Why has the law failed to capture public support? Our research provides a novel explanation that pundits have overlooked.
Doubt breeds dissent
Obama's health-care reform is unpopular not simply because it's complicated, or because it increases government spending at a time when people are in a budget-cutting mood. Rather, it's unpopular largely because it doesn't seem inevitable.
And the key to gaining widespread support for Obama's signature piece of domestic legislation is not to help Americans understand it better, but to convince them that the Patient Protection and Affordable Care Act is here to stay.
Uncertainty can play a major role in reducing support for legislation. Consider a study in which we asked people to imagine that their local government had recently passed a bill to lower the speed limit, spurred by new evidence that such a law would save lives. The people we surveyed embraced the new law, feeling thankful that legislators were paying attention to public safety.
However, we told some of the people we surveyed that the government was about to pass the law but hadn't yet voted on it - that is, it wasn't official yet. In contrast to the first group, these people felt strongly that the proposal was heavy-handed and paternalistic.
So the same legislation was viewed more favorably after it was passed than when it was merely pending.
What about health-care reform then? It has become law. Shouldn't it be gaining in popularity?
Not if people don't believe it's the settled law of the land. When the Republican-led House voted to repeal health-care reform, Washington insiders recognized it as a symbolic gesture with no legislative consequence. But many Americans thought the vote had actual legal implications. In fact, recent polls show that one-fifth of Americans believe health-care reform has been repealed, and another fifth aren't sure if it's still law. These Americans have less reason to embrace the law.
Recent court rulings have created even more uncertainty about the law. While most have focused on the constitutionality of the health insurance mandate, one judge went so far as to opine that the entire law should be voided. This has left even more people wondering where the bill stands.
Behavioral science has shown us that most people find uncertainty very difficult, especially when it surrounds a possible change in their lives. Halfhearted attempts at change often produce knee-jerk negative reactions. People are not inclined to adapt to a change that may never occur or that seems unlikely to stick. Such situations are likely to breed backlash.
Mandating change
But when the uncertainty is removed, backlash tends 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 - they tend to begin the process of rationalizing and adapting to the change.
Over the next few months, the real battle over health-care reform will go beyond the specifics of budgetary debates and regulatory wrangling. The fate of the law depends mainly on when and whether the public comes to feel that it is an enduring fact. If the public continues to see the law as less than permanent, that will become a self-fulfilling prophecy.
Peter A. Ubel, Aaron Kay, and Gavan Fitzsimons are behavioral scientists at Duke University.
