Liking Health Reform But Turned Off By Toxic Politics

When President Barack Obama signed the Affordable Care Act (ACA) into law in 2010, many congressional Democrats anticipated that once implementation was under way, the public’s polarized attitudes would dissipate and support for the law would grow. ¹ Advocates’ expectations for support might have risen even further in light of some of the reform’s notable positive effects, which include an expansion of insurance coverage for over twenty million nonelderly Americans (ages 18–64) and an uninsurance rate that has fallen by nearly 9 percentage points. ²

Six years after passage of the law, however, pollsters report that the public has remained deeply divided on the law. As of March 2016, according to the Henry J. Kaiser Family Foundation, 47 percent of Americans held an unfavorable view of the ACA, while 41 percent had a favorable view. ³ Although public opposition to the law has moderated from its high of 53 percent in July 2014, discontent continues despite notable progress. ³ Why does the public continue to tilt against reform, as these polls suggest?

This question cannot be answered accurately on the basis of the polls that are typically reported upon because they depict only the views of a cross section of Americans at a single moment in time. This snapshot approach is incapable of detecting how individuals may be experiencing and responding to health reform as implementation unfolds over time. An astute recent overview of the impact of the ACA spotlighted the paucity of evidence about potential changes in public opinion and questioned specifically “whether the contributions of the ACA to the health and health care of Americans will moderate [public opinion].” ⁴

To overcome the limitations of cross-sectional survey data, we relied on a panel study conducted since 2010 to track changes in public opinion. Our study used a stable pool of the same respondents to determine whether the public’s evaluations of the ACA are remaining constant or changing as people experience or learn about the implementation of specific and tangible reforms.

We found that beneath the din of conflict over general assessments of the law, support for its provisions is on the rise, as is a willingness to let it work instead of repealing it. A toxic political atmosphere—not the popularity of the ACA’s tangible benefits—remains the barrier to public support. ^5,6 The crosscurrents of public attitudes toward the ACA are playing out in today’s state and national politics: The philosophical embrace of conservatism and mistrust of government has been showcased by the insistence on repeal of the law by Republicans in Congress and by those vying for the Republican presidential nomination, while the pragmatic acceptance of the ACA’s concrete new benefits is vividly displayed in the increasing number of states, including those with Republican governors, that are adopting the Medicaid expansion. ⁷

Study Data And Methods

We tracked the responses of Americans to the ACA’s implementation through three waves of a panel study that were conducted in September and October of 2010, 2012, and 2014, respectively. Our study tracked individual reactions to the ACA from the time it became law through the tumultuous political battles and Supreme Court decision in 2012 to the implementation of new provisions—most notably, the start of health insurance exchanges (also known as Marketplaces) in fall 2013 and the expansion of eligibility for Medicaid in January 2014. We conducted the waves of the study during the two-month period leading up to national elections, when health reform was consistently likely to receive heightened attention, instead of during an arbitrary month when the issue might have lost or gained salience.

Each wave of the study consisted of a telephone survey that used the same survey instrument, asking identical questions. (The full wording of the survey questions and our coding of them are provided in the online Appendix.) ⁸ The first wave was conducted by the Survey Research Institute at Cornell University and consisted of a national sample of 1,200 adults. Abt SRBI conducted the second and third waves, returning to the same individuals. All waves were administered by telephone, using landline telephones only in 2010 and also including mobile phones in 2012 and 2014.

One of the most important features of panel studies is keeping the same individuals in the pool over time. We preserved our pool through regular communication with respondents and incentives for hesitant respondents. (Our approach to incentives is discussed in the Appendix.) ⁸ Fifty-five percent (660 out of 1,200 panelists) responded in all three waves, providing the data we used for the first half of our analysis below. Sixty-six percent (792 out of 1,200) responded in both 2010 and 2014, providing the data for the second half of our analysis. Although we did not compare the first two waves, the response rate in 2012 of the original 2010 participants was 65 percent (781 out of 1,200); 10 percent of respondents who participated in 2010 and 2012 did not in 2014.

We also used survey weights to match representative demographic targets and produce nationally representative samples. This allowed us to generalize from our panel to the adult population in the United States. To test for significance, we used two-sided $p$ values and 95 percent confidence intervals.

Methods and Variables

We began by examining the contours of public opinion toward health reform, comparing changes every two years since 2010. We used descriptive statistics to assess changes in the percentage of the public favoring repeal of the ACA as opposed to giving it more time to work (among those who were initially unfavorable toward the law), the percentage who perceived it to be widening access to medical care and health insurance for themselves and their families, and the percentage who perceived an impact of specific ACA provisions on themselves and their families.

