The passage and initial implementation of the Affordable Care Act (ACA) were imperiled by partisan divisions, court challenges, and the quagmire of federalism. In the aftermath of Republican efforts to repeal the ACA, however, the law not only carries on but also is changing the nature of political debate as its benefits are facilitating increased support for it, creating new constituents who rely on its benefits and share intense attachments to them, and lifting the confidence of Americans in both their individual competence to participate effectively in politics and that government will respond. Critics from the Left and the Right differ on their favored remedy, but both have failed to appreciate the qualitative shifts brought on by the ACA; this myopia results from viewing reform as a fixed endpoint instead of a process of evolution over time. The result is that conservatives have been blind to the widening network of support for the ACA, while those on the left have underestimated health reform's impact in broadening recognition of medical care as a right of citizenship instead of a privilege earned in the workplace. The forces that constrained the ACA's development still rage in American politics, but they no longer dictate its survival as they did during its passage in 2010.
The implementation and operation of the Affordable Care Act (ACA), though tumultuous, fraught, and obstacle ridden at every stage, have nonetheless transformed the politics of health reform in the United States. Since the New Deal, American reformers had struggled uphill to guarantee health coverage to all Americans. They eventually succeeded in attaining government coverage for seniors, disabled, and certain categories of low-income people. They failed, however, to establish national health insurance for the working-age population—until the enactment of the ACA.
It was remarkable enough for the law to be enacted, but all the more so for it to survive over the next decade. Political division and dysfunction bombarded the ACA at every turn: throughout its arduous journey through Congress to President Obama's desk, during the repeated court challenges that followed, and as much of its implementation took place amid the quagmire of federalism. The rigid partisan divide in Congress produced a party-line vote on passing the Affordable Care Act in 2009–10 and, after its passage, foreclosed possibilities for national lawmakers to create practical, technical adjustments. Partisanship in state governments slowed or stymied their efforts to shepherd the rollout of the law's programs for low- and middle-income Americans. The partisan divide also split ordinary Americans in their views about the law. The election of Donald Trump and a Republican Congress in 2016 initiated an unprecedented attack on this landmark legislation: bills to repeal the ACA passed in the US House of Representatives and came within one vote of clearing the US Senate, surviving only when Senator John McCain joined his Republican colleagues Susan Collins and Lisa Murkowski in opposing it.
The persistence of the ACA over its first decade of such formidable odds represents an immense achievement. It did not occur readily or automatically; in fact, it nearly failed at multiple junctures. Yet today, the law not only carries on but has gained greater support and generated political involvement among ordinary Americans. The ACA is increasingly changing the nature of political debate. The forces that constrained its development still rage in American politics, but they no longer dictate the ACA's survival as they did during its passage in 2010.
New policies often remain fragile during their early years; ideally, policy makers can nurture them, enacting helpful adjustments along the way and providing administrators with ample resources and other assistance to ensure success (Berry, Burden, and Howell 2012; Patashnik 2008). The ACA, however, emerged amid a firestorm in American politics, as intensifying partisan polarization and congressional gridlock fostered an environment that is inhospitable to reform. The resilience and growing strength of the ACA, even in the midst of this environment, present a puzzle that requires explanation.
Together and separately we have been tracking the topsy-turvy history of the ACA. In studies represented by a string of publications and papers, we conducted elite interviews, examined primary and secondary sources, collected multiple waves of panel data, and conducted multivariate regression analysis. While some of our findings, particularly regarding early implementation, confirm aspects of the familiar patterns associated with partisanship, lobbying by powerful interests, and legislative gridlock, we also found that these patterns did not dictate the ACA's first decade. As time went on, we found, the ACA itself generated policy feedback dynamics that have enabled it to survive and even, in some respects, to thrive. In these regards, it presents striking—if contingent—exceptions to the dynamics of contemporary American politics.
