Abstract

Messaging about the Affordable Care Act (ACA) has seemingly produced a variety of outcomes: millions of Americans gained access to health insurance, yet much of the US public remains confused about major components of the law, and there remain stark and persistent political divides in support of the law. Our analysis of the volume and content of ACA-related media (including both ads and news) helps explain these phenomena, with three conclusions. First, the information environment around the ACA has been complex and competitive, with messaging originating from diverse sponsors with multiple objectives. Second, partisan cues in news and political ads are abundant, likely contributing to the crystallized politically polarized opinion about the law. Third, partisan discussions of the ACA in political ads have shifted in volume, direction, and tone over the decade, presenting divergent views regarding which party is accountable for the law's successes (or failures). We offer evidence for each of these conclusions from longitudinal analyses of the volume and content of ACA messaging, also referencing studies that have linked these messages to attitudes and behavior. We conclude with implications for health communication, political science, and the future outlook for health reform.

The decade since the passage of the Affordable Care Act (ACA) has produced a mixed bag of outcomes from the perspective of health communication. On the one hand, more than 20 million people became insured by 2016 as a result of the law's implementation (Obama 2016), although there is evidence of an erosion of these gains since 2017 (see, e.g., Griffith et al. 2020). The sheer volume of this increase is unprecedented in recent US history: millions of people gained insurance through Medicaid expansion, insurance newly available for young adults, and new plans available and subsidized on the individual marketplace. These increases in coverage reduced health care access disparities by income and race/ethnicity (Lipton, Decker, and Sommers 2019; Griffith et al. 2020; Kominski, Nonzee, and Sorensen 2017). Of course, some of these insurance gains can be attributed to specific policy mechanisms, such as changes in Medicaid eligibility and the availability of financial subsidies. Yet research also makes a strong case that messages conveyed via news media as well as strategic communication campaigns by federal, state, private, and nonprofit entities, also contributed to increases in rates of health insurance coverage (Karaca-Mandic et al. 2017; Gollust, Wilcock, et al. 2018; Goldin, Lurie, and McCubbin 2019; Shafer et al. forthcoming). These sources of public communication also helped to shape public awareness, information searching, and attitudes about the law (Shafer et al. 2018; Fowler et al. 2017; Sommers et al. 2015).

On the other hand, we end the decade observing a public as confused as ever about the ACA's provisions and its achievements (Brodie et al. 2020). In 2019, fewer than 6 in 10 Americans were aware that the ACA expanded Medicaid or that the law provides financial help to purchase insurance—estimates that are even lower than they were in 2010 (Brodie et al. 2020). In January 2018, just after passage of the tax law that repealed the penalty for the individual mandate, 17% of Americans believed that the ACA “has been repealed and is no longer in effect,” while an additional 14% didn't know if it was still in effect (KFF 2018). A January 2017 poll found that 35% of respondents were unaware that “Obamacare” and the “Affordable Care Act” are names used for the same legislation (Dropp and Nyhan 2017). Public opinion data documents profound political polarization in perspectives on the law—with a partisan divide between the share of Democrats and Republicans having a favorable view of the ACA averaging 54 percentage points between 2010 and 2018 (Brodie et al. 2019). These persistent, polarized views may even have led to differential uptake of health insurance, with some evidence showing that Republicans were less likely to gain insurance via the Marketplace than Democrats (Lerman, Sadin, and Trachtman 2017; Sances and Clinton 2019). Here we seek to unpack how the media environment may have contributed to both (a) significant mobilization of the public to gain insurance, but also (b) persistent confusion and political polarization.

Our research team's analyses of televised messaging offer a few important lessons for the health politics we observe at the end of the decade. By examining the volume and content of local television news as well as television advertisements (ads) (including both health insurance and political campaign ads)—as we have done since 2013—we draw three conclusions about the media ecology that help explain these phenomena. First, the information environment is increasingly complex and remains competitive. Second, partisan cues are abundant even in news coverage, likely reinforcing polarized opinions about the ACA. Third, the partisan ACA-related discussion in political ads has notably changed over the decade. We present evidence for each of these conclusions and then draw implications for health policy, health communication, and the future outlook toward health reform.