Next we conducted three types of quantitative analyses that used explanatory variables to test competing explanations for public evaluations of the ACA. First, we assessed the determinants of Americans’ growing appreciation of the ACA’s impact in widening access to medical care and health insurance for themselves and their families. In particular, we used ordered logistic regression because the dependent variable (agreement that reform is increasing access) was measured along ordered points from “none” to “a little,” “some,” “quite a bit,” and a “great deal.” The results were in odds ratio format, meaning that coefficients greater than 1 indicate a positive effect and those less than 1 signify a negative effect.

Second, we used ordinary least squares regression to study the impact of the ACA’s policies by 2014 on increasing support for improving the law instead of repealing it among those who in 2010 held unfavorable views of it. The third analysis used ordinary least squares structural equation modeling based on maximum likelihood estimation to disentangle distinct and potentially competing influences on the public’s overall favorable or unfavorable evaluations of the ACA. This third analysis demonstrated that the public’s appreciation for the ACA’s tangible effects is swamped by the general political environment of distrust and partisanship.

Our three sets of quantitative analyses relied on similar explanatory variables, drawn predominantly from the 2014 wave of the panel study. We accounted for individual perceptions of the tangible impacts of the ACA through the following three new provisions: subsidies to help pay for insurance, aid to seniors to afford prescription drugs, and new coverage for children until age twenty-six if their parents had insurance.

In addition to perceptions of new policies, we considered the influence of insurance status and the broad political environment—that is, party identification and trust in government. In addition, we isolated the effects of health reform, insurance status, and the political environment by controlling for the following other potentially confounding influences: age, sex, race/ethnicity, income, year of birth, education, and political knowledge. Finally, we included the 2010 values for our dependent variables. We used this potent statistical technique to study change over time and to account for influences that might have eluded us.

Our statistical analyses focused on the 792 individuals who participated in the 2010 and 2014 surveys, although the number of respondents varied as we explored subgroups (such as people who initially held unfavorable views of the ACA) and particular analyses. More information about the survey questions and our methods are available in the Appendix. ⁸

Limitation

Our panel study provided unique data on individuals’ changing evaluations of the ACA as it was implemented. However, the samples for any one year were not large enough to provide an adequate number of cases for us to conduct more fine-grained analyses. For instance, there were not enough respondents to detect significant differences across small subgroups of individuals or within particular states.

Study Results

Overall Assessments Of Public Opinion On Health Reform

Like previous research that relied on cross-sectional polls, the most recent wave of our study indicated that the public remained split over the ACA in 2014, with 45.6 percent holding unfavorable views and 36.2 percent favorable. Independents have grown substantially more inclined toward reform: As a group, their unfavorable opinion of the ACA declined by 17 percentage points from 2010 to 2014 ( $p<0.05$ ), while their favorable opinion increased by 13 percentage points ( $p<0.05$ ). This is politically significant given that independents can swing elections.

We also found an important shift among the harshest critics of the ACA—that is, those who voiced unfavorable views toward the law in 2010. The percentage of these respondents who still supported repeal of the ACA remained high, but it shrank by 9 percentage points from 2010 to 2014 ( $p<0.10$ ), as more of them came to believe that the law should be given additional time to work and lawmakers should be given time to improve it ( Exhibit 1 ). This change is striking given that those who supported repeal in 2010 were a fairly conservative group: 68 percent of them were Republicans (see the Appendix). ⁸

SOURCE Authors’ analysis of data from three waves of a panel study conducted in September and October of 2010, 2012, and 2014, respectively. NOTE The full wording of the relevant survey question is available in the Appendix (see Note  8 in text).

Although our research did not directly connect changing public opinion to specific policy changes, the shift away from repeal occurred after many states expanded eligibility for Medicaid and the state and national health insurance exchanges were established.

Impacts Of The Affordable Care Act

Appreciation for the ACA increases as individuals focus on concrete impacts—a pattern that resembles those for other policies such as Social Security, Medicare, and the educational and training benefits of the GI Bill. ^9,10 Americans increasingly perceived the effects of the ACA on themselves and their family as expanding access to health care ( Exhibit 2 ). The share of respondents believing that reform had little or no impact diminished by 18 percentage points from 2010 to 2014, while those considering reform to have “some” or a “great” impact increased by 19 percentage points ( $p<0.001$ ). Despite the problems associated with the implementation of the ACA, the public appears to be growing more convinced that health reform is having its intended impact of increased access to health care.

