With ACA, ambivalence seems best course

The Affordable Care Act (ACA) has become the policy equivalent of cheese-stuffed pizza crust or reality show housewives. The American public disapproves of their existence while simultaneously ensuring they endure. For that, providers should breathe a sigh of relief.

"Obamacare" ambivalence rules the realm. A Kaiser Family Foundation poll reports that  57 percent of those without  health insurance disapproved of the law. That's nearly as many respondents who didn't know they could receive financial assistance to buy coverage (46 percent), didn't know that the government was expanding Medicaid (51 percent) and didn't know that insurers could no longer deny coverage due to pre-existing conditions (53 percent),  And 55 percent said lawmakers should accept and improve the law.

Meanwhile, CNN reports that at least 9 million people have signed up for some form of coverage to date--that's probably not as many people who eat pizza or watch "Real Housewives," but it's enough to keep the law moving forward.

And now that the ACA is here to stay, the Republican party has ceased demonizing it and halted their robotic threats to repeal it. They've even offered their own alternative, a mouthful known as the Patient Choice, Affordability, Responsibility, and Empowerment Act. But it will merely be employed as a stump speech pivot during the upcoming mid-term elections. And that should also be a relief for hospitals and their patients.

One factor that is missing from this alternative proposal is Medicaid expansion. The plan would roll back eligibility  to 100 percent of the federal poverty level. That's a particularly cruel move. A recent study by Health Affairs projected as many as 17,000 people will die in the next year in the two dozen states that have refused to expand eligibility.

Another concern with the proposal is the bar on pre-existing conditions--if consumers didn't have insurance in the past 18 months, insurers don't have to offer them coverage. And the oldest enrollees could pay up to five times what younger enrollees pay for coverage, compared to the one-to-three ratio of the ACA. That could be a nearly 70 percent premium increase for those age 50 and older.

In other words, forget the poor, long-term unemployed and the aging, who may have had to give up their coverage in order to keep food on the table or the lights on. And forget the hospitals as well-- they would be completely on the financial hook for their care.

Ditto for the middle class. Under the ACA, the premiums they pay are 100 percent tax deductible. The new proposal scales that back to 65 percent, as well as slashes the income cutoff for receiving tax subsidies to about $70,000 a year for a family of four, down from the current $94,000.

Translation: The proposal will mean lots more people wouldn't get coverage and couldn't pay their bills when they get sick.

Of course, I was amused that Forbes, not exactly warm and fuzzy for the ACA, declared the alternate plan as a huge tax increase on the middle class (while feigning amnesia about the proposed rollback of subsidies).

Another bit of ambivalence centers around Rep. Cathy McMorris Rodgers (R-Wash.)  who delivered the "official" response to President Barack Obama's State of the Union speech (four members of Congress delivered some form of retort). Rodgers said the ACA "wasn't working"--something along the lines of a reprobate child who won't get off the couch to look for a job. She cited a constituent known as "Bette" who was facing another $700 a month in premiums.

But the consituent, Bette Grenier,  does not have feet of clay--more like a head of rock, according to the Spokesman Review. She has refused to look at her options on the state health insurance exchange, even though she admitted a friend of hers found a policy for $129 a month.

Meanwhile, Timothy Egan of the New York Times noted that the rate of signups in McMorris Rodgers' Spokane district for coverage either through Washington's state-operated exchange or Medicaid has exceeded the statewide averages.

But the ACA's "whatever" parade wouldn't be complete without the frenemy-like support of some of its biggest champions. Minority Leader Nancy Pelosi (D-Calif.), who probably played the biggest role of any member of Congress in getting the ACA passed, couldn't rouse herself during a recent appearance on "The Daily Show" to say outright that the law is working. Kathleen Sebelius, secretary of Health and Human Services, had a similarly dispiriting discussion with Jon Stewart a few months before.

Is it asking too much for the champions of the law to provide at least a fraction of the enthusiasm for the ACA that its opponents have had in tearing it down?

Apparently not. But if that's what makes healthcare reform work, whatever. I guess. I plan to consume bad pizza and even worse reality TV while awaiting for the next chapter to unfold. Ron (@FierceHealth)