Competitive Media Information Environment

The media ecosystem surrounding the ACA exemplifies a competitive information environment (Chong and Druckman 2007). Not only do news media tend to present the law using a horse-race or game frame—focusing on which political party is winning or losing related to the law's implementation (Gollust et al. 2017)—but there is also competition with the news from other information sources seeking to persuade the public. These include ads by political candidates for office and ads promoting health insurance by government, nonprofits, and the private sector (Gollust et al. 2014).

Figure 1 displays the weekly volume of health insurance ads and political ads referencing health care (not exclusively the ACA), based on Wesleyan Media Project analyses of Kantar/CMAG data, across six Healthcare.gov open enrollment periods between 2013 and 2018. The volume of health insurance ad airings (the solid gray line) corresponds with the open enrollment periods, with highest peaks during these weeks in the late fall of each year.1 Notably, because of the co-occurrence of the political campaign season (in 2014, 2016, and 2018) with the health insurance open enrollment periods, the volume of political ads referencing health care (the dashed line) reaches almost equivalent volumes in 2014 and 2016 to that for health insurance ads. Strikingly, the volume of health care–related messaging from campaign ads vastly exceeds the volume of health insurance–sponsored ads in 2018, as we discuss in more detail below.

These aggregate patterns of volume, however, mask important changes in the composition of televised messages since the initial implementation of the ACA. First, immediately after the Trump inauguration in January 2017, the administration implemented both political messaging changes and administrative changes in ACA-related media investment, which appeared to contribute to declines in health insurance applications in the postinauguration period, particularly for HealthCare.gov states (i.e., those relying on the federally facilitated marketplace) (Anderson and Shafer 2019). Notably, the Trump administration zeroed out the budget for Healthcare.gov television advertising starting with the 2018 open enrollment period (Kliff 2017) and also reduced the grants available to health insurance navigator organizations, leaving fewer resources for marketing and outreach in states relying on the federally facilitated marketplace (Galewitz 2018). At the same time, the composition of health insurance ads was shifting, with a rising share of private insurance ads and diminishing proportion of advertising from federal sponsors (even before the full decline to zero in 2017) (Gollust, Baum, et al. 2018). Our own work also found that ads sponsored by insurance companies rarely referenced the health care law explicitly, and the proportion that did so declined over time (Barry et al. 2018; Gollust, Baum, et al. 2018). Thus, as federal ads disappeared and left the private sector to communicate about the ACA with rare mentions of the law itself, the paid media environment about health insurance plans appears to epitomize what has been referred to as a “submerged state” (Mettler 2011) where consumers are not made aware of the government's role in facilitating and regulating the Marketplace (see also Shafer et al. forthcoming).

Changes in the ACA-related television (TV) news environment are also evident across the decade. Given that local TV news is the most preferred source of local news for Americans (Pew 2019a),2 we conducted a content analysis of local evening TV news coverage of the ACA during the initial implementation period (October 2013 through April 2014), based on a sample derived from searches of health care and ACA-related keywords in local news closed captioning. We found that less than half of news coverage focused on health insurance plans available, while the remainder focused on political disagreements (Gollust et al. 2017). Substantial coverage was devoted to website glitches and number of enrollees to date, with fewer stories mentioning enrollment-related policy details. In fact, less than 7% of news stories mentioned subsidies available and a similar proportion mentioned (7%) or focused on (5%) Medicaid (Gollust et al. 2017).

In an effort to compare TV news coverage five years out from ACA implementation, we again implemented keyword searches from local evening television news closed captioning to identify stories about health insurance policy.3Figure 2 displays the volume of evening news coverage of health insurance-related policy from July 30, 2018, to July 31, 2019, across all 210 US media markets. As shown in the figure, news attention to health insurance was event-centered, with news volume tracking key political and policy events: a sharp rise right around the November 8 midterm election, a dramatic drop until the end of the open enrollment on December 15, and spikes in coverage around the announcement of key events in the ongoing Texas v. United States court case on the constitutionality of the ACA.