SOURCE Authors’ analysis of data from three waves of a panel study conducted in September and October of 2010, 2012, and 2014, respectively. NOTE The full wording of the relevant survey question is available in the Appendix (see Note  8 in text).

Between 2010 and 2014 Americans increasingly credited health reform with delivering tangible benefits to themselves and their families ( Exhibit 3 ). The proportion of individuals who perceived “some” or a “great” impact of the ACA’s new requirement that insurers cover adult children on their parents’ plans until they are twenty-six years old grew by 13 percentage points ( $p<0.001$ ). Moreover, Americans are also seeing the tangible effects of reform in helping seniors pay for prescription drugs, with a 7-percentage-point increase in those perceiving “some” or a “great” impact ( $p<0.05$ ). In addition, individuals are also more aware of the impact of tax credits and other subsidies to help people pay for health insurance: There was a 7-percentage-point increase in those reporting “some” or a “great” impact ( $p<0.10$ ).

Authors’ analysis of data from three waves of a panel study conducted in September and October of 2010, 2012, and 2014, respectively. NOTE The full wording of the relevant survey question is available in the Appendix (see Note  8 in text).

Analysis Of Trends In Opinions About The Law

Why are individuals becoming more positive about the ACA’s impact on access to health insurance and medical care? Why do Americans remain split on the ACA overall, even as they become more appreciative of its tangible impacts?

Our findings defy a simple political narrative. Some of the evidence supports the early optimism of Democrats and reformers: A growing number of Americans are coming to appreciate the tangible benefits of the ACA. Yet that appreciation has not so far translated, as reformers predicted it would, into favorable overall assessments of the law. This failure has equipped Republicans to charge that Americans do not want health reform.

Snapshot polls permit us only to speculate about why individuals are forming particular attitudes. The unique and vital contribution of panel studies is that they enable us to identify changes reliably and to use the rigor of quantitative analysis to examine change among individuals.

Impact Of Policy Changes On Perceptions Of Access

The implementation of the ACA’s concrete policies since 2010 has increased public appreciation of the law’s significance in widening access to health insurance and medical care. In particular, specific changes in health care experiences—both receiving tangible new benefits and gaining insurance coverage—are affecting individuals’ broader assessments of the law’s impact on access. The odds ratios in the first two columns of Exhibit 4 show that in 2014, individuals either who perceived the ACA as having greater specific, tangible impacts for themselves or their families or who experienced gaining insurance coverage were more likely than those who did not to gain greater appreciation of the influence of health reform on widening access to medical care and health insurance.

The odds ratios point to two significant drivers of the public’s increased appreciation for how health reform widens access. People who perceived a greater impact of subsidies were 1.55 times more likely than others to see the ACA as exerting a greater impact on widening access—that is, the odds ratio was 1.55 ( Exhibit 4 , column 1). Individuals who recognized the assistance to seniors for prescription drugs were 1.29 times more likely to appreciate the ACA’s impact on access. Coverage of adult children up to age twenty-six did not have a significant influence on respondents’ opinions.

Personal experiences with changes in insurance status, not just perceptions of ACA benefits alone, affect views of the ACA’s impact on access to insurance and medical care. People who were uninsured in 2010 and 2014 had 19 percent lower odds of crediting health reform with widening access, compared to a reference group of people who were insured in both 2010 and 2014 ( Exhibit 4 , column 2). However, the experience of gaining insurance between 2010 and 2014 more than doubled (increased by 2.75 times) the likelihood that individuals would credit the ACA with widening access, compared to the reference group.

We included only one tangible new program in this analysis: ACA subsidies. The program retained a significant effect, making people who perceived a greater impact of subsidies in 2014 (compared to those who did not) 1.8 times more likely to see the ACA as exerting a greater impact on widening access ( Exhibit 4 , column 2).

The disagreement between Democrats and Republicans over health reform occurs not only among public officials in Washington but also among ordinary Americans. ¹¹ We explored how political party identification influenced perceptions of the impact of the ACA, while accounting for appreciation of specific features of the law. As expected, party affiliation had a significant influence on people’s attitudes about the ACA’s impacts on access: Individuals who identified themselves as strongly affiliated with Democrats had 11 percent greater odds of being more impressed with the ACA’s impact than those who identified themselves as weakly affiliated Democrats ( Exhibit 4 , column 1). The strong Democrats had 52 percent greater odds of appreciating the ACA than those who leaned Republican (data not shown).

