PRINCETON, NJ -- The Supreme Court is likely to release its landmark decision on the constitutionality of the 2010 Patient Protection and Affordable Care Act within the next week. Americans show at best mixed support for the law and widely view the individual mandate that requires Americans to have health insurance as unconstitutional.
The high court's decision could stretch anywhere from finding the entire law unconstitutional, to finding parts of it unconstitutional, to upholding all of the law -- and will have important implications, not only for the future of healthcare in the U.S., but also for the 2012 presidential race.
President Obama made passage of the healthcare act the signature focus of his first years in office. Republicans, on the other hand, generally opposed the law and have made their promise to repeal it a major part of their campaign strategy.
The full impact of the Supreme Court's decision on public opinion will likely not be evident until weeks or months after it is handed down, in part depending on how the relevant political players involved respond to and "spin" it.
Still, enough is known about Americans' attitudes about the PPACA and healthcare more generally at this point to provide some context for how they may react to the decision, whatever it is.
1. Americans No More Likely to Support the Law Now Than When It Was Passed
Although President Obama and his supporters predicted that Americans would become more positive about the law after it passed and they had time to better understand it, that has not been the case. Americans appear as negative or more negative now than they were when the PPACA was first passed.
Gallup last assessed the healthcare law in February, when Americans essentially were evenly split in their views; 45% said its passage by Congress was a good thing, while 44% said it was a bad thing. Americans were slightly more positive in March 2010, just after the law passed, when 49% said passing the healthcare law was a good thing, and 40% said it had been a bad thing.
Other polls conducted more recently have tended to show a more negative assessment, including the Kaiser Family Foundation May update in which Americans were more unfavorable than favorable toward the law by a 44% to 37% margin. A new June 14-18 AP/GfK poll found 47% opposed to the law, while 33% were in favor.
Another indication of the fragility of public support for the law comes from a question Gallup asked in February about possible repeal of the law. In line with the even split on basic opinions of the law, Americans were about as likely to say a newly elected Republican president should repeal the law (47%) as to say a Republican president should not (44%).
2. Americans See Little Impact of Bill on Healthcare Now
Gallup also asked Americans in February about the impact of the PPACA on their family's healthcare situation, with the question wording indicating that "a few of the provisions of the healthcare law have already gone into effect," thus cueing respondents that much of the law has not yet gone into effect. Perhaps as a result, seven in 10 Americans at that time said the law had had no effect on their family.
A second question asked Americans to think ahead to when all of the provisions of the healthcare law will have gone into effect, and found that 38% said the law would ultimately make their family's healthcare situation worse, 24% said it would make their situation better, and 34% said it would ultimately make little difference.
These perceptions notwithstanding, Gallup-Healthways Well-Being Index data have demonstrated that the part of the new healthcare law that allows young people to be covered under their parents' healthcare insurance through age 26 has apparently had an impact. The percentage of 18- to 25-year-olds who are uninsured has dropped from 28% in the third quarter of 2010 to 23% in the second quarter of this year. By comparison, the percentage of 26- to 64-year-olds without insurance has risen over that same period.
3. Americans See Individual Mandate as Violation of Constitutional Liberties
Perhaps the most controversial aspect of the PPACA is the "individual mandate" provision specifying that individuals must have their own health insurance -- that is, if they are not otherwise covered by an employer or government program such as Medicare.
Despite this being a central element of the law, Americans are remarkably unified in believing the individual mandate violates constitutional liberties. Overall, 72% say the individual mandate is unconstitutional, while 20% consider it constitutional. Naturally, the vast majority of Republicans (94%) and opponents of the healthcare law (94%) say the provision is unconstitutional, but so do the majority of Democrats (56%) and those who broadly favor the law (54%).
