐stratifying based on demographics. Table 1 displays various percentages needed for the calculation of response rates for the survey and displays various the breakdown for the response rates for both surveys. Rate A. Panel Recruitment Response Rate (AAPOR Response Rate 3) B. Household Profile Rate C. Household Retention Rate D. Survey Completion Rate E. Active Rate ORR1 (A*B*C*D*E) ORR2 (A*B*D) ORR3 (A*D) Table 1: Response Rates 2010 17.2\% 2012 17.2\% 61.5\% 61.5\% 35.0\% 35.0\% 70.0\% 57.3\% 99.2\% 2.6\% 7.4\% 12.0\% 99.2\% 2.1\% 6.1\% 9.9\% Appendix B displays the demographic profiles of both samples. 6 Measures Knowledge and Certainty Respondents were asked 18 knowledge quiz questions, probing whether specific provisions were in the health care bill. Respondents read one description at a time and indicated whether they thought the provision was “in the bill” or “not in the bill” that Congress passed in 2010. Twelve of the elements were principal provisions of the ACA. The remaining six elements were not in the bill but had been frequently discussed in public debate; these elements were identified by experts at the Associated Press and researchers at Stanford University. Appendix A shows the instructions for respondents, the full list of questions, and the correct answer for each item. Following each quiz question, respondents were asked, “How sure are you about this?” The answers “extremely sure” and “very sure” were coded 1 (certain), and the answers “moderately sure”, “slightly sure”, and “not sure at all” were coded 0 (uncertain). To measure each respondent’s level of knowledge, we first computed the percent of the 12 provisions of the ACA that the respondents correctly identified as such with high confidence. Next, we computed the percent of the 6 provisions not in the ACA that the respondent correctly identified as such with high confidence. Then, we averages these two percentages to yield a final knowledge score for each respondent. Consequently, the fact that twice as many questions tapped knowledge about provisions in the bill as tapped provisions not in the bill did not cause the final index score to be based more on understanding of the elements in the bill than on understanding of the elements not in the bill. The final knowledge score ranged from 0\% for people who did not identify any provision correctly with high confidence, to 100\% for people who properly identified all provisions with high confidence. Evaluation of the ACA In the 2012 survey, respondents were asked, “In general do you favor, oppose, or neither favor nor oppose the law changing the health care system that the U.S. Congress passed in March 2010?” The responses “favor strongly” and “favor somewhat” were coded 1 (indicating favoring), and the responses “neither favor nor oppose”, “oppose somewhat”, and “oppose strongly” were coded as 0 (not favoring). Support for ACA Plan Elements Respondents were also asked to indicate whether they favored or opposed each of the 18 provisions addressed by the quiz questions. On each screen, respondents were asked “Do you favor oppose this change?” along with a statement des ... Purchase answer to see full attachment