Partisan Cues in News Are Abundant and Persistent over Time

Further examination of the news content about health insurance policy demonstrates that partisan cues, one strong signal of the politicization of health issues in news media (Fowler and Gollust 2015), are abundant in this coverage. As noted above, ACA news stories in 2013–14 frequently referenced political discussion over policy substance (Gollust et al. 2017). For the purpose of this commentary, we reexamined the 2013–14 news stories that were at least somewhat about health insurance plans (N = 1,153). Of these, almost half (49%) contained at least one reference to a person with a partisan identification—such as President Obama (or his administration) or another federal, state, or local elected official identified with their political affiliation. Digging deeper, 45% of news stories contained at least one reference to a Democratic official, 22% included at least one reference to a Republican official, and almost one in five news stories (19%) contained both a Democratic and Republican reference. These signals are important because partisan cues contribute to the public's tendency to accept (or reject) and interpret information according to their political predispositions (Druckman, Peterson, and Slothuus 2013)—meaning that partisanship may be particularly salient when the public interprets news about the ACA.

Turning now to the 2018–19 period of health insurance TV news, we also conducted a content analysis of a strategic sample of news coverage by creating a constructed week sample, similar to the method we employed in our previous study (Luke, Caburnay, and Cohen 2011), yielding a sample of 1,247 news stories.4 To compare news stories from the 2013–14 period (which all concerned the ACA) and the more extensive health insurance policy discussions in later news coverage, we divided 2018–19 evening news coverage in Table 1 into ACA related and not directly ACA related. News coverage still frequently featured the ACA, with 55% of news stories mentioning an ACA-related topic and 25% focusing on an ACA-related topic (although only 21% explicitly mentioned the ACA or Obamacare). Much more news coverage in 2018–19 mentioned Medicaid (36%, compared to only 7% of news coverage mentioning Medicaid in our 2013–14 study), and 13% of stories focused on Medicaid. This difference could be the result of much more substantive news coverage that surrounded the ACA repeal fights in 2017, as journalists seemed to learn to focus on policy detail (including Medicaid) (Rovner 2020). However, these differences could also be attributable to the change in our search terms. Other major health insurance policy topics that received at least moderate attention in TV news in the 2018–19 period included Medicare, health care costs, and prescription drugs.

Table 2 shows partisan cues in local TV news coverage of health insurance policy in 2018–19 to compare to the high frequency of ACA-related political discussion in 2013–14. The results indicate that references to any partisan actor persisted at almost the identical prevalence from 2013–14: as noted above, 49% of news stories in 2013–14 referred to at least one partisan actor, whereas 45% of 2018–19 news coverage referred to any partisan actor, and this rate was higher in stories that mention ACA-related topics (54%). Regardless of whether the story itself was linked to the ACA or not, about 20% of all health insurance policy stories referenced President Trump, 30% referenced at least one Democratic politician, and 23% referenced both parties (again, almost the same prevalence as in the earlier period). Notably, partisan references in news were not confined to election season but persist throughout the year (fig. 3). While it is perhaps obvious that discussions of health politics and policy would include partisan references, the high volumes we observed—half of all coverage—signifies that the public is exposed to persistent reminders that health insurance issues are politically partisan, and only half of stories discuss substantive health policy matters without reference to the political environment. These findings reinforce the idea that the politicization of health issues in news coverage is “sticky” and persistent over time, as we have also seen in the cases of mammography and the HPV vaccine (Fowler and Gollust 2015). This phenomenon could explain why even with new information and evidence consistently emerging about the law and its effects, opinion about the law prior to 2017 shifted little and remained polarized (Brodie et al. 2019). Political signals contribute to citizens using motivated reasoning (i.e., differentially weighing arguments that support an existing [often partisan] position, not logical deliberation) in processing ACA-related information (Druckman, Peterson, and Slothuus 2013; Petersen et al. 2013), limiting the public's ability to incorporate or evaluate evidence about the ACA into updated judgments of government accountability (James and Van Ryzin 2017).

