News & Analysis

Challenges Ahead Major challenges remain for the affected countries and international groups working to eliminate the transmission of Ebola. The already fragile health systems of Liberia, Guinea, and Sierra Leone have suffered serious damage. More than 800 health workers have had confirmed Ebola infections and at least 488 have died of the disease, according to the WHO. Liberia is just beginning to reopen hospitals shuttered during the epidemic, and MSF is running mobile clinics to help meet primary care needs. “An added struggle is the paralysis of the public health system [in Sierra Leone],” said Karline Kleijer, MSF’s emergency coordinator, in a statement. “One in ten of the country’s health workers have died of Ebola, the medical facilities are in disarray, and people with non-Ebola illnesses struggle to get the treatment they need,” she said. Some populations have been difficult to reach, such as those communities in

forested areas of Guinea, or are resistant to public health measures aimed at reducing the spread of Ebola virus disease. In certain regions, it is customary to wash the body in preparation for burial, explained Damon. If proper precautions are not taken during this process, the high levels of virus still present on the body may infect others. Damon said that the CDC and others are working to develop alternative, safe burial practices, “that are respectful of religious beliefs and allow the family and clergy to be appropriately attired and protected.” Although sustained reductions in infection rates would be welcome news, the dwindling number of new infections could pose challenges for clinical trials that rely on large cohorts of patients to produce robust results. Already, Chimerix, the manufacturer of brincidofovir, ended its participation in the University of Oxford–led clinical trial of the drug for Ebola treatment, citing declining case numbers in Liberia (http://bit . l y/ 1 8 H J q h 0 ) .

Nonetheless, even trials with inadequate statistical power to demonstrate efficacy can still provide useful safety and subgroup efficacy data that can be used to gain approvals for an intervention, Fauci explained. Schuchat noted that the CDC Sierra Leone trial testing the efficacy of the yet-to-be-chosen vaccine has been designed to account for reduced cases. Some emerging evidence suggests that the Ebola virus might be evolving (Kugelman JR et al. MBio. doi:10.1128/mBio .02227-14 [published online January 20, 2015]). Geisbert and his colleagues are currently investigating genetic changes in the Ebola virus and acknowledge that this presents a valid concern, particularly because such changes could influence the effectiveness of experimental interventions in development. “Our work is focused on the leading candidate vaccines and therapies and making sure they still protect [against mutated forms of the virus],” he said.

The JAMA Forum

Why Does the Affordable Care Act Remain So Unpopular?


n mid-November, just as the second enrollment period for health insurance under the Affordable Care Act (ACA) was starting, a Gallup poll indicated that only 37% of the US public approved of the ACA—a record low percentage (

Since the ACA was passed in 2010, its overall approval rating has never been high, generally hovering in the low-to-mid 40% range. Approval of the law took a conspicuous dip in November 2013 after several million people received notices that their current policies were being cancelled. Not surprisingly, approval varies sharply by party: 74% of Democrats approve of the ACA vs only 8% of Republicans. What is more noteworthy is that the approval rate among political independents is also low, only 33% as of November 2014. Enthusiasm for the ACA has decreased even among nonwhites, who disproportionately identify as Democrats, with only 56% favoring the law compared with the 76% who reported they liked it when it passed.

Popular ACA Provisions

Gail Wilensky, PhD


The ACA’s supporters have pointed out that some of the law’s features are very popular, much more so than the legislation as a whole ( This is particularly

true for some of the insurance reforms, such as provisions that require insurers to allow young adults to stay on their parents’ health insurance policy until the age of 26 years, that prohibit insurance companies from denying coverage for preexisting conditions or charging enrollees higher rates because of preexisting conditions, and that limit the variations in premiums allowed for enrollees of different ages. Before the ACA’s passage, these changes were mentioned most frequently by President Obama in promoting the legislation’s passage and continue to be cited as important reforms associated with the law. What is rarely mentioned is that these popular measures carry almost no governmental costs (the higher insurance costs they produce are spread across everyone who buys insurance). What’s more, these measures could have been enacted as part of a narrow package of insurance reforms, providing many of the protections already provided to people with group insurance to

JAMA March 10, 2015 Volume 313, Number 10 (Reprinted)

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American Medical Association

