Confusion, Division Run Deep as Health Care Reform Goes to the Supreme Court

Tea Party supporters attend a rally in Searchlight, Nev., in 2010. Photo by Robyn Beck/AFP/Getty Images.

Love it or hate it, most Americans don’t understand the health care reform law.

As the Supreme Court prepares for next week’s arguments on the constitutionality of the Affordable Care Act, six of every 10 Americans say they don’t know enough about the basics of health reform to judge its potential impact on their lives.

Four in 10 aren’t even sure whether it’s still the law of the land or they think it’s already been overturned. And roughly 60 percent seem fine with the confusion — they say they’re either not closely following news of the looming health reform case or they’ve tuned it out altogether.

That’s all according to the Kaiser Family Foundation’s latest poll. Claudia Deane, associate director of the foundation’s Public Opinion & Survey Research team, has been taking the nation’s health reform pulse since the law was just a highly controversial bill. And from the start, she says, many Americans reacted to all the complex policy talk and political noise by hunkering down in their respective camps and refusing to budge.

This interactive poll breaks it down a little further — by party ID, gender, income, age, race and insurance status. Check it out, then read our Q&A with Deane for some context.

Where do Americans stand on health care reform today?

Deane: Americans are incredibly divided on health care reform. To me, the amazing thing about public opinion on this topic is that, despite the incredible number of events that we’ve seen over the past two years — the beginning of implementation, repeal on the House floor — we really haven’t seen opinion change that much. Right now, we are showing Americans evenly divided. Forty-one percent support the ACA, 40 percent oppose it, and 19 percent are undecided. We’ve been in the field with the survey every single month and we have seen a very similar, even pattern. To the extent that there has been a tilt, it’s been toward opposition. But we’ve never gone extremely far in that direction. Overall, it’s a very divided public.

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How do those numbers compare with public opinion in the lead-up to the law’s passage?

Deane: We saw from the very beginning that these proposals never managed to obtain majority support. Neither did opponents of the proposals manage to get majority opposition. What we saw again was just a big divide in the public. I wouldn’t have been able to predict this, but we probably could have saved ourselves a lot of money and just skipped about half of those polls in the middle, because really, like I said, there has been incredible opinion stability. I’ve been doing this for a number of years now and I really haven’t seen too much like this, especially during such a volatile time.

Now, I say the public’s divided, but there are some real overarching gaps underneath that divide. The main one is a partisan gap. Even though overall we get the public half and half, if you ask people to self-identify as Democrats or Republicans — how they think of themselves in everyday life — what you see is most Democrats, at passage and now, say that they like and support this law. There has not been a big change there — something like six in 10. On the other side of the spectrum, Republicans never liked this law. They didn’t like it before passage, they didn’t think we needed to take on health care right now. And what you find now is that around seven in 10 Republicans say they oppose the law. Independents tend to be divided and sort of tilting negative.

The other thing we see is an intensity gap between Democrats and Republicans so that among those Republicans who say they don’t like the law, most really don’t like it. Most Democrats are a little less enthusiastic. They are not as likely to hold strong opinions. They like the law and leave it at that.

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What does that firm and consistent partisan divide tell us?

Deane: Certainly for something like health care, it affects people in different phases of life differently — if you’re older, if you have less money to afford your own health insurance, etc. And we’ve looked at all of those divides consistently, but the partisan divide is the one that is largest and most consistent over time. And what that says to me is that this law is still being seen through an ideological lens. It is not yet being seen as something that is a practical change in people’s lives. And that’s because the major provisions of this law have not yet been implemented. So people are thinking about this as a political issue. We all know we’re in the middle of an extremely political year — a presidential campaign year. And people are seeing it through that lens.

We found in our surveys that over two-thirds of Americans say they haven’t been impacted either way by the ACA yet. And that’s probably about right. It’s not something tangible for a lot of people. It’s been difficult for supporters of the law to convince people that they will benefit some time in the future. A lot of the major provisions don’t kick in until 2014, and we’ve never seen more than a third of Americans say that they think they’ll be better off under this law. About the same percentage say they’ll be worse off and a bunch in the middle don’t think it will affect them either way.

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Since the beginning, there’s been a lot of confusion around health reform. Is that still true today?

Deane: There’s an enormous amount of confusion. And again, there really hasn’t been much change. We were in the field a month after passage in 2010, and we found that just over half — 56 percent — were saying they didn’t have enough information about the law to understand how it would impact them personally. Fair enough. Well here we are two years down the line — March 2012 — and we’re seeing the same numbers. Fifty nine percent are now saying that — a tiny bit higher.

We also see a lot of misinformation still out there. For example, we’re coming up to the Supreme Court case and we found that four in 10 Americans aren’t sure whether the ACA is still the law of the land or perhaps they think it’s already been overturned. So there’s basic confusion around the status of the law.

