It is hard to imagine that after three years of acrimony and debate we could still be so confused about President Obama's Affordable Care Act.
Is it actually possible Americans know less about Obamacare now than they did three years ago? Apparently that is the case, and the news comes just as the most sweeping effects of the law are about to kick in.
According to a new poll by the Kaiser Family Foundation, 80 percent of people don't know whether their state is going to expand Medicaid under the law, a huge piece of the health care changes coming down the pike.
Half of people don't know whether their states are going to be setting up so-called health exchanges, and half of people think the law gives undocumented immigrants health care subsidies — it doesn't. The poll also shows that 40 percent of people still think the government is going to set up death panels to decide if someone gets heath care when they're dying — it won't.
To further illustrate confusion about the law, 70 percent of people said they like the initiatives in the law when they were asked specifically about each one, but only 37 percent of people said they liked the law itself.
Where Are We Now?
NPR's health policy correspondent Julie Rovner says a lot of the confusion regarding the Affordable Care Act comes, in part, from a commanding "misinformation and disinformation" campaign.
"It has worked better than the people who were trying to put the law into effect, who have been working to put the law into effect rather than messaging about it," Rovner tells weekends on All Things Considered guest host Laura Sullivan.
There are essentially three big pieces to the Affordable Care Act: the insurance reforms (also known as the patients' bill of rights), quality and cost measures, and the health care mandate.
The insurance reforms portion has mostly taken effect, Rovner says, and includes things like allowing adult children to stay on their parents' health insurance until they are 26, and not letting health plans cancel coverage after you get sick. These are things she says most polls show Americans back.
The quality and cost measures are mostly behind-the-scenes changes that are meant to change the way health care is delivered to improve the care patients get to save money for both the patient and the government.
The third part goes into effect on Jan. 1, and is the one that has caused the most controversy: the health care mandate. In an effort to get about 30 million more people health insurance, those who don't have coverage will pay a penalty.
"This October is when small businesses and people without insurance can start enrolling in these so-called health exchanges," Rovner says. "That's where they'll be able to shop for health plans if they have moderate incomes [and] they'll be eligible for subsidies from the government to help pay for the plans."
For low-income Americans who live in a state that has decided to accept the option to expand Medicaid, they can see if they qualify. As part of the Supreme Court's decision to uphold the Affordable Care Act, it made the Medicaid expansion portion of the law optional.
"So we're still waiting to see how many states take up the federal government's offer to pay for most of that cost," Rovner says.
Despite the law's efforts to get all Americans health coverage, she says, some Americans could still fall through the cracks if their state doesn't take the option to expand Medicaid.
The Risks Of Opting Out
In order to get everyone health care coverage — whether a 22-year-old working in a coffee shop or a 58-year-old who's just been kicked off another insurance plan — the idea was that every state would create something called a health care exchange. This is a fancy way of saying each state would build a website and offer folks a sampler platter of low-cost insurance options.
The law, however, gave states the chance to opt out of creating one. So far 26 states — mostly red states and mostly on ideological grounds — have done just that. It doesn't mean the exchanges aren't coming to those states or that people in those state's wont have to get insured, it simply means the federal government will build the exchange for those states.
One of the states opting out of building its own health exchange is Texas.
"Texas has the distinction of having the most uninsured people as a percentage of the population [than] any place in the country," says Ron Cookston, executive director of Gateway to Care, a nonprofit health care advocacy group in Houston.
Almost 30 percent of adults in Texas lack health care insurance, according to the research company Gallup. Cookston and other advocates have to find a way to reach out to all those people and let them know what's coming.
"The state of Texas ... [has] great capabilities, and it would have been wonderful if since the passage of the Affordable Care Act they had begun to help communicate and inform our public so they would be ready," Cookston tells NPR's Sullivan. "People just don't have any idea about how they will be impacted."
Texas Gov. Rick Perry has been outspoken about his opposition to Obamacare, saying it costs too much and "kills too many jobs." Perry has also rejected Medicaid expansion in his state, which would have provided care to more than 1 million poor Texans.
President Obama says the federal government would pick up the tab, but Gov. Perry says he believes the state will be left with higher costs in the long run.
In Houston, where Cookston's group operates, few people who will be required to use the health care exchange know anything about it.
"When leadership in any state talks about things in a negative way, it becomes awfully easy for the general public to dismiss it and not think about it," he says.
The federal government is going to send organizations like Cookston's group some money to help get the word out, but he says what they're missing is a coordinating central body.
"The government of the state of Texas, they are not doing anything at this point in time," he says. "We certainly are, neighborhood by neighborhood ... because that's how this will have to be done — church by church, community by community. Unfortunately, we've not had the support of the [state]."
Spreading The Message
Unlike Texas, California has decided to build its own health exchange. The state has even gave it a catchy name, Covered California.
"[We're] doing consumer surveys, marketing and focus groups," says Peter Lee, who is running the state's health care effort. "So come this summer, we're going to hit the ground in a big way with messages that we know will resonate."
The state is hiring thousands of people to get Covered California off the ground, and the federal government is giving the state $900 million to do it. The "ground troops" needed to spread the message, Lee says, will come from the community.
"We'll be funding groups in communities across the state that are based in faith-based organizations, schools [and] unions," he says. "Because we know that delivering this message needs to come from your neighbor, from people in your community."
About 2.5 million Californians will be eligible for subsidies through Covered California, a diverse group of people, says Lee. He says the state needs to have outreach that speaks to farmers and people in rural communities, and in dozens of languages in downtown urban areas.
About half the states are following California's lead, setting up their own exchanges and using what is essentially seed money from Washington to get them off the ground.
"These are states that have said, 'Lets get this venture capitalist funding from the federal government to set up an exchange that works right for our state,' " Lee says.
For consumers, however, it doesn't matter if you're in Texas or California or anywhere else in the country, the law is clear: The uninsured are expected to get coverage by January. Whether those folks will be informed and ready by then is not so clear.