Healthcare Reform Revisited: the Devil is in the Details

Several weeks ago the Supreme Court reviewed part of President Obama’s 2010 healthcare reform (the Patient Protection and Affordable Care Act). Specifically, they examined the “individual mandate” that requires (almost) all Americans to have some sort of insurance coverage. The Supreme Court review has put “Obamacare” back in the crosshairs of public debate and the debate has not been kind.

In particular, many professional pundits and Republican politicians have been quite negative about the law’s prospects. They maintain that Obama’s signature healthcare initiative is not long for this world and presents a serious electoral weakness for the President. They point out that Obamacare finds very little support among public opinion in both past and present public opinion polls (  And many experts attribute the large Republican gains during the 2010 mid-terms to the use of “Obamacare” as an effective wedge issue (as in here or counterpoint here).  The healthcare reform’s lack of popular support, together with a Supreme Court somewhat predisposed against the Democrats on economic issues, is bad news for Obama’s agenda and record, or so the argument goes.

Is this a fair assessment of healthcare reform?

I would say unequivocally both yes and no—clarity at its best! Healthcare reform is a great case study of public opinion for two reasons: (1) it represents the challenge of measuring public opinion on diffuse policy issues and (2) it clearly demonstrates the strategic communication pitfalls associated such diffuse, or as I like to say, fuzzy issues.  Let me detail my logic below.

As mentioned above, Americans are truly not too keen on Obama’s healthcare reform bill.  Indeed, polling finds a majority of Americans oppose the measure (here).

At first blush, the detractors seem to have a case—people really do not like the measure.

But is this the final word on the issue? Well, no.  It’s actually much more complicated.  I explain below.

On fuzzy issues like healthcare reform, we may not be measuring what we actually think we are measuring. We have found that those who oppose the measure do so for very different reasons (see here). Indeed, almost a third of the people who oppose the measure do so because they believe that it did not go far enough. Most of these nay-sayers tend to be staunch Democrats (see table below).

This ‘fuzziness’ has both measurement and strategic implications. In terms of measurement, it demonstrates that general ballot questions on healthcare reform often have multiple meanings—for some, it means too much change, while for others not enough. Ultimately for the analyst it presents a conundrum: what does oppose and support really mean? This measurement confusion, in turn, can produce false positives for the strategist. Case-in-point is the 37% of people who oppose Obamacare because they think it does not do enough.

Third, when it comes to the healthcare reform, the devil truly is in the detail. Once the measure is reduced to its basic components, it is not all bad news.  Indeed, a majority of Americans support many of the individual items in the bill. The only most unpopular component among the regularly discussed features of the law is the requirement for mandatory health care insurance (see table below).

So a majority of Americans are against healthcare reform generally but are in favor of many of the specific items that will impact their lives. What does this all mean?


First, polling on complex policy agendas, like healthcare reform, is not like polling on elections. Healthcare reform is a perfect example of how general ballot questions  work well for elections but leave something to be desired for complex policy issues. For elections, our consideration set is well established. After a certain point (in most cases the primaries), we know exactly who is running for the given office, so measurement is easy—a straight-up question which asks for whom the respondent will vote. Here the key point is that we know what we are measuring.

In contrast, the interpretation of ballot questions on healthcare reform is much more diffuse and complex. What exactly are we measuring? Most Americans say they do not support the administration’s version of healthcare reform in general.  But we actually find that a majority of Americans support most of the specific healthcare reform items. Some would argue that the general ballot question is actually a statistical artifact, and we pollsters are actually inventing public opinion by asking  such questions (see Bishop, George F.). I would not go this far but would say when we poll on fuzzy issues like healthcare reform, we should combine general measures with specific items in the bill, and do so in a way that captures as many of the bill’s components as possible.

Second, fuzzy issues, like healthcare reform, lend themselves to being easily re-framed.  Political actors, as such, should tread lightly and seriously consider their strategic approach.  For instance, in early 2009  the Obama Administration believed that public opinion was strongly behind healthcare reform in general (see here) and decided to allow Congress to deal with the details. However, healthcare reform was a slogan in want of a definition.  Leaving this leadership vacuum was a mistake.

In this definitional vacuum, Republicans took the advantage and were able to define the issue in their favor—that healthcare reform was actually a “big government” attempt to dictate how Americans should live their lives (see here). Ultimately, the Republican view was stickier and has prevailed.

Third and finally, all reform initiatives are ultimately defined by their weakest link. Here we had a large omnibus bill which included multiple items. For the most part, Americans support the items in the bill and only significantly oppose the individual mandate. However, this one part of the bill has come to define its entirety. Understanding that this outcome was always likely, perhaps the administration’s strategic approach should have been different: to have a number of smaller bills, rather one overarching one.