And then in terms of the different rumors that have gone around, we find that just over half of Americans aren’t sure whether “death panels” are in the law, which they are not. We find that seven in 10 aren’t sure whether there’s a government-run insurance plan being offered, which it’s not. For your everyday person — your aunt in New Jersey — it’s difficult to keep up with all of this. You hear a lot of loud noise about it and it becomes hard to sort through exactly what’s going on.

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We know that the public is sharply divided on the law itself, but some of the individual provisions are quite popular, right?

Deane: One hallmark of public opinion on the ACA has always been that people like the parts of the law much more than they like the whole. When it comes to the parts, almost everything is quite popular. Even the big, sweeping provisions and certainly the more targeted, early implementation provisions, like putting your dependents on your health insurance through age 26. When we surveyed the public on this in the summer of 2010, right before implementation, seven in 10 had a favorable view of the provision.

But even the idea of the exchanges are quite popular — eight in 10 back those. Seventy one percent support subsidy assistance. Seventy percent favor the Medicaid expansion. Tax credits for small businesses — that gets at least 75 percent approval across Democrats, Republicans, and independents. Same with the provision requiring easy-to-understand health plan summaries. Really, the one provision that is not popular is the individual mandate, which is the requirement that people have health insurance after 2014. In our March survey, 66 percent of Americans had unfavorable views of the mandate.

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Do you know anything about how people would feel about the law if the individual mandate were removed?

Deane: We’ve asked about this a fair amount and most people didn’t anticipate that it would change their views. We know that the individual mandate is the least popular provision of the law, but most people see the entire law through a very ideological lens. So removing it wouldn’t make much of a difference in how they feel. Most people think that parts of the law will be implemented anyway, so striking down the individual mandate won’t make much of a difference. Policy wonks may not feel so unanimous, but in terms of the public, they just seem to think that much of the law is going to go on as it would otherwise.

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Are there major divides out there as far as race, age, or insurance status?

Deane: The biggest divide is partisan — every other division pales in comparison. Seniors seem to have a less favorable view of the law. These are people who are over 65 and are eligible for Medicare. Opponents of the law often say that some of the cost savings in the law will come from changes to the Medicare program. Proponents of the law say that’s not true and that the law will actually benefit seniors, but that message doesn’t seem to have gotten through as much. So up to this month, unfavorable views among seniors have outstripped favorable views by roughly 10 percentage points, sometimes up to 20 and above. This month we saw, for the first time, favorable views of the ACA pull even with negative views among seniors (44 percent favorable, 42 percent unfavorable), so we’ll be watching to see whether that’s the beginning of a trend or just a blip in the radar.

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As far as differences by race, blacks and Hispanics tend to be more supportive of the law. That could be because most African-Americans tend to identify as Democrats, and Democrats tend to favor the health law. One interesting trend we found is that the uninsured are not particularly more likely to back the law than the insured. That surprised me. Aren’t we supposedly about the politics of self-interest? In this case, it didn’t play a role. We did find that only about half of the uninsured are aware of the subsidies and expansion of Medicaid that are part of the law. So it could be tied to a lack of familiarity or that people are just seeing the law through a purely political lens.

Tell us about your most recent poll. How do Americans feel about the chances of repeal — and the Supreme Court in general — as we head into arguments next week?

Deane: The good news is the Supreme Court is much better-respected than Congress. Seven in 10 of the people we polled said they have some confidence in the court. About a quarter said that it’s too conservative and just as many said that it’s too liberal. Americans have mixed views on how the Supreme Court makes its decisions. We found that a number, roughly half, thinks the judges make their decisions based upon liberal or conservative ideology or whether they were appointed by a president who was a Republican or Democrat, and they’re not so enamored with that.

As for the health reform suit, about half — 53 percent — think that the court will rule the individual mandate unconstitutional, a third — 33 percent — expect it will be found constitutional, and 14 percent weren’t prepared to hazard a guess. It’s worth noting that most Americans weren’t following news about the Supreme Court case all that closely as of the start of the month: just under four in 10 — 37 percent — said they were following it at least “fairly closely,” while the majority — 63 percent — said they weren’t following the news of the case too closely or weren’t following it at all.

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Are you confused about all the health care reform and Supreme Court chatter? Watch a NewsHour primer on next week’s argument’s here. Catch the broadcast March 26-28 for nightly analysis from NewsHour health correspondent Betty Ann Bowser, Marcia Coyle of the National Law Journal and Susan Dentzer of Health Affairs. And of course, check the NewsHour’s Health Page regularly for more online-exclusive content.

Have a question about the Affordable Care Act or the Supreme Court case? Ask them here and on Twitter using hashtag #HCRchat.