Gail Wilensky, PhD

News & Analysis

Because many of those cancelled insurance policies purchased in the individual market were very costly or provided limited coverage, they were not highly regarded either Why Is Support for the ACA so Tepid? Before 2014, I had assumed that once the by their purchasers or by insurance experts. coverage expansions began, those who ben- But not everyone who purchased insurance efitted from the new subsidies for private in- in the individual markets had been unhappy surance or expanded Medicaid coverage with their coverage and some were unwould be supportive of the legislation while happy to lose those options. For example, under the ACA, single inmost others would be neutral or indifferent. But that has clearly not been the case. dividuals and middle-aged couples were So why does this legislation continue to re- being told they had to have policies that inceive such low enthusiasm from the Ameri- cluded maternity care, full dental coverage for children, and other coverage features of can public? It is possible that ACA’s low approval rat- little use to them. Requiring the purchase of ings are in some way related to President comprehensive benefits was probably not Obama’s relatively low job approval ratings objectionable for those with incomes low Gallup’s daily polling ( enough to receive substantial subsidies. But indicated that the average approval rating for many middle- or upper-middle-income the President from December 1, 2014 couples or individuals who would receive through January 4, 2015 was 44%). If the 2 small subsidies or no subsidies at all were unhappy at being forced to Assessing a penalty to people who delay buy a product they didn’t want buying health insurance until they need that was more it is a way to compensate for the cost expensive than they impose on others. their previous coverage. The approval ratings are related, however, it’s not cancelled policies also made a mockery obvious whether one is causing the other or of the President’s assurance that “if you whether both reflect generalized dissatis- like your coverage, you can keep your faction with the President and with the di- coverage.” rection in which his leadership is taking the It remains a mystery why the Presicountry. The large loss in the number of Sen- dent made that statement (repeatedly)— ate and House seats held by Democrats is and the related claim that “if you like your certainly consistent with a generalized mood doctor, you can keep your doctor.” I have of public disapproval. been asked by reporters both on-camera There may, however, also be factors spe- and off-camera whether I thought the cifically associated with the ACA that con- President knew that was a promise he tribute to its low approval rating. The ACA couldn’t keep. I, of course, have no idea disapproval rate was almost as high in the fall what the President knew, but his policy of 2013 as it is currently; it presumably re- advisers had to know these were promises flected dissatisfaction with the rollout of the that weren’t the President’s to make. dysfunctional insurance exchanges in most Maybe they thought that so few would be parts of the country and the anger re- affected that it wouldn’t matter, or that ported by many individuals who were noti- people who had been without insurance fied that their health insurance was being would be so happy to have it available that cancelled because their policies didn’t com- these cases would seem unimportant. ply with the ACA’s requirements. Whatever the gain at the time, I believe the those who purchased insurance in the individual marketplace.

repercussions have been significant and have contributed to a view held by some that the current leadership can't be trusted ( But pushback against the individual mandate (the ACA’s provision that requires most individuals to have a minimum level of heath insurance coverage) may be the strongest reason for the continued disapproval rates ( This antipathy is likely to only get worse if the Internal Revenue Service begins to assess penalties to those who remain uninsured. What I find frustrating is that the whole national trauma associated with the mandate might have been avoided if the administration had followed the lead of Medicare. Medicare doesn’t require seniors to buy Part B coverage (which covers physician payments) or Part D (which covers outpatient drugs). But if seniors choose to buy either coverage after the enrollment period ends a few months after their 65th birthday or after they stop being covered by group employment insurance, they are penalized for every month they delay their purchase. I realize seniors tend to be more risk-averse than younger individuals, but at some point, most people will want or need coverage. Assessing a penalty to people who delay buying health insurance until they need it is a way to compensate for the cost they impose on others. This strategy would surely have been worth a try. Author Affiliation: economist and Senior Fellow at Project HOPE, Millwood, Virginia. Corresponding Author: Gail Wilensky, PhD ([email protected]). Published online January 7, 2015 at http: // Disclaimer: Each entry in The JAMA Foum expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. Additional Information: Information about The JAMA Forum is available at http://newsatjama.jama .com/about/. Information about disclosures of potential conflicts of interest may be found at http: //

(Reprinted) JAMA March 10, 2015 Volume 313, Number 10

Copyright 2015 American Medical Association. All rights reserved.

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Why does the Affordable Care Act remain so unpopular?

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