You’d expect the National Federation of Independent Businesses (NFIB) — a lobby that has practically aligned itself with the Republican party and is a co-plaintiff in a lawsuit challenging the constitutionality of the Affordable Care Act — to release a survey that substantiates the GOP’s most popular criticisms of the law: it’s a job killer that will force businesses to stop offering health care coverage. But that’s not the story the group’s latest report, One Year After Enactment Of PPCA, tells. Instead, the group’s survey of small businesses finds that less than half of employers are familiar with the law (which itself says something about what they think about its impact) and relatively few expect to drop coverage as a result of it:

– The number of small employers offering employee health insurance has not changed appreciably in the last 12 months, the post-PPACA passage time frame.

– The number of small employers offering employee health insurance is likely to change little over the next 12 months. Virtually no small employer now offering expects to drop health insurance in the next year and virtually no nonoffering employer expects to add it in that time frame.

–[M]ost small employers indicate they will not drop unless a large number of employees leave. The survey did not ask if they had actually calculated the possible cost savings of doing so. Nor did it ask if they would drop their health insurance following a competitor’s lead.

– 18 percent of small-business owners claim to be “very familiar” with the highly publicized health legislation. Another 40 percent report they are “somewhat familiar” and another 24 percent say they are “not too familiar” with it. The remainder, also 18 percent, are “not at all familiar” with the new law.

The report does put a negative spin on business opinion. It concludes that “[s]mall employers think the consequences of PPACA will almost uniformly be negative. Those who have at least some familiarity with PPACA expect the new law will increase taxes, will increase the federal deficit, will not slow health insurance cost increases, will not ease their administrative burdens, and will not improve public health.”

But those fears sound a lot more like GOP talking points than a measured analysis, and they echo the concerns some employers expressed about day one, month one, and year one of the law. Those doomsday predictions have not come to pass, and if the law is implemented well, they likely never will — at least not to the degree many imagine.

Yale professors Theodore Marmor and Jerry Mashaw have an editorial in today’s Philadelphia Inquirer that offers what may be the clearest explanation for why Republican prescriptions that try to lower health care costs by forcing individuals to have more “skin in the game” are likely to have a negligible impact on spending:

Over four decades of economic analysis of American medical care, there has been a persistent emphasis on patient cost-sharing as a solution to growing public health budgets. The case for it would be straightforward if medical care were an ordinary market good.

We allocate bread and circus tickets to those willing to spend what bakers and circus managers charge. Those willing and able to pay get the services and goods, and no central authority need interfere. Hence, if we make patients pay more, those who cannot pay will do without, and total costs will go down. This is doubtless true, but most Americans do not believe medical care should be allocated that way.

Or there’s the argument that cost-sharing will get patients to forgo unnecessary care. But there is no solid evidence for this claim, and much contrary evidence. If free medical care led to more reckless overuse, countries like Canada and Germany, where patient costs are either zero or minimal, would suffer disproportionate inflation in expenditures or severe access pressures. They don’t.

Indeed, the theory doesn’t even hold up in the American health care system. As Austin Frakt pointed out recently, if individuals with higher cost sharing really do use less care, then beneficiaries in employer-sponsored insurance (who receives a 40 percent tax subsidy, on average) should spend less than Medicare enrollees — who receive a far higher government subsidy. But data from the Kaiser Family Foundation suggest that this just isn’t the case:

Republican governors who complain about the effect of Affordable Care Act’s expansion of Medicaid on state budgets, would be happy to read John Reichard’s report about the uncertainty surrounding the program’s enrollment growth. Two analysts speaking before an Institute of Medicine workshop on “health literacy” last week — Alice Weiss of the National Academy for State Health Policy and Georgetown University’s Sabrina Corlette — laid out the following challenges beneficiaries could face in applying for Medicaid of private insurance coverage through the exchanges:

1) Outdated paper-based systems: “People trying to enroll in Medicaid for example are used to a technology-enabled environment but are entering an antiquated paper-based system that involves going from office to office as part of the sign-up process. Weiss noted that according to a survey by the Pew Charitable Trusts, 35 percent of American adults now use smart phones, enabling them to download information from the Internet.”

2) Language barriers: “One in six adults in the U.S. do not speak English, she said. Many families have ‘mixed status,’ with one parent legally in the country, the other parent an illegal immigrant and the children U.S. citizens. Trying to help them figure out how to navigate the system is going to be a challenge, she said.

3) Changing eligibility: “Weiss also noted that fluctuating income levels during the year is going to require states to find a way to shift people back and forth from Medicaid to subsidized private coverage in exchanges. “States are going to have to make that process seamless,” she said.

Corlette noted that exchange users in Utah — which established the marketplaces before the Affordable Care Act became law — “objected to having to fill out detailed questionnaires about their health histories” and claimed that the “enrollment process was not easy.” Seventy-four percent “said they used a broker to help.” “In Massachusetts, people going to exchanges initially complained that there were too many plans to pick from and that they were overwhelmed by the level of choice.”

A lot of this rests on the shoulders of the various state systems and the state government’s willingness to adopt reforms that would help establish the kind of “enrollment superhighway” that federal health care reform advocates envisioned. But given the concerns about increasing Medicaid costs, some governors — particularly those who are not interested in expanding public health programs — may be less than willing to adopt changes that aim to increase enrollment and expand the state’s spending on Medicaid. Should that occur, health care reform will fail to bring much needed uniformity to the country’s patchwork of a health care system.

As a wave of abortion restrictions sweeps the nation, a new Gallup Poll conducted between July 15-17 finds that “large majorities of Americans favor the broad intent of several types” of laws limiting access to abortions, but have very “mixed or negative reactions to others.”

An overwhelming majority — 87 percent — supported “informing women of certain risks of an abortion in advance of performing it,” and 70 percent backed “requiring parental consent for minors and establishing a 24-hour waiting period for women seeking abortions.” Fifty-seven percent, however, said they opposed “laws prohibiting health clinics that provide abortion services from receiving any federal funds”:

Interestingly, the partisan divides are far greater than differences of opinion based on gender:

As the Guttmacher Institute reports, 19 states enacted 80 new anti-abortion laws in the first half of 2011, “up from 23 such laws enacted in 2010 and shattering the previous record of 34 set in 2005.” Eight states have passed laws restricting abortion coverage that is “offered in any private health plan (including coverage through an exchange), and six others have restrictions that apply only to coverage through health exchanges.”