National Gridlock and State Implementation
In an unprecedented departure from the pattern followed previously by partisans of both parties when landmark legislation passed over their disapproval in Washington, DC, Republican opposition to the ACA's passage has yet to subside. Following the 2010 elections, party leaders took note of the influx of Tea Party Republicans that successfully flipped the House to Republican control and identified ACA repeal as a winning issue that mobilized their voters. This in turn produced widespread agreement among political commentators and the news media that health reform was doomed to paralysis or collapse (e.g. Boyer 2010; Edsall 2013). This narrative of doom made sense early on, but over time it has obscured immense shifts in the law's development.
Public opinion toward health reform initially followed a pattern that has become familiar in an age of polarization: Americans split into rigid partisan groupings who shared similar conservative or liberal mindsets generally, and they adopted positions of support or opposition to the ACA accordingly (Abramowitz 2010; Levendusky 2009). Such partisan sorting, according to social psychologists, results from “hot cognition,” in which individuals are triggered by elite or media cues and respond with near automatic reflex (Taber and Lodge 2006).
The combination of the partisan standoff over the ACA among elected officials in Washington and polarized views about it among the public reinforced each other, producing gridlock over it in Congress. This prevented the passage of incremental adjustments and even technical legislation to fix glitches (Holahan and Blumberg 2017). Such technical fixes were familiar in the past, even after heated congressional disputes. For instance, the enactment of the Medicare Modernization Act of 2003 was fiercely contested, and yet, after it was signed by President George W. Bush, lawmakers worked together in a bipartisan manner to revise and improve the law.
The patterns of partisan polarization and gridlock that hindered the ACA in its early years broke down in the states, however, as implementation proceeded. For sure, there was a close association between early state adoption of the Medicaid expansion and Democratic control of state legislatures and especially governorships. Yet, sweeping conclusions about the ACA's prospects generated by journalists and others were typically based on the loud and vociferous conflict in Washington and among national politicians and crucially missed the cracks in partisan stalemate that were starting to appear at the state level. While partisanship remained (Republicans controlled all the states that blocked Medicaid expansion), a steady pattern commenced of GOP lawmakers adopting the new benefits.
One of the factors that contributed to the implementation of health reform by states was their strategic maneuvering to engage in intergovernmental bargaining. In an analysis of 50 states, Callaghan and Jacobs (2014) found that states with prior experience seeking federal waivers for social welfare programs made more progress toward Medicaid expansion than those lacking that track record, after controlling for party control in government. In particular, this points to the mechanism of “upward federalism” in which states that requested 1115 waivers from Medicaid before 2010 treated the ACA's original design of Medicaid expansion as an opening bid for negotiations to press for greater leeway. For federal agencies, the process of back-and-forth consultations and negotiations with interested states was welcomed as a means to identify areas of potential compromise in order to induce state adoption of the Medicaid expansion (as was the case with Arkansas's “private option”). However, states that either lacked the experience of requesting waivers or were unrelentingly opposed to implementing the ACA viewed the 2010 law as a “take-it-or-leave-it” order and refused to engage in negotiations.
Empirical research added additional explanations for the loosening grip of partisanship on state implementation of the ACA, as GOP governors in Arizona, Nevada, Michigan, and other states moved forward with the Medicaid expansion. The analysis pointed to several factors that would later prove to be significant drivers: states appeared predisposed toward expanding Medicaid if they had previously established programs to assist low-income people (what we more fully describe below as “policy feedback”) or possessed the administrative capacity to manage health care programs (Jacobs and Callaghan 2013). By 2015, the partisan control of government continued to influence Medicaid expansion and, in particular, variations in new enrollment across all 50 states. But empirical evidence also continued to reveal the impact of state health policy and administrative capacity on the enrollment of individuals in Medicaid after taking into account the influence of partisanship (Callaghan and Jacobs 2017). An important pattern became evident: political parties still mattered, but they did not impose rigid control outside of Washington.
Cracks in America's Oligarchy
Rising economic inequality, along with the political organization of corporations and the affluent, has produced a reinforcing cycle of increasingly concentrated power and resources in contemporary American politics that some describe as “oligarchic” (Gilens and Page 2014; Jacobs and Page 2005; Skocpol and Hertel-Fernandez 2016). The results of lopsided organized combat are evident in tax and labor policies that advantage corporations and the wealthiest individuals.