4. Views of Healthcare Law Highly Polarized by Party
Regardless of the content of the Supreme Court decision, it is almost certain that Republicans and Democrats will have very different reactions to it. Gallup polling on the topic shows Republicans have overwhelmingly negative views of the healthcare law, and Democrats, overwhelmingly positive. Specifically, 71% of Democrats said it was a good thing the law passed and 81% of Republicans said it was a bad thing in Gallup's most recent update. Independents' views have been more variable, though more often than not they have tilted toward opposing it.
A majority of Republicans, 68%, also believe the healthcare law will make the healthcare situation in their family worse in the future if all of its provisions go into effect. Democrats are more divided in their views as to whether it would make things better (40%) or not make much difference (43%).
5. Americans Prefer a Private Health Insurance System
A major reason Americans have not broadly embraced the new healthcare plan could be their underlying resistance to government involvement in healthcare. Even though the Affordable Care Act is based largely on a private health insurance system, it gives the government a greater role in determining who and what must be covered, as well as in providing coverage directly through the expansion of Medicaid to more low-income families.
Gallup polling in 2010 and 2011 found Americans showing a solid preference for a healthcare system based on private insurance rather than a government-run system.
![Trend: Which of the following approaches for providing healthcare in the United States would you prefer -- [ROTATED: a government run healthcare system, (or) a system based mostly on private health insurance]?](http://content.gallup.com/origin/gallupinc/GallupSpaces/Production/Cms/POLL/h56ozyslre6iivt_p6q7-a.gif)
Additionally, since 2009, Americans have been closely divided on the question of whether it is the federal government's responsibility to make sure all Americans have healthcare coverage. Prior to 2008, Americans were significantly more likely to assign responsibility to the government; however, that changed in 2008 and 2009, possibly due to the elevation of healthcare reform as a national issue during the 2008 presidential election and the start of Obama's term.
Gallup trends by party ID on this question provide evidence for increased political sensitivity regarding the role of government in healthcare in 2008 and 2009. Republicans, who were already suspect of government taking responsibility for healthcare, became even more so. Independents' support for the government's taking primary responsibility also declined sharply in those two years, from 73% to 42%. Democrats' belief in the government's role declined in 2008, but leveled off in the 70% range thereafter.
6. Americans' Healthcare Concerns Revolve Around Access and Cost
Americans are in general agreement that the U.S. healthcare system is in need of repair -- 16% say it is in a crisis and 57% say it has major problems. These views have not improved since the passage of the 2010 healthcare law.
Americans' frustrations center much more on the cost and access to healthcare than on its quality. Thirty-three percent say healthcare coverage in the U.S. is excellent or good, compared with 59% who rate healthcare quality in those terms. Twenty percent are satisfied and 78% are dissatisfied with the cost of healthcare in this country.
Significantly, when asked to name the most urgent health problem facing the country, Americans do not cite any disease or specific health threat. Rather, their most common responses focus on healthcare access and costs.
7. Healthcare Not as High a Priority as the Economy
In some respects, healthcare is a high-priority issue for Americans. When presented in a list of issues facing the United States, Americans' concerns about the availability and affordability of healthcare rank near the top. Similarly, registered voters rank the 2010 healthcare law among the most important issues to their presidential vote this year.
At the same time, economic issues are foremost in Americans' minds, and are most top-of-mind when Gallup asks, in an open-ended format, what the most important problem facing the country is. Earlier this month, 6% said healthcare was the most important problem, compared with 31% who said the economy in general and 25% who said unemployment or jobs. Healthcare also placed further down the list when Gallup asked voters the most important reason they were supporting Obama or Romney this year.
Thus, Americans see healthcare as an important issue when they are reminded of it, but it is not the most salient issue to them.
Implications
The Supreme Court's decision on the 2010 healthcare law is one of the most anticipated in recent memory. It clearly will have an effect on the U.S. healthcare system, but also on the 2012 presidential campaign and on President Obama's legislative legacy.
It is unclear how Americans might react if the entire law is upheld or overturned, since Americans as a whole are divided on or slightly opposed to it. But the data suggest the public would favor the court's voiding the individual mandate aspect of the law that requires all Americans to have health insurance.