Changing Partisan Discussion about Health Care in Political Ads

While the above discussion demonstrates that the sheer volume of partisan references in health care news stayed consistent between 2013–14 and 2018–19, our analysis of partisan content and messaging in political ads reveals a different story. Indeed, the Wesleyan Media Project has documented dramatic shifts in both the volume and the tone of health care messaging in advertising for US House and US Senate races from 2008–18 (Fowler, Franz, and Ridout 2020). More specifically, as shown in Figure 4, while advertising for both parties discussed health care at roughly the same rate in 2008 (13% for pro-Republican advertising and 18% for pro-Democratic advertising), subsequent pro-Democratic messaging all but ran away from health care in the next several rounds of elections. From 2010 (just after the passage of the ACA) through the 2016 campaign, pro-Democratic advertising only obliquely referenced the law, if at all. This makes sense, given that the law did not have majority support during this time period (Brodie et al. 2020). By contrast, nearly a third of pro-Republican advertising took health care head-on between 2010 and 2014 with many ads explicitly promising to repeal, or repeal and replace, Obamacare. Following Republican attempts to follow through on this promise, however, Democrats placed health care messaging front and center in the 2018 campaign, following the law's growing popularity among the public (Brodie et al. 2020). This, combined with a large increase in advertising and the fact that pro-Republican mentions of health care stayed steady at roughly 30% of their advertising, meant that citizens were exposed to an unprecedented amount of political ad messaging on health care in the 2018 midterm election cycle, one that was often contested between parties. Although Republicans no longer touted repeal and replace in the same way, they often discussed government intervention in health care unfavorably and expressed concern for coverage of preexisting conditions. This means that many citizens were frequently exposed to two very different partisan stories about the ACA and the future direction of health insurance reforms. Political science research indicates that when candidates from different parties discuss the same issue (“issue convergence”), this can sometimes confuse voters more than it helps boost knowledge or clarify positions (Lipsitz 2013).

Implications for Health Policy and Politics

As should now be clear, messaging about the ACA over the past decade has come from a variety of sources: citizens tuning in to television might have received information from local television news, from health insurance advertising and/or from campaign advertising—and potentially all three types of information during the same half-hour news segment. These competitive messages varied in goal (information versus persuasion), in content (substantive policy information versus cursory detail) and in the availability of relevant cues (pro-Republican messaging attacking government contrasted sharply with private insurance submerging the state while many news stories contained explicit partisan references). Behind these messages are multiple sources of information competing to shape public attitudes and behavior: policy, political, and corporate leaders all trying to educate and persuade the public at the same time—to buy a health insurance plan, to support the ACA (and candidates who do so), or to call on legislators to repeal the ACA (and shape their chances of reelection). Further, the audiences affected by these messages are diverse. Some of the audience of ACA messaging includes those who could (and indeed, many did) benefit from new insurance options made available. Other audience members were not directly influenced by the law's individual market regulations or Medicaid expansion, yet were still exposed to a diverse array of messages with partisan signals and politicized content.

Considered together, all of these features of the media environment likely lead consumers to be confused about the law and its impact on regular people, and to interpret impact through a partisan lens, despite clear evidence of the ACA's success in contributing to increased rates of health insurance coverage. As Brodie and colleagues (2020) note, the partisan gap in favorability rose to 64 percentage points in 2019, with Democrats' favorable perceptions of the law increasing following repeal threats in 2017, while Republicans' views remained persistently unfavorable. And misperceptions have persisted, such as 57% incorrectly believing there was a governmental panel to make decisions about end-of-life in 2010, and 56% believing the same in 2019 (Brodie et al. 2020). As mentioned above, partisan cues in messaging encourage individuals to engage in motivated reasoning in the processing of new information (Druckman, Peterson, and Slothuus 2013; Petersen et al. 2013). Motivated reasoning likely limits the public's ability to incorporate or evaluate evidence into their judgments of government accountability (James and Van Ryzin 2017) or even recognize that popular elements (including guaranteed issue for people with preexisting conditions or elimination of cost sharing for preventive services) are attributable to the ACA (Brodie et al. 2020). Public recognition is made even harder by private sector messaging that submerges the ACA role and by some Republican candidates' misleading political ads that describe support for insurance coverage for preexisting conditions, despite their position on the Texas v. United States case that would invalidate such protections. It's no wonder, then, that public perceptions of whether the ACA has helped or hurt Americans are filtered by partisanship, with 38% of Republicans in 2019 saying the ACA has hurt them, and only 8% of Democrats saying the same (Brodie et al. 2020).