The Obama White House launched its campaign to pass the ACA in 2009 by making concessions to the medical professions and the powerful interests associated with commercial insurers, hospital, pharmaceutical producers, and more (Jacobs and Skocpol 2015). These types of accommodations are a familiar pattern in American politics, typically present particularly when reform is attempted in a domain already populated by stakeholders. Previous efforts at health care reform failed, in part, because such groups opposed it; for example, the American Medical Association stymied the reform efforts of Presidents Franklin D. Roosevelt and Harry Truman, and the health insurance industry thwarted efforts by President Bill Clinton (Blumenthal and Morone 2010).
Nonetheless, the ACA departs, in crucial respects, from the pattern of bias toward the organized and affluent. Even though health reform contained concessions, they were granted for the purpose of its central achievement: the extension of the right to health care as a basic component of citizenship (Jacobs 2014). The ACA succeeded in bringing health insurance coverage to more than 20 million people and preventing more than 19,000 deaths due to the lack of medical care, according to one estimate (Miller et al. 2019). The law was financed predominantly through new taxes on the wealthiest Americans, including a higher Medicare tax on earnings and a new 3.8% tax on investment income (Tax Policy Center 2018). These historic gains occurred, in part, because of another departure: the dynamics of organized politics changed in several respects.
Organized interests often unify against expanding social welfare benefits for the less advantaged, fearing tax increases and new regulations that might accompany such policies. In the case of the ACA, however, such groups split, as some voiced their typical opposition but others came out as supporters. In particular, health care providers, suppliers, and segments of the insurance industry valued the law's distribution of subsidies and other benefits that increased demand for health insurance, medical care, prescription medications, and medical equipment (Hertel-Fernandez, Skocpol, and Lynch 2016; Jacobs and Ario 2012; Jacobs and Skocpol 2015). Business associations, especially the US Chamber of Commerce and the Koch network (including its conservative American Legislative Exchange Council), contested the passage and implementation of the ACA but found their resources and influence offset, in part, by medical groups and other health care stakeholders that favored the law's success.
As well-resourced business and professional organizations splintered, the public interest advocates for ACA implementation weighed in. Over 9,200 lobbyists registered in state capitols to push for their clients' preferred health policy. Callaghan and Jacobs (2016) found that states that included a greater number of lobbyists for the uninsured and vulnerable, such as those associated with unions and consumer and charitable organizations, made greater progress in implementing the ACA's Medicaid expansion by 2015 than did states that had fewer such advocates in their capitols. The positive and significant impact of public interest advocates held up even after controlling for the partisan control of state government, the well-funded pressure from businesses and professionals, and other potentially confounding factors.
The Politics That Health Reform Created
The old saw about generals is that they fight the last war with less regard for intervening changes. Political commentators following health reform have tended to fall into the same trap, assuming that the battle lines of 2009–10 would continue to define the politics surrounding the ACA going forward. Of course, they are correct with respect to the partisan split in Washington, DC, which has certainly persisted. Nonetheless, this first decade of the ACA's implementation has changed the politics of health reform, specifically with respect to Americans' attitudes and political behavior.
The Changing Public
We have been carefully tracking the reactions of everyday Americans to the ACA. As reform was moving through Congress in 2009, we set up a panel of 1,000 randomly selected American adults as well as 200 people from groups who are often underrepresented in surveys—lower income and younger people. We have interviewed this panel every other fall from 2010 through 2018, creating five waves of interviews with the same group of people. Our panel is weighted to represent US demographic characteristics and has retained many of our original interviewees.1
By 2014, the ACA's programs were already tarnished by administrative mishaps even though most were not yet implemented; Americans' attitudes toward health reform at this stage reflected this (Jacobs and Mettler 2018). Our analysis of the first three waves in 2010, 2012, and 2014 found that Americans were generally supportive of the ACA's specific benefits, such as subsidies to purchase private insurance or help for seniors to purchase prescription medication. As the years unfolded, there were also signs that resistance to the ACA might be receding a bit: support for outright repeal remained robust but was declining, and fewer members of our panel reported that the ACA had little or no impact on access to health care than had done so at the outset. Still, the partisan divide created a toxic environment that undermined support for health reform overall. No regular observer of American politics would be surprised to learn that Democrats favored the law and Republicans retained unfavorable views of it.
