For Obama, a Signature Issue That the Public Never Embraced Looms Large - Social Security was popular from the start, supported by 73 percent of Americans in early 1937 and 78 percent the next year in Gallup polls. Medicare had the approval of 62 percent in early 1965 and 82 percent by the end of that year in Harris polls.

From The New York Times:

On the day President Obama took the final step in turning the Affordable Care Act into law, his senior adviser, David Axelrod, predicted the public would eventually embrace his ambitious effort at health care reform.
      

“As the American people become familiar with what this program is and what it isn’t,” Mr. Axelrod said, “they’re going to be very, very happy with it.”

      

Two years later, the public is no happier with the law than it was then. Mr. Obama’s signature initiative may have prevailed in the Supreme Court, but a White House that vowed a public relations blitz selling the act’s virtues never fully followed through, much to the frustration of many Democrats and even some of the law’s authors.

      

Now Mr. Obama faces the consequences as he heads toward a hotly contested election that will decide whether he has a second term and, by extension, whether the law will survive efforts to repeal it.

      

And while the White House and its allies sent e-mails and held conference calls promoting the overhaul soon after the Supreme Court victory on Thursday, they privately made clear their interest in moving the national conversation back to the economy, the main electoral battleground.

      

“Unfortunately, we never had a really effective strategy around communicating to the public the benefits and the rationale behind health care reform,” said Ezekiel J. Emanuel, a physician and University of Pennsylvania vice provost who was a top White House adviser involved in developing the program. “We never had a spokesperson, and the public never really understood what we were doing.”

      

That failure still baffles supporters like Dr. Emanuel, given the significance of health care to Mr. Obama’s legacy. Some see it as a result of the president’s own instinctive diffidence or the natural desire to move to the next challenge. Others note the complexity of the act itself, or criticize the president’s advisers for not being more assertive.

      

But there was also calculation on the part of White House officials who concluded that the public was fatigued with the subject and more concerned about jobs. As they pondered plans to sell the overhaul, they found few troops to rally. Democratic lawmakers ran away from it and party donors refused to finance advertising to promote it.

      

“No one in history has ever been able to communicate successfully about health care, because it is a deeply personal and polarizing issue and people are therefore afraid of the unknown,” said Dan Pfeiffer, the White House communications director. “We need the law to be fully in effect before the known overtakes the unknown.”

      

Mr. Obama’s team holds out hope that with the validation of the court ruling, the health care law will generate more popular support as it is phased in through 2014. And they take heart from polls showing that elements of the law, like protections for those with pre-existing conditions, rate high with the public.

      

Some supporters have argued that other social programs in the past were controversial at first before becoming embedded in American society. But polling suggests that is not so.

      

Social Security was popular from the start, supported by 73 percent of Americans in early 1937 and 78 percent the next year in Gallup polls. Medicare had the approval of 62 percent in early 1965 and 82 percent by the end of that year in Harris polls.

      

By contrast, just 32 percent supported the Affordable Care Act when it was approved in March 2010, according to a New York Times/CBS News poll. As of a month ago, 34 percent supported it, virtually unchanged. To be sure, about a fifth of those who oppose it say it did not go far enough, essentially frustrated liberals.

      

That Mr. Obama’s presidency may be defined by the law would have seemed unlikely in March 2007, when as a presidential candidate he showed up for a health care forum in Las Vegas unprepared, by his own admission. When he finally developed a plan, he rejected requiring American adults to obtain health insurance and pilloried his chief opponent, Hillary Rodham Clinton, for supporting it.

      

As he took office, health care was on his agenda but not yet dominant. The economy was in a free-fall; health care competed with issues like climate change and immigration for Mr. Obama’s political capital. One adviser said if the White House had realized the economic troubles would be as sustained as they have been, health care might never have been on the table. Others disagree, arguing that health care did not detract from efforts to promote recovery.

      

Either way, health care rose to the fore in part through circumstance. The House passed a climate change bill, but it took deal-making and lobbying that alienated some around Mr. Obama. The White House concluded that the Senate could not pass the climate plan with only Democrats, since some from coal states opposed it. Likewise, Mr. Obama lost Republican cooperation on immigration, leaving health care the most plausible initiative.

      

“It wasn’t a choice so much as, of the three issues, the only one that had a chance was health care,” said a senior administration official who asked not to be named discussing priorities.

      

To pass health care, Mr. Obama abandoned his campaign position on the mandate. “The president we had to convince, because it was going back on what he promised,” Dr. Emanuel recalled. “But once we effectively laid out for him why this would be a better argument, he was convinced this was the right move.”

      

Still, some urged the president to narrow his ambitions, including Rahm Emanuel, his chief of staff and Dr. Emanuel’s brother. And victory came after an ugly process: closed-door deals with the pharmaceutical industry, policy inducements to recalcitrant lawmakers, legislative legerdemain after a Massachusetts special election cost Democrats their filibuster-proof supermajority.

      

To win over an unenthusiastic public, officials promised an aggressive campaign. In April 2010, a month after the law was signed, the White House hired Stephanie Cutter, a prominent Democratic strategist, to handle public outreach for it. But she was given other projects as well, and by August had been reassigned as Mr. Axelrod’s deputy. The White House and its allies made efforts to educate the public, hosting events and posting information online, but it was sporadic.

      

Critics say public discontent stems not from how the president sells the overhaul, but what he is selling.

      

“Democrats can point to a couple of aspects that light up some numbers for them, but when weighed against the negatives they get blown away,” said Jonathan Collegio, communications director for American Crossroads, a group that supports Mitt Romney for president.

      

Groups like Crossroads swamped the president’s allies with television advertising. Since the law’s passage, $235 million has been spent on ads attacking it, compared with $69 million for those supporting it, according to Kantar Media’s Campaign Media Analysis Group.

      

“I’d be a heck of a lot happier if I had $100 million too,” said Eddie Vale, communications director for Protect Your Care, which supports the law. “But we’re playing with the hand we’ve been dealt.”

As for the president, he has promoted his program in fits and starts. In his State of the Union address this year, he devoted two sentences to it — 44 words out of more than 7,000. Aides said they decided to focus on jobs.

      

“That is the A-No. 1 issue on people’s minds,” Mr. Pfeiffer said. “You can’t do both. You have to make choices.”