Such intense polarization in the media environment contributes via policy feedback to dynamics that will likely shape the future direction of health reform efforts. A recent study demonstrates that polarized views about the law may have even contributed to insurance marketplace affordability and ultimately Republicans' experiences of the law. Trachtman (2019) describes a positive relationship between Republican vote share and growth in individual marketplace premiums; as more Republicans opt out, those that remain in the marketplace experience higher premiums, leading them to support the law even less, and thus contributing to a reinforcing cycle of partisan policy feedback.

This finding is substantively important since public opinion data (as of 2019, before the COVID-19 pandemic) suggested that the top health care issue in 2020 for voters was around unacceptably high health insurance costs. In fact, the data indicated bipartisan unity over the importance and urgency of this problem for politicians to address (Blendon, Benson, and McMurtry 2019). However, given a decade of polarized messages about the ACA, the prevalence of partisan cues in news stories about health care policy (pervading even non-ACA-specific coverage), and continued competition over who owns the issue of health insurance entering the 2020 election, policy efforts to address health care costs may be hampered by messages that associate these issues with the ACA. Policymakers seeking additional health reforms will likely need to overcome a decade of partisanship in political messaging about the ACA to identify new communication strategies to reach the public, although the shifting political ground associated with COVID-19 may open the agenda in ways considered impossible before the spring of 2020. Similarly, communication research in both health and political communication subfields should continue to evaluate the content and effects of health policy messaging, and identify new evidence-based ways to overcome partisan motivated reasoning and boost public support for needed health policy reforms.

Acknowledgments

We thank Colleen Bogucki, Margaret Tait, Laura Baum, and the team of undergraduate research assistants from the Wesleyan Media Project. We also acknowledge funding from the Robert Wood Johnson Foundation (grant nos. 73619, 75347, and 77117) and the Russell Sage Foundation (grant no. 1808-08181). The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the Russell Sage Foundation or the Robert Wood Johnson Foundation.

Notes

1.

The health insurance ads included in this graph include all sponsors, including ads for Medicare and private plans not available on the health insurance marketplace, so some of the spikes are attributable to the annual cycle of Medicare enrollment and employer-sponsored insurance open enrollment. That said, the volume of ads nonetheless likely provides a cue to consumers seeking marketplace insurance, and we have shown that health insurance ad volume is associated with consumers' health insurance enrollment behaviors (Gollust, Wilcock, et al. 2018).

2.

The media industry and audiences' media consumption preferences changed somewhat over the decade following the ACA's passage. Americans' preferences for getting news online have increased, with 37% preferring online news (15% via social media, 23% via news websites or apps) in 2018, an increase from earlier years (Pew 2019b). Newspaper readership declined from 56% in the early 1990s to 29% in 2012 (Pew 2012); only 17% of Americans often relied on a local print newspaper in 2018 (Pew 2019a). However, local TV news was still the dominant source of news in 2019 just as it was in 2013: 38% of Americans reported they “often” tuned into local TV news in 2019 (and 86% said that they ever did so, more than any other source) (Pew 2019a) compared to 48% who reported regularly watching local news in 2012 (also the top source of news then) (Pew 2012).

3.

We tracked news coverage from July 30, 2018, to July 31, 2019, using keyword searches in the TV Eyes database. The keywords we searched were different than the previous period to capture changes in the health policy discourse. The keyword searches we implemented were: (“affordable care act” OR “health insurance” OR medicaid OR medicare OR obamacare OR “obama care” OR “trump care” OR “universal healthcare” OR “universal health care” OR “single payer” OR [(“health care” OR healthcare) AND insurance]) AND (act OR bill OR initiative OR law OR legislation OR mandate OR policy OR reform).

4.

For each month from October 2018 through July 2019 when we had video data, we randomly selected a Monday through Friday from all dates available in the month to create a constructed week. A total of 2,063 keyword hits occurred on the 50 constructed week dates; 623 of them were advertisements, and 88 were not local news; another 105 had problems that prevented coding. This left 1,247 news stories in our sample.

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