One year ago today, President Barack Obama signed the Affordable Care Act into law. Despite all the controversy that preceded the bill's passage, most health policy experts confidently predicted that the public would soon embrace the legislation.
To back up these predictions, they pointed out that Medicare was quite controversial when it was established in the 1960s but rapidly grew in popularity. Much the same happened more recently with Medicare Part D, the law championed by President George W. Bush to extend Medicare coverage to medications.
Recent polls belie these predictions, however, as support for health care reform has hit an all-time low.
Why has the act failed to capture public support? Our research provides a novel explanation, one that pundits have failed to recognize to date.
Obama's health reform bill is unpopular not simply because it is complicated, nor simply because it costs government money at a time when people are in a mood to balance the budget. Instead, it is unpopular in large part because it no longer feels inevitable.
The key to gaining widespread support for Obama's signature piece of domestic legislation is not to help the public better understand the intricacies of the bill, but instead to convince the public that the bill is here to stay.
Uncertainty can play a large role in reducing support for legislative actions. Consider a study we conducted in which we asked people to imagine their local government had recently passed a bill to lower the speed limit, legislation spurred by new evidence that such a law would save lives. The people we surveyed embraced the new rule, feeling thankful that legislators were paying attention to public safety.
However, in assessing public attitudes toward this bill, we conducted an experiment in which we told some of the people we surveyed that the Legislature was about to pass the law but hadn't yet voted on it — that is, it wasn't officially a law yet. These people, in contrast to the first group, felt strongly that such legislation would be heavy-handed and paternalistic.
The same bill, when passed into law, was viewed more favorably than when it was merely pending legislation.
What about health care reform, then? It has passed into law.
With some of its provisions already benefiting people — young adult children able to receive insurance coverage through their parents, insurance companies already forbidden from excluding people for pre-existing conditions, relief for Medicare enrollees burdened by high drug costs — shouldn't it be gaining in popularity?
Not if people don't believe the bill is the law of the land. When the Republican-led House voted to repeal the bill, its action was recognized by Washington insiders as a symbolic gesture with no legislative consequence.
But many Americans thought this vote had actual legal implications. In fact, recent polls show that one-fifth of the American public currently believe the act has been repealed, and another fifth are unsure if the bill still stands as law. This misperceived state of affairs provides no reason for these Americans to embrace a law they believe no longer stands.
Recent court rulings have created even greater uncertainty about the legal standing of the act. While most rulings have focused solely on the constitutionality of the health insurance mandate, one judge went as far as to opine that the entire law should be voided. This has left even more people wondering where the bill stands: as current law, pending law or past law?
Behavioral science has shown us that most people find uncertainty to be a very difficult pill to swallow, especially when it surrounds a proposed change to their lives. Half-hearted attempts at change often produce knee-jerk, negative reactions; people are not inclined to adapt to a change that may never occur or seems unlikely to stick. These are the types of situations most likely to breed backlash.
But when the uncertainty is removed, backlash reactions tend to dissipate and sometimes even reverse. When people know what cards they have been dealt — when they feel confident about what to expect in the future — people tend to begin the process of rationalizing the change and adapting to it.
The real battle over health care reform in the next few months will extend beyond the specifics of budget debates and regulatory wrangling. Instead the fate of health care reforms stands mainly on how soon, if ever, the public come to feel that the legislation is enduring. If the permanence of the Affordable Care Act continues to feel unsettled, that will become a self-fulfilling prophecy.
Peter A. Ubel, Aaron Kay and Gavan Fitzsimons are all behavioral scientists at Duke University.