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What Americans Really Think about Health Reform

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University of Minnesota
Scholars Strategy Network Founder and Director
Harvard University

Hardly a week goes by without headlines blaring that “most Americans” oppose President Obama’s health reform. Opponents of the 2010 Affordable Care Act wield national polls to proclaim that voters favor repeal. But a careful look at the evidence paints a different picture.

Americans are split in their overall assessment of the law scheduled to take full effect in 2014. Most have not yet experienced any impact, and nearly half acknowledge that they remain unsure what reform entails. When survey respondents hear objective descriptions of actual reform provisions, bipartisan majorities support most of them. Even with incomplete and hazy public understanding, only a fraction of Americans want Affordable Care to be fully repealed.

Divided on the Whole, but Favorable to Most Parts

As the most rigorous organization polling on health reform, the Kaiser Family Foundation regularly asks Americans whether they have a “generally favorable or generally unfavorable opinion” of the “health reform bill signed into law in 2010.” As of April 2012, 42% were favorable, and 43% unfavorable – very close to the split ever since the law was passed. Republicans are overwhelmingly and strongly opposed, Democrats generally supportive, and Independents divided. Higher levels of opposition register in polls (such as those by Fox News) that name President Obama and turn a question about health reform into a referendum on him.

When asked about specifics, most people (including many Republicans) are very supportive:

  • 71% approve “financial help to low and moderate-income Americans who don’t get insurance through their jobs to help them purchase coverage.”
  • 60-69% favor prohibiting “insurance companies from denying coverage because of a person’s medical history.”
  • 78% approve the law’s gradual closing of “the Medicare prescription drug ‘doughnut hole’ or coverage gap” to help affected senior citizens afford their medication.
  • 71% favor the rule that allows “children to stay on their parents’ insurance until age 26.”
  • 80% favor “tax credits to small businesses that offer health insurance to their employees.”
  • 57% approve requiring “insurance companies that spend too little money on health care services and too much on administrative costs and profits to give their customers a rebate.”

Narrower majorities support the rule that employers with more than fifty workers must provide health coverage or pay a fine, favor taxes on upper-income Americans to pay for reform, and favor the rule that insurance plans must offer minimum benefits “defined by the government.”

The Mandate Muddle

But two-thirds or more of Americans, including many Democrats, disapprove of one core provision of the Affordable Care Act – the so-called “individual mandate” rule that everyone must purchase basic health coverage or else pay a fine. Like the requirement for drivers to have auto insurance, this rule is meant to keep uninsured people from shifting costs for accidents or illness onto their neighbors who buy insurance and pay taxes.

Although the idea originated with conservatives, opponents of Affordable Care have waged fierce legal and political battles against the mandate and have succeeded in spreading confusion. Many Americans do not understand that everyone will have subsidies or tax credits to help make insurance affordable, and many worry the mandate will apply broadly (when, in fact, fewer than two percent might be fined for failing to purchase insurance when the law is fully in place). Nevertheless, demonization has worked; most Americans want to see the mandate eliminated.

Following the highly politicized debates surrounding the March 2012 Supreme Court hearings, many Americans also came to the mistaken conclusion that Affordable Care cannot survive if the mandate is removed. In truth, substitutes for that provision could be found, and the expansions of affordable insurance to millions of additional Americans can succeed anyway.

What Should Happen Next?

Do most Americans want all of Affordable Care thrown out by Congress or the Supreme Court? Not by a long shot, as surveys compiled by and show:

  • Fewer than four out of ten Americans support calls for health reform to be fully repealed.
  • About one in four of those who favor repeal actually want more sweeping measures. These people are not right-wing libertarians, but citizens who oppose Affordable Care because it did not go “far enough,” in the phrasing of a CBS/New York Times survey in April 2012.
  • Fewer than 20% of Americans want to “replace” reform with a Republican law.
  • About a fifth to a quarter of all Americans say they want Affordable Care to be left as it is, while another 30-33% take the view that the law should be modified but not thrown out.
  • A March 2012 Bloomberg poll gave respondents the option to say they want to “See how it works” rather than have Affordable Care “repealed” or “left alone.” Forty-six percent chose the wait-and-see option, compared to 37% for repeal and 11% for standing pat.

Despite using loud megaphones, enemies of Affordable Care have not been able to persuade Americans to support complete repeal – although many people remain unaware of the highly popular features included in the law. Reform supporters have done a very poor job communicating with everyday Americans, and a lot of confusion persists.

If Affordable Care survives, more and more citizens will learn that the law contains a lot they like. By all indications, public approval will improve as more Americans experience and understand what health care reform actually does, and what it does not do.