Our sustained analysis has detected an important development as the years proceeded, however: the implementation of the ACA was changing the politics of health reform, modestly at first and then more robustly by October 2018. This pattern is consistent with research on policy feedback: individuals' personal experiences with established programs and those with designs that make government's role visible can change public attitudes and political engagement, including voting behavior (Campbell 2003; Mettler 2005, 2011).
Our research found early signs of the ACA's effects on the politics of health reform. By late 2014, Americans who gained insurance coverage and saw tangible benefits of subsidies and help for seniors became, compared to their earlier atttitudes, more appreciative of the law's impact in expanding access to coverage (Jacobs and Mettler 2018).
Despite these signs of increasing appreciation of the law's specific benefits, however, our analysis of public attitudes toward it in late 2014 made evident why overall public support for the ACA generally had not yet grown (Jacobs and Mettler 2018). The ACA had created benefits, but it also introduced burdens in the form of taxes. Although the taxes fell predominantly on a small group of Americans in the top 1% of the income distribution, they initially contributed to antireform judgments (Tax Policy Center 2018). Partisanship and distrust of government, moreover, continued to overwhelm even Americans' positive experiences of it when it came to their overall evaluations of health reform. Compared to their assessments in 2010, individuals who identified as Republicans and resented government and taxes increased their unfavorable assessment of reform's impact on access, as did those who lost insurance coverage since the ACA's enactment. Nonetheless, the upward trend in the appreciation of the laws' features would, within the next few years, harken more fundamental shifts in public opinion and political behavior.
Four Features of the New Health Politics
When President Obama and Democrats struggled to pass health reform in 2009–10, the stakes remained vague to most Americans, as neither the scope of the benefits nor the recipients of the burdens were apparent. As the ACA reaches its 10–year anniversary, it provides concrete services and its impact on the lives of everyday Americans has become tangible—and expected. Anticipated burdens have failed to materialize for most people.
New health policy changed the politics of health reform in four respects. First, Americans have become increasingly accustomed to receiving the ACA's benefits, and that has led to growing support. The partisan frame that initially defined responses to the ACA has given way, for many Americans, to a pragmatic frame, in which more acknowledge the value of receiving needed health coverage. Panel data shows that support for the ACA increased by the fall of 2018 to its highest level since the law's enactment, and the most intense opposition had receded to its lowest point. More individuals have also been reporting that the ACA affected their lives and improved their access to health care, even after Republicans and the Trump administration attempted to undermine the law. In particular, individuals have grown more appreciative by 2018 compared with earlier years of the ACA's help for seniors to achieve prescription drug coverage, subsidies to purchase private health insurance, and guarantee of insurance for the children of insured parents until 26 years of age.
Second, the Washington GOP's threat to repeal the ACA in 2017–18—once they controlled both the White House and both chambers of Congress—jolted a broad swath of Americans to become more supportive of the law than they had been before the 2016 elections (Zhu, Mettler, and Jacobs 2019). Democrats had long been supportive of the law, but in the wake of the GOP threat, support for it increased among rank-and-file Republicans. The GOP threat also changed voting behavior: it mobilized Democrats to assign greater importance to the ACA in their candidate selection and depressed the intent of Republicans to cast a vote based on health reform. In other words, the strategy of the Washington GOP backfired: repeal rallied Democrats to become more politically engaged and muted opposition among everyday Republicans.
Third, the ACA is giving rise to new constituents who rely on its benefits and share intense attachments to them. The GOP's repeal threat awoke several groups of beneficiaries, making them more fully appreciative of the new health care benefits by the 2018 elections than they were previously. Americans who had realized that the ACA expanded access before the 2016 elections became more supportive afterward. More striking, the GOP threat stirred greater appreciation for the ACA's impact among individuals who had not registered such views previously as well as among low-income people who were especially dependent on the new coverage (Zhu, Mettler, and Jacobs 2019).
New policy that creates new constituents represents a politically potent form of policy feedback (Campbell 2003). The ACA's decade of operations is now starting to coalesce new beneficiaries as a self-conscious set of constituents, although the extent to which political leaders or groups will mobilize them as such remains to be seen.
