Klein/Kliff on Part D and the ACA

Ezra Klein and Sarah Kliff just posted a worthwhile long-read on implementation of the Affordable Care Act (ACA). One part at the end caught my attention because it relates to the theme of my recent JAMA Forum post.

Months before it launched in 2006, Medicare Part D was less popular than today’s Affordable Care Act: 21 percent of the public viewed it favorably while 66 percent did not understand how it would work.

The rollout was a disaster. Some seniors who earned too much to qualify for subsidies received them anyway. Some low-income enrollees who should have received financial aid didn’t. On Fox News Sunday, then-Minority Leader John Boehner didn’t mince words. “The implementation of the Medicare plan has been horrendous,” he said.

Today, Medicare Part D has more than 50 million beneficiaries and is extremely popular. In a survey last October, over 90 percent of enrollees described themselves as satisfied. “The temporary issues were just that, temporary,” said Mark McClellan, who led Medicare during the rollout. “The memories didn’t last that long. In the end, it comes down to how good the insurance coverage is.”

Should we expect a similar trajectory of popularity for the ACA?

The administration contends its signature legislative accomplishment is on a similar trajectory. In fact, officials say, it’s already working better than expected. A recent study by Avalere Health found that the premium bids in the marketplaces were coming in below the Congressional Budget Office’s early estimates.

But Medicare Part D didn’t face the kind of sustained political opposition that Obamacare faces. In 2006, the Senate Special Committee on Aging held a hearing on the then-flailing program. Rather than calling for repeal, Sen. Herb Kohl of Wisconsin, then the top Democrat on the panel, said it was important “to put aside any partisan thoughts to work together to get this program running.”

Though I disagree with many of the arguments offered and “facts” cited by those who oppose the ACA, they are entirely within their rights to do so. However, as I wrote, I expect such vocal opposition to make a difference in program participation. The prior work I described is fully consistent with the view that the more public figures denounce a program, the less those who trust those figures participate. Indeed, isn’t that the point?


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