It is also worth emphasizing that the inclusion of political party in our quantitative analyses means that the effects of the ACA’s new policies that we discussed above—the impacts of subsidies, aid to seniors, and new insurance coverage—occur independent of partisanship. If a Republican and a Democrat both experienced positive impacts of ACA provisions, both had greater odds of considering the law to be expanding access to health coverage than their fellow partisans who had not experienced positive impacts ( Exhibit 4 , columns 1 and 2). This is a notable finding, given the intense partisan polarization over health care reform since 2010.

We assessed the following alternative explanations for the public’s growing appreciation of the ACA’s policies to expand access: trust in government, political sophistication (indicated by high level of knowledge about the governing process and greater educational attainment), and measures of low socioeconomic status that may boost support for government activism (for example, low household income). We also accounted for the public’s perception in 2010 of the ACA’s impact on access to make sure that we were tracking genuine changes in attitudes by 2014 instead of original attitudes that had become locked in. Nothing on this long list of potentially competing influences on public opinion overshadowed the impact of the ACA’s tangible programs in driving greater appreciation of the new law’s contribution to widening access. We also found no conclusive evidence that people’s opinions of the ACA were effected by whether or not they lived in states that expanded eligibility for Medicaid.

Overall, as the ACA has delivered discernible benefits, Americans have increasingly recognized the effect of its subsidies and of their own experiences of gaining insurance. In turn, this recognition has led to a growing acknowledgment that the new law is improving access to health insurance and medical care.

Explaining The Eroding Support For Repeal Of The Law

The ongoing implementation of the ACA is also eroding public support for repealing the law and increasing the willingness of those once fiercely opposed to reform to give the law more time to work and policy makers more time to improve it. We used ordinary least squares regression to study the relative effects of insurance status, political context, and other factors on individuals who expressed an unfavorable view of health reform in 2010. Gaining health insurance between 2010 and 2014 had the greatest influence on individuals who initially opposed health reform: Compared to those who were already insured in 2010 and remained so, the newly insured in 2014 moved away from favoring repeal and toward giving the law more time to work, shifting by an average of 2.57 points on a 9-point scale ( Exhibit 4 , column 3). Not surprisingly, individuals who lost insurance coverage between 2010 and 2014 were less inclined to back improvement and more supportive of repeal.

In probing why people who strongly opposed reform in 2010 were moderating their views, we tested the impact of the same potential factors reviewed above: partisanship, trust in government, and initial attitudes toward the ACA. The effect of gaining or retaining insurance remained robust in the face of these potentially strong counterpressures.

The ACA has faced steadfast opposition since 2010 from individuals who not only dislike health reform but want to see it repealed. However, our unique set of findings demonstrates that the new circumstances created by the ACA’s implementation—specifically, its expansion of insurance coverage—are eroding opponents’ resistance to the law.

Explaining The Persistence Of Polarized Views Of The Law Overall

As Americans become more appreciative of the ACA’s tangible impacts, why do they remain split on health reform overall? After all, Democrats and reformers had assumed in 2010 that distributing benefits would produce steadily rising support for the ACA as a whole.

We now turn to the influences on favorable (as opposed to unfavorable) attitudes toward the ACA overall, focusing on the same set of explanatory variables as above (perceptions of the ACA’s tangible impacts, changes in insurance status, partisanship, and trust in government). Our results from structural equation modeling are presented as standardized coefficients, which makes it possible to compare the magnitude of influence across competing variables. (A fuller analysis is available in the Appendix.) ⁸

We found that the attitudes individuals formed toward the ACA in 2010 tended to become entrenched ( Exhibit 4 , column 4). This reduced the potential effects of specific ACA programs. Even with the hold of initial evaluations of the ACA as a whole, however, individual opinions continued to evolve and were strongly influenced by general political considerations (party identification and trust in government). Party identification had the greatest influence on evaluations of health reform as a whole, with Democrats becoming more supportive of the ACA over time and Republicans less so ( Exhibit 4 , column 4). People’s assessments of the law were also strongly influenced by trust in government: Those who were more trusting were more likely to have developed more favorable views of the ACA over time, while those who were less trusting adopted more unfavorable views.

In our analysis above, we showed that people credited the ACA’s tangible effects with widening access. However, the ACA’s programs to supply subsidies, help seniors with prescription drugs, and expand coverage of young adults failed to have a significant influence on overall evaluations of health reform ( Exhibit 4 , column 4). Party identification (0.34, $p<0.01$ ), trust in government (0.19, $p<0.01$ ), and the lagged effect of the 2010 view of the ACA (0.38, $p<0.01$ ) all had a stronger impact than gaining insurance between 2010 and 2014. By contrast, losing insurance (–0.07, $p<0.01$ ) or remaining uninsured (−0.08, $p<0.01$ ) led to reduced support of the law, though the effect was comparatively weak.

