USA TODAY/Pew poll: Health care law faces difficult future

• New poll shows confusion and misinformation still exists about the law
• Among young people%2C just 56%25 realize there%27s a mandate to be insured
• Knowledge about the law is higher in states that are setting up their own exchanges

This story was originally published Sept. 16, 2013.

WASHINGTON -- Republican lawmakers have failed in dozens of attempts to repeal the Affordable Care Act, but a new USA TODAY/Pew Research Center Poll shows just how difficult they have made it for President Obama's signature legislative achievement to succeed.

As the health care exchanges at the heart of the law open for enrollment in two weeks, the public's views of it are as negative as they have ever been, and disapproval of the president's handling of health care has hit a new high. Confusion and misinformation about the law haven't significantly abated, especially among the law's main targets.

Among the 19% polled who are uninsured, nearly four in 10 don't realize the law requires them to get health insurance next year. Among young people, whose participation is seen as crucial for the exchanges to work, just 56% realize there's a mandate to be insured or face a fine.

And in the states that have refused to participate in the insurance marketplaces — defaulting instead to the federal exchange — knowledge about the Affordable Care Act and support for it are notably lower than in states that are setting up their own exchanges.

"There has been a full-court press from Day One from the opposition to characterize and demonize the plan," says Thomas Mann of the Brookings Institution, who wrote about the GOP efforts in a 2012 book about Washington he co-authored, It's Even Worse Than It Looks. "The campaign against the law after it was enacted, the range of steps taken, the effort to delegitimize it — it is unprecedented. We'd probably have to go back to the nullification efforts of the Southern states in the pre-Civil War period to find anything of this intensity."

Opponents say the law's own shortcomings are responsible for its travails. "This program is not ready for prime time," says Rep. Diane Black, R-Tenn., chief sponsor of a bill passed by the U.S. House last week to delay the exchanges until additional anti-fraud measures are put in place. (Like dozens of previous House-passed measures on Obamacare, it isn't expected to pass the Senate.)

When Obama signed the law more than three years ago, supporters predicted Americans would embrace it as some of the most popular provisions went into effect, including measures that have helped seniors pay prescription costs, protected children who have serious medical conditions and enabled young adults to stay on their parents' insurance plans until age 26.

But that turnaround in public opinion hasn't happened, at least not yet. Now the biggest test for the Affordable Care Act looms in two weeks, when the marketplaces for the uninsured are scheduled to open for enrollment on Oct. 1.

In the USA TODAY/Pew poll:

Opposition hits new highs: 53% disapprove of the health care law, the highest level since it was signed; 42% approve. By an even wider margin, intensity favors the opposition; 41% of those surveyed strongly disapprove while just 26% strongly approve. Fifty-three percent disapprove of Obama's handling of health care policy, an historic high. And Democrats have lost their traditional advantage on the issue. For the first time in polling that stretches back more than two decades, Americans narrowly prefer Republicans in dealing with health care policy, 40%-39%.

A boost in approval for the law that followed the Supreme Court decision in July 2012 upholding most of its provisions, to 47% approve-43% disapprove, has disappeared.

Confusion continues: Only one in four say they understand the law's impact on them and their families well while one-third say they have little or no understanding about how the law will work. Despite increasing education efforts by the administration, advocacy groups and some states, the percentage of Americans who don't understand the law has declined only modestly, to 34% from 44%, since it was passed.

Expectations are downbeat: Most haven't seen much impact from the law, but they are inclined to expect bad news down the road. Forty-one percent predict in coming years the effect on themselves and their families will be negative; just 25% think it will be positive. Even more, 47%, say the law will have a negative impact on the country as a whole; 35% expect a positive impact.

The poll of 1,506 adults was taken Sept. 4-8. The margin of error is +/–3 percentage points.

A GOP DIVIDE ON WHAT NEXT

Republicans were united in opposing the law when it was proposed, and they haven't budged since. Just 12% of Republicans surveyed favored the health care proposals being considered by Congress in the summer of 2009, when opponents flooded congressional town halls. Now an almost identical 11% of Republicans approve of the law.

Still, significant differences have developed within the GOP over what to do now that the Affordable Care Act is law, a division that could complicate the hard line party leaders are taking. The most fervent opposition, the poll finds, is driven by Tea Party Republicans; two-thirds of those who oppose the law want elected officials to do what they can to make sure it fails.

However, non-Tea Party Republicans who oppose the law are inclined to think officials should do what they can to make the law work as well as possible. Among all opponents of the law, a narrow majority, 51%-42%, want officials to help the law succeed.

Vermont Gov. Peter Shumlin, chairman of the Democratic Governors Association, says voters eventually will appreciate officials who are now "scrambling" to implement the law and create state exchanges that work. "It's been politically popular to be against the Affordable Care Act," he says. "My prediction is it's going to be much less popular when constituents understand that your political posturing is costing them affordable health care."

In the Green Mountain State, officials and advocates of the state exchange called Vermont Health Connect have held more than 200 events at community forums and local festivals. They have aired TV, radio, print and on-line ads and posted informational videos on YouTube.com. ("For Vermonters, By Vermonters," the videos declare.) Organizers expect about a quarter-million people to have signed up for private insurance or Medicaid through the exchange by next March, when open enrollment is scheduled to close.

But in Tennessee, Rep. Black says she doesn't feel comfortable giving information to constituents who call her congressional office with questions about how the program will work. Since the Volunteer State isn't setting up a state exchange, residents will use the federal exchange.

"At this point, we don't really have a good idea, because the president and the administration doesn't have a good idea," she says. And she's reluctant to refer them to so-called "navigators" who have been hired to provide guidance because of what she sees as a lack of safeguards protecting applicants' Social Security numbers and other personal information.

The decision by 27 states (all but three of them with GOP governors) against participating in a state exchange may be contributing to the law's considerable challenges.

In the 23 states and the District of Columbia that will have state exchanges, residents split about evenly on approval and disapproval of the law. In the states that are defaulting to a federal exchange, however, residents oppose the law by an overwhelming 20 percentage points.

In states with their own exchanges, 59% of those surveyed understand that an exchange will be available to people in their state. In states using the federal exchange, just 44% realize that.

WHAT'S IN THE LAW?

Most Americans know the act, also known as Obamacare, means uninsured people have to get health insurance. About seven of 10 correctly say that's the case; just 12% say it's not.

On other specific provisions of the law, however, only half of those surveyed know there will be a health care exchange available in their state. Only half are aware that there will be federal subsidies for lower-income citizens to buy insurance.

Even so, for a starting point, consider this: Nearly two-thirds of the uninsured say they plan to get health insurance over the next six months, and not quite half of them say they're going to do so because of the law. That means 12% of those who don't have insurance now plan to get it soon. That translates to millions of Americans, more than double the administration's estimate that 7 million will enroll through the exchanges next year.

Shumlin cautions there are sure to be problems ahead.

"This is not going to be a hiccup-free ride," he says. "Just from the technology perspective, there are going to be bumps in the road." But time is on the side of supporters of the Affordable Care Act, he says, once the exchanges are implemented and Americans understand how they actually work. "When constituents in states governed by Republican governors who are trying to make a political point with Obamacare figure out that their son, their daughter, is not getting health care because of their political posturing, well, I wouldn't want to be on the receiving end of that."

Black expresses equal confidence that time is on the side of opponents of the Affordable Care Act, when the exchanges open for business and Americans understand how they actually work. "Once this actually starts impacting people in their real lives, in their everyday life — 'My rates are going up; my full-time job is becoming a part-time job because of Obamacare' — once all of that starts happening, that's a negative," she says.