In early December, the Los Angeles Times published an apology to President Obama from a woman who wrote that she had “blacked out the top of the ‘h’ on my Obama bumper sticker, so that it read, ‘Got nope’ instead of ‘got hope.’” A recent diagnosis of cancer prompted the woman — who had lost her health insurance after her husband lost his job — to apologize to the President. She found a new source of health insurance thanks to “Obamacare,” the Patient Protection and Affordable Care Act (ACA). The ACA established a Pre-existing Condition Insurance Plan, to provide immediate coverage for people like her. She wrote that she’s “getting a new bumper sticker to cover the one that says ‘Got nope.’ It will say ‘ObamaCares.’”

The story captures the quandary in which President Obama and supporters of the health care act find themselves. The biggest problem the ACA was written to solve was the fact that 50 million Americans are uninsured, mostly because they cannot afford coverage. But the ACA’s solutions for most of the uninsured don’t kick in until 2014. The writer benefited from a stop-gap measure for long-time uninsured people with a serious medical condition. Most of the uninsured, including the 9.3 million American adults who lost health insurance coverage due to higher unemployment rates in the 2007-2009 recession, will need to hold on two more years before they get relief.

When the ACA was passed, Democrats in the White House and Congress delayed implementation of the central provisions of the legislation — expanding coverage of Medicaid and providing income-based subsidies to uninsured people — until 2014. These key provisions, which are likely to result in 95 percent of Americans having health insurance coverage, were delayed for two reasons. One was to delay raising revenues to pay for the legislation while keeping the promise that it won’t increase the deficit. The other was to provide time for states to implement the new health insurance marketplaces that will provide uninsured people with access to subsidized coverage.[1]

Mindful of the delay’s impact on public opinion, the law’s authors included elements that took effect in 2010 or 2011, such as the Pre-Existing Condition Insurance Plan, which covered 41,427 people as of October 1, 2011. A provision allowing people under 26 to stay on their parents’ health plans has resulted in 2.5 million more young adults with health coverage. The law also provided $535 million in 2010 for health insurance plans that cover early retirees and gave tax credits to thousands of small businesses that employ lower-wage workers.

Seniors on Medicare benefitted immediately from two parts of the new law. Some 3 million seniors got lower prescription drug prices in 2010 under a provision that provides rebate checks and lower drug prices for seniors who fall into the Medicare prescription drug program “doughnut hole.”Another 1 million Medicare beneficiaries are likely to avail themselves of the savings from eliminating copayments on preventive care, another feature of the law that went into effect last year.

However, these incremental measures, which impact only a small percentage of Americans — who may not realize their new benefits are tied to the ACA — have not been successful in burnishing the law’s image with much of the public. The November 2011 Kaiser Health Tracking Poll found that “Americans remain somewhat more likely to have an unfavorable view of the law (44 percent) than a favorable one (37 percent).” The divide remains highly partisan, with 62 percent of Democrats supportive, while 78 percent of Republicans view the legislation unfavorably. For many of those unhappy with the law, their concern has little to do with what the law actually does; 44 percent who view the law unfavorably said their negative view has more to do with their general feeling about the direction of the country, while 25 percent said it is based on what they know about the law.

Public support continues to be undermined by the information that people are receiving, with 50 percent basing their most recent views of the law on coverage of Republican presidential candidates urging the ACA’s repeal. Much of that coverage focuses on the most unpopular provision of the law, the mandate for individuals to purchase coverage, which is disliked by 63 percent of those surveyed. Still, support remains very strong for other major features of the law, including subsidies to help people buy coverage (75 percent favorable) and guaranteed coverage for people with pre-existing conditions (67 percent favorable). From a policy point of view, the individual mandate is integrally related to these two popular provisions. But until the law is implemented, people won’t see that the so-called “individual mandate” is accompanied by subsidies to buy coverage and access for people now denied care or priced out of the insurance market because of their health history. And until people see that, the hope of affordable coverage will seem like one more example of a broken government promise.

The confusion about the ACA’s impact will not be resolved until 2014, if the law survives that long. There are two looming threats. The first is the upcoming consideration by the Supreme Court of the constitutionality of the law, and in particular of the individual mandate. Two positive rulings by respected, conservative appeals court judges give supporters of the law hope that the Supreme Court will uphold the individual mandate, despite the fact that the Court has been characterized by conservative decisions on hot-button issues. If the mandate is not upheld, the ACA will need to be revised in order for some of its remaining key provisions to be workable, which will have the impact of throwing the whole issue back to Congress and the President.

The second obstacle is the 2012 election. If President Obama is re-elected, he will veto any substantial repeal of the ACA. It’s anybody’s guess what may happen with a Republican president, a Congress that must consider repealing both popular and unpopular provisions, and the likely ability of Democrats in the Senate to filibuster an outright repeal.

In the meantime, the promise of the ACA still holds tremendous appeal for the public. It will mean that losing a job, retiring early, or starting a small business won’t result in losing access to affordable health coverage and the specter of incurring high medical debts. However, as long as the only thing the public hears is attacks, the law will continue to suffer in popularity. Supporters, starting with the President in his re-election bid, will likely defend the ACA by linking its promise to the underlying economic insecurity that many Americans continue to have.

In an increasingly cynical political culture, the challenge for the President and other supporters of ACA will be getting people to believe that help really is on the way.