A fourth feature of the new politics of health reform is the ACA's impact on political efficacy (Mettler, Jacobs, and Zhu 2019). According to our panel data, between the ACA's passage in 2010 and the 2018 elections, the survival of health reform and distribution of its concrete benefits prodded individuals to higher levels of confidence in their individual competence to participate effectively in politics and lifted their confidence that government will respond. These effects hold up despite potent controls for political ideology, demographic factors, and other potential influences.
During the ACA's first decade, it endured criticism from both the Left and the Right. While the two sides differed on their favored remedy, both shared a view of reform as a fixed endpoint instead of a process of evolution over time. This stagnant view blinded conservatives to the network of support for the ACA that now extends well beyond beneficiaries themselves to the well-organized ranks of medical providers, commercial insurers, pharmaceutical companies, and states that have adopted Medicaid expansion. The aspirational Left's failure to understand the implementation of health reform as a process has handicapped it from appreciating the program-expanding dynamics that the ACA has initiated, including the growing number of states that have adopted expanded Medicaid. Its operations both highlight shortcomings and identify tangible remedies for future reform, such as expanding subsidies to make premiums and deductibles more affordable. Perhaps most important, the ACA sets the terms for new reforms by framing health care as a right of citizenship instead of a privilege earned in the workplace and by legitimating the government's responsibility for health care coverage of the working population instead of deferring to employers or the individual acting alone (Jacobs 2014).
Treating the ACA as an endpoint instead of a policy undergoing a process of development over time has also distorted judgments about its distributional effects—its winners and losers. While verdicts issued soon after the law's enactment may have been accurate at the time, they miss the changes that have ensued, including the “comebacks”—the groups of Americans who were initially considered to be on the losing end but are now benefiting. The Supreme Court's 2012 decision altered the original legislative plan by replacing the relatively straightforward national implementation of the new Medicaid benefits with cumbersome, uneven battles within each state. This created gruesome disparities in mortality and illness across states that adopted or failed to adopt the Medicaid expansion. As time has passed, however, the ranks of adopting states have steadily grown to 37, with 3 states in the process of accepting the new programs and more still in the process of debating it. States and groups of people who were initially declared “losers” are now coming back and gaining needed medical care; little attention has been given to these comebacks that resulted from the evolving process of reform.
There may also be signs that the initially anointed “winners” among powerful businesses and interests—such as pharmaceutical producers—are facing future constraints. As drug prices have continued to rise, there is rare bipartisan agreement on the problem and initial legislative steps toward a response, at least in the Senate. While significant concrete solutions are not imminent, the need to impose restraints on drug prices and the pharmaceutical industry now appears on the agendas of voters and federal and state governments.
The ACA also appears to be evolving from its early status as a politically vulnerable target amid Washington's partisan conflicts and gradually becoming a more politically resilient program than anticipated in the past. GOP politicians who attacked the ACA faced a backlash during the 2018 congressional elections, and the Republican governor of Kentucky, Matt Bevin, was punished for his attacks on the state's Medicaid program in the 2019 election. Compared to the electorate in the first four elections after the ACA was enacted, voters in 2018 who supported the ACA were intensely focused on the choice among candidates, had become more engaged politically than those who opposed health reform, and were more likely to take it into account when selecting candidates (Jacobs, Mettler, and Zhu 2019). While the ACA is not a “third rail of American politics” at this point, Republican politicians who attempt to repeal or roll it back now face scrutiny and potential political risks. Ambitious conservatives will have to take that into account in the future or face defeat.
Winston Churchill famously quipped in 1940, when British pilots fought off the German Luftwaffe and the threat of an invasion, that “never was so much owed by so many to so few.” As the ACA emerges from a decade of fierce partisan warfare, its accomplishments also stand out: health reform has done so much but has been recognized for so little of it.
Overall, 66% (949 of 1,473) of panelists from prior waves sampled completed the wave 5 interview. Forty-four percent of the original 2010 survey (524 individuals) responded to all five waves, and 58% (691 individuals) participated in both 2010 and 2018.