It's no secret that 2010's Affordable Care Act is unpopular - except when it's not. Reuters/Ipsos polling reveals a remarkably high level of approval for nearly all the provisions of the act, often in the 80 percent range, even though respondents oppose the legislation, commonly known as "Obamacare," by 55 to 45. Remarks made during the October 3 presidential debate added confusion rather than clarity to the healthcare issue.
Polled in midsummer, shortly after the Supreme Court upheld most of the ACA law, almost two-thirds of respondents favored allowing those under the age of 26 to keep their parents' coverage. Eighty-two percent supported a ban on denying coverage because of preexisting conditions, and 86 percent agreed companies should not be allowed to cancel policies when the owners become ill.
Similarly, 80 percent favored the creation of insurance pools and a ban on the lifetime healthcare cost cap. Almost 70 percent supported regulating private insurance companies to make sure they offer comparable coverage.
Despite Republican grumbling about how the changes could harm businesses and the economy, almost three-quarters of respondents favored requiring companies with 50 or more employees to provide coverage. All these provisions are part of ACA, although some of them do not take effect until 2014.
How such popular measures became the Achilles' heel of the Obama administration - only 21 percent strongly approved of the president's handling of healthcare in a September poll, while 34 percent strongly disapproved - can be traced to a single term: "the individual mandate."
The requirement that all citizens obtain healthcare coverage was opposed by 59 percent of respondents in the summer poll and has been lambasted by critics as a step toward "socialized medicine" and a "welfare state." Yet more than 53 percent of respondents strongly agreed that all Americans have a right to healthcare. A substantial 75 percent support subsidies to help the poor pay for health insurance, and 64 percent are in favor of expanding Medicaid to families with incomes under $36,000.
Architects of the ACA understood that unless everyone is covered the insurance risks cannot be spread broadly enough to make healthcare affordable - that you cannot have the popular features without the mandate. "No one is over the moon about the mandate, but it is necessary to provide those provisions people need and support," a Democratic official in Ohio said. But did it fail to adequately explain this in selling ACA?
In July, Obama told CBS News his first term's biggest mistake was prioritizing policy far above messaging. A version of this criticism has been one of the most persistent knocks on Obama's tenure from the left.
Jonathan Gruber, a Massachusetts Institute of Technology economics professor who advised the White House on the Affordable Care Act as well as Massachusetts on the law enacted by Governor Mitt Romney in 2006 doesn't buy it. "I spend a lot of time trying to critique moves made by the general manager of the Red Sox. But at the end of the day, he's better at this than I am," he said. "It's the same thing with Obama. If there was an easy, good message, they would have found it."
Paul Starr, a Princeton University professor who advised President Bill Clinton on his healthcare policy, said the law's timing has also hindered its popularity. "I know people all the time blame the messenger, but the particular problem this time has been the extraordinary delay in implementation," he said.
"Until people actually see how this works in practice, they are going to be susceptible to all kinds of fears about it, and won't have a very clear idea about what it is."
The individual mandate was also a central feature of Governor Mitt Romney's 2006 healthcare reform in Massachusetts, which continues to enjoy broad support. But as a candidate for president, Romney appears to believe that you can expand coverage without getting everyone insured: Although he has vowed to overturn ACA "on day one," he has also said he supports some of its popular features, and reaffirmed in Wednesday's debate that he would prohibit discrimination against preexisting conditions.
But a Romney campaign official explained that this will apply only to "people who have maintained continuous coverage." He added that Romney supports giving states the flexibility and resources to craft programs that will assist those who cannot afford coverage on their own to obtain access to the care they need."
In July, 57 percent of respondents said the American healthcare system is headed in the wrong direction, but only 29 percent preferred Mitt Romney's plan for healthcare. Forty-one percent preferred Obama's approach, despite the dramatic ambivalence about ACA.
(Additional reporting by Sam Youngman and Eric Johnson; Editing by Lee Aitken and Prudence Crowther)