It's been almost two years since President Obama signed healthcare reform into law. And even now, it seems most Americans still have no clue as to what was approved or how it works.
A USA Today / Gallup poll released this week shows that almost three-quarters of us think a requirement for nearly all people to buy insurance — the so-called individual mandate — is unconstitutional.
About 70% of poll respondents say the reform law hasn't affected them personally. Roughly a third of Americans say the changes won't make any difference for their family, and 38% say they'll make things worse.
Only 24% of respondents say they expect the reform law to improve things.
It's not my intent to take sides here. There are some things about the law that I like (such as guaranteeing coverage to all, regardless of medical condition), and some that I don't (not enough attention to curbing sky-high costs; millions left uninsured).
But in the interests of cutting through some of the disinformation out there, let's take a closer look at what this law actually does and doesn't do.
"People don't seem to understand that the healthcare reform law already has a very significant impact on their lives," said Shana Alex Lavarreda, director of health insurance studies at UCLA's Center for Health Policy Research.
For example, she said, Medicare patients are now entitled to free preventive care, as well as more comprehensive coverage of prescription drugs. And there are other changes that touch virtually everyone in everyday ways.
"If you walked into a restaurant and looked at the calorie counts on the menu, and if you changed your order as a result, you were affected by the healthcare reform law," Lavarreda observed. "The law put those calorie counts in place."
California has required such info on menus since 2009 for chain restaurants with 20 or more locations. The reform law applies that same standard on a nationwide basis.
What about some of the bigger issues highlighted by the Gallup poll? First, the notion that an individual mandate may be unconstitutional. More specifically, the U.S. Supreme Court will be tackling the question of whether Congress has the right to impose such a mandate nationwide.
Proponents such as Harvard law professor Laurence Tribe say this falls under well-established precedents for Congress to do whatever is "necessary and proper" to regulate interstate commerce. Allowing people to remain uninsured yet still be assured emergency care merely shifts medical costs to others.
"There's no right to force a society to pay for your medical care by taking a free ride on the system," Tribe said during a debate at Harvard last year.
Critics say Congress is overstepping its authority by requiring people to buy a product they may not want. "The bill requires everyone to buy health insurance whether they seek healthcare or not," Georgetown University law professor Randy Barnett said at the same debate.
Reform backers counter that it's not as if lawmakers are holding a gun to people's heads and forcing them to be insured. Rather, most people who aren't covered through their jobs would have to buy insurance or face a fine of up to 2.5% of household income.
For those pulling down $60,000 a year, that's as much as $1,500. If you're cool with paying such a sum instead of buying discounted coverage from a private insurer, as will be the case when online "insurance exchanges" open for business in 2014, that's your business.
The key point here is that health insurance works effectively only when everyone's in the risk pool — young and old, sick and well.
A mandate is what makes feasible the reform law's guarantee of coverage of everyone, no matter what their medical condition. Without a mechanism to expand the risk pool, many people would naturally wait until they need insurance before buying coverage.
This would cause premiums to skyrocket and make insurance even less affordable and accessible than it is now. Anyone who opposes a mandate, therefore, needs to accommodate this outcome in some other way, such as maintaining the current system of allowing insurers to pick and choose whom they'll cover.
More than two-thirds of respondents to the Gallup poll say the reform law hasn't affected them personally. In reality, it almost certainly has — they just don't know it.
As UCLA's Lavarreda noted, calorie counts on menus are a modest example of how everyone is touched by the law. Another is a requirement that insurers provide coverage through family plans for young people up to age 26.
According to the Census Bureau, almost a quarter of the nation's more than 311 million people are under 18. That's nearly 75 million young people. It's unclear how many others are between 18 and 26, but we're clearly talking millions of young adults.