Four years after President Barack Obama signed the Affordable Care Act into law, many Americans still don’t know what’s in it.

“My take is when you poll Iowans, there is widespread agreement on what is in the law …  but they just don’t know what the act does,” said Dan Shane, a University of Iowa assistant professor of health policy and management.

“You have to blame the administration. Is it fair, given the opposition to the law? Not really, but this was the most significant legislative accomplishment in the first term, and it should have been the highest priority.”

Health-care policy analysts say problems persist about informing people even after Monday’s deadline. Most people had to sign up during the first open enrollment period for what is commonly known as Obamacare.

Dara Rasavanth sees the problems first-hand every day as a health-care navigator for Visiting Nurses Services of Iowa, one of three organizations statewide that received grants to help people enroll.

A result, she said, is a lack of young people seeking insurance where she works, primarily in Des Moines. Among those who don’t place a high importance on the coverage, many decide to take a tax penalty instead of paying a premium. The penalty will be on Americans’ 2015 tax returns and will amount to 1 percent of their income or $95, depending on what is more.

“I don’t feel [those in favor of the law] do a good enough job preaching the need for health insurance,” Rasavanth said.

Planned Parenthood of the Heartland also received a grant to deploy health-care navigators across Iowa. Tristin Johnson works mostly in Des Moines for the organization but has held events as far away as Council Bluffs. She said that while there was not a large response from college students, she has worked with “an overwhelming majority” of people between the ages of 18-36.

The federal government has not released detailed enrollment information, but UI Public Policy Center Director Peter Damiano said young people — who tend to be predominately healthier — are a major component of the law’s success because they balance the risk with those who frequently need health care.

Damiano said supporters and opponents share the blame for confusion about the law, but some of the misunderstanding rests on how complex it is. Moreover, the very populations who most need the coverage are the hardest to reach, for a variety of reasons that include access to information technology.

Confusion has led to “many panicky people” coming in to work with navigators such as Rasavanth. In most cases, she said, people still can get coverage after the deadline.

Shane said one of the biggest areas the Obama administration and others struggled with was the poor implementation of the law in October, people from getting information at a critical time.

Iowans saw these effects because Iowa and 35 other states rely on the federal government to run the insurance exchange. This arrangement created issues when the federal government’s website, healthcare.gov, was inoperable at times.

Bruce Gronbeck, a UI communication-studies professor emeritus, said these errors crippled proponents of the law at a critical time.

Republicans were surprisingly unified in their response to the law, which allowed for a tightly controlled narrative to be repeated ad infinitum, Gronbeck said.

“The Democrats knew [opponents of law] were coming, but I don’t think they were ready to be so overwhelmed by the conservative wave of attack after attack,” he said, noting that this was rare time when conservatives were unified on an issue.

David Yepsen, who spent more than 30 years covering politics for the Des Moines Register, said Republicans have been able to continually hammer home attacks on the law while Democrats have been unable to articulate a sufficient response.

“Supporters of the act have been on the defensive all of the time,” said Yepsen, who is now the director of the Paul Simon Public Policy Institute at Southern Illinois University. 

Sen. Tom Harkin, D-Iowa, said from the start there would be “bumps in the road,” but believes the constant attacks on the act have spread lies and in some cases misinformation.

“We’ve had a constant two-year, almost three-year assault on this by Republicans,” he said during a weekly press call. “They have never given up on saying we’ve got to repeal it, repeal it, repeal it … that doesn’t mean you throw the whole thing out and start over again.”

The five-term senator said Republicans are simply not interested in fixing the law.

“We’re not going to turn back the clock,” he said. “Republicans refuse to work with us to fix some of the things in the health-care bill. We’re not going to repeal it, the American people don’t want us to repeal it. Fix the flaws; don’t repeal it.”

Republicans were adamant they had concerns about Obamacare from the start, but Democrats won the political argument and now are responsible for any of the law’s outcomes, said Sen. Chuck Grassley, R-Iowa.

“Republicans can’t be blamed for the president’s broken promise that if you liked your health-care coverage, you could keep it, or the higher premiums and deductibles many people will face, or the many shifts in deadlines that have confused people trying to comply with the law,” he said in a statement.

Obama announced on Tuesday that 7.1 million people have signed up for coverage through the federal exchange as of Monday’s deadline. But with an estimated 48 million uninsured people nationwide before the law went into effect, subsequent enrollments will have to reach even further, a health-care insurance expert said.

Shana Lavarreda, director of health insurance studies at UCLA, said she welcomes the news that the law reached its first-year goal. But she said future efforts need to be expanded to include uninsured people who still are not getting information about the law. These people respond to polls and the census, which illustrate the problem, but they are not hearing about a possible solution.