In short, political distrust, partisanship, and ingrained attitudes toward the ACA—not features of the law itself—are driving the public’s negative opinion of reform. This pattern is consistent with research on the pervasive impacts of polarization on American politics. ¹²

Two Voices Of Public Opinion And The New Politics Of Health Reform

Many Americans speak with two voices in expressing their opinion of the ACA, appreciating the law’s specific effects and disliking the law as a whole. Given these different reactions, what does the future hold? As we see it, three scenarios are possible. The likelihood of the two put forward by the political right and left, respectively, has been fading with time.

Conservatives hope that the ACA will collapse, like the Medicare Catastrophic Coverage Act of 1988—which was repealed shortly after its passage. Of course, the ACA has not collapsed, and prospects that it will are dimming. The ACA’s implementation has created operating programs, distributed new benefits that many people have come to rely upon, and led to regulations that in turn have produced new business models in the insurance and provider industries. These developments have created constituencies and interest groups that would vociferously protest their “losses” that would result from repeal. Although conservatives remain determined to roll back the ACA’s individual mandate, that would be impractical in a system with guaranteed issue—a new bedrock principle that enjoys enormous public support.

On the left, the initial hope of health reformers that the ACA’s benefits would quickly reduce the partisan discord has proved mistaken. Partisanship and political distrust prevents the ACA from gaining the kind of lopsided support that Social Security and Medicare enjoy today.

The most likely scenario is that the politics of the ACA will continue to develop as they have in the past. On the one hand, the ACA is being implemented in the most politically polarized era the United States has experienced in at least a century, and health reform is likely to remain a partisan lightning rod, even as its tangible programs seep into the fabric of everyday life. ^13,14 To distinguish itself from the Democratic Party, the Republican Party and its activists selected the law in the course of its enactment as a symbol of big government and lack of individual choice. Although a growing number of states governed by Republican lawmakers have adopted the ACA’s Medicaid expansions, as of mid-April 2016 the GOP-controlled US House of Representatives had voted more than sixty times to repeal the ACA, defund it, or delay the implementation of some of its provisions. ¹⁵ On the other hand, President Obama and Democrats remain stalwart, convinced that the ACA is good public policy and politics. They take comfort in the Supreme Court’s two decisions upholding the constitutionality of the ACA’s core operations.

Unless there is a profound turnover in Washington that puts power in the hands of one party alone, the most likely scenario for public opinion in the near term is a locking in of the dueling evaluations of the ACA. The public’s growing approval of the ACA’s tangible effects is quite significant but not determinative. Polls confirm the enormous influence of political parties on public opinion: When Americans are asked about their overall assessments of the ACA, they tend to rely on partisan cues and provide the answers that fit with the message provided by the party with which they identify. ³ The partisan clamor among politicians can be expected to intensify, of course, during the 2016 campaign, perpetuating the divide in citizens’ overall assessments.

Conclusion

The public’s view of health reform is a peculiar combination of appreciation of the tangible effects of the ACA and deep reservations about the law flowing from partisan and political distrust. This combination may well have some lasting power, as Democrats and Republicans can credibly draw on competing strains of public evaluations. ⁷

However, the sustained battle over health reform may not preclude incremental changes that advance each party’s agenda within the ACA framework. Republicans at the national and state levels may focus their political efforts on promoting markets and increased consumer choice by encouraging the use of government subsidies in private exchanges and allowing catastrophic health plans that permit individuals to choose lower premiums in exchange for reduced coverage. Democrats may be willing to compromise and accept certain Republican modifications if they can achieve improvements in coverage and affordability. An era of grand vision may transition to one characterized by the slow grind of the legislative process.

ACKNOWLEDGMENTS

A version of the findings reported here was presented at the annual meeting of the American Political Science Association, San Francisco, California, September 2015. The authors acknowledge the helpful comments of the anonymous reviewers and Don Metz, the terrific research assistance of Brianna Smith and Marissa Theys, and the expertise of Matt DeBell. Lawrence Jacobs received funding from the Walter F. and Joan Mondale Chair and the Humphrey School of Public Affairs. Suzanne Mettler received funding from a Robert Wood Johnson Foundation Investigator Award and Cornell University. [ Published online April 13, 2016. ]

NOTES

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