Impervious to Elite Influence: Americans’ ACA Attitudes, 2009–2020

For generations, many Democrats considered extending health insurance to be among the major unfinished aspects of the American social welfare state (Hacker 1999; Jacobs and Skocpol 2015). But where presidents from Harry Truman to Bill Clinton had largely failed in their efforts to move the United States toward universal health insurance (Skocpol 1997), Barack Obama was positioned to succeed upon his 2009 inauguration. He entered office with sizable Democratic congressional majorities (Cohn 2021), and decades of legislative polarization meant that he assumed the reins of Democratic congressional caucuses that were more homogeneously liberal than those facing Jimmy Carter in the 1970s or Bill Clinton in the 1990s (Lee 2009; McCarty et al. 2006). But in tandem with party nationalization (Grumbach 2022; Hopkins 2018; Rogers 2023), the polarization that helped Obama keep Democrats together also had profound consequences for how the Affordable Care Act (ACA) took shape—and for how the public responded to the law before and after its enactment. Here, I draw on my recent book Stable Condition: Elites’ Limited Influence on Health Care Attitudes (Hopkins 2023) to show how the polarization around the ACA helps explain two incongruent aspects of the law's politics: elite-level tumult and mass-level stability.

Elite Conflict over the ACA

Building on McCarty's (2019) definition, I take partisan polarization to be a condition in which policy polarization—increasing extremity in political views—is organized along party lines. The influence of partisan polarization is evident in the ACA's passage and content, and has been widely chronicled elsewhere (Brodie et al. 2020; Brown 2011; Cohn 2021; Jones 2017; Oberlander 2020). Even after the implementation of the ACA's primary policies in 2014, the law's future remained in doubt. The ACA was an incremental reform that built on America's system of private health insurance, and some of its core ideas had previously been advanced by conservative policy makers. That did not stop Republicans in federal or state politics from making its repeal their signature issue for years following the ACA's enactment.

After Donald Trump's unexpected 2016 presidential win, the ACA's opponents got their chance, as the GOP then enjoyed unified control of Congress and the White House. Even so, repeal legislation failed to clear the Senate after former GOP presidential candidate and Republican Senator John McCain joined with Republican Senators Susan Collins and Lisa Murkowski to vote down their own party's bill.

Federal polarization, whether in Congress or the courts, set the stage for a series of high-stakes battles in which the ACA's existence was at stake. From John Roberts (who cast the decisive vote in a 2012 Supreme Court decision ruling the ACA constitutional) to Bart Stupak (who played an influential role in shaping ACA-related abortion funding provisions) and Olympia Snowe to Susan Collins, that polarization also gave those at the center of American politics profound influence over the ACA's contours and survival. With Republicans almost uniformly opposed to the law and Democrats almost uniformly supportive of it, the elite-level politics of the ACA was the politics of a knife's edge.

Unexpectedly Stable: Americans’ ACA Attitudes

While elite-level conflict led to a dramatic decade of near-death experiences for the ACA between 2009 and 2020, at the level of the mass public, polarization instead stabilized public opinion. Consequently, the elite-level drama was seldom evident in public opinion—public opinion displayed little volatility, even on secondary questions about knowledge of the law or on the favorability of specific ACA provisions. The drama onstage was riveting, but the audience was mostly in the lobby.

Consider figure 1, which presents ACA favorability measured via the Kaiser Family Foundation's health tracking polls from 2010 through 2020. Overall, public opinion was quite stable and somewhat negative on balance. Even before the law's implementation, members of Congress who had supported it lost votes in the 2010 midterms relative to those who had not (Nyhan et al. 2012). While key elements of the ACA were highly popular, for millions the law was synonymous with its least popular element, the individual mandate. There was a meaningful but limited downturn in favorability in late 2013 as the ACA's main insurance provisions were being implemented—and as rollout of the healthcare.gov website initially went off the rails. Then, in the wake of Donald Trump's 2016 election, just as repealing the ACA became a legitimate possibility, public opinion swung in the law's favor. The ACA's popularity was bolstered by the threat to repeal it, in part because of status quo bias (see also Mettler, Jacobs, and Zhu 2023).

What role did partisan polarization play in stabilizing public opinion? In October 2012, at the height of the presidential race pitting Barack Obama against Mitt Romney, the Institute for the Study of Citizens and Politics surveyed more than 2,000 Americans about their political attitudes. The survey asked whether respondents planned to support Romney, Obama, or neither—and also whether they wanted to see the recently enacted ACA repealed. Among those who leaned toward repeal, 79% backed Romney. But among those who wanted to see the ACA kept as is, 88% backed Obama. The survey also found that 80% of Republicans supported Romney and that 79% of Democrats backed Obama. Simply put, a respondent's views on the ACA were more predictive of her preferred presidential candidate than whether she called herself a Republican or Democrat. Attitudes toward the ACA were highly partisan. Nor were they cheap talk. Partisanship even shaped the use of the subsidized health insurance exchanges created by the ACA, with Republicans less likely to buy insurance via the exchanges than Democrats (Lerman, Sadin, and Trachtman 2017).

One critical source of polarization is elite cues: if partisan elites provide consistent cues to voters that their side is for or against a policy, opinions typically polarize (Berinsky 2009; Jacobs and Shapiro 2000; Zaller 1992). That was certainly the case for the ACA. Ironically, though, the polarization of attitudes toward the ACA limited the impacts of subsequent persuasion efforts. Despite the barrage of messaging from Democrats and Republicans, public opinion moved slowly, with only limited adoption of elites’ language (see also Hopkins 2017). That is partly because consistent GOP messaging in opposition kept Republican opposition high (see also Patashnik and Oberlander 2018).

Even racially inflicted messages, which often influence public opinion in other domains (e.g., Hutchings and Jardina 2009), proved incapable of moving the public on the ACA once polarization set in. Across seven separate survey experiments conducted in different places and different times, I find that the attitudes of white respondents toward the ACA remained largely unchanged in response to primes reminding them of the law's Latino and Black beneficiaries. Long-standing narratives about social welfare benefits and deservingness appear to have helped structure how Americans thought about the ACA. Short-term messaging did not.

Once public opinion snapped into its partisan grooves, the subsequent impact of messaging was muted. But as a now-extensive literature on “policy feedbacks” attests (see Campbell 2012 for a review), politicians who seek to shape public opinion also have another potential tool: policies can themselves shape public and elite opinion and preferences in some cases. For example, programs such as Social Security and the GI Bill helped new constituencies identify themselves as such while also giving them the resources to mobilize politically (Campbell 2003; Mettler 2005). But such policy feedbacks are not automatic and can be limited by key features including the policy's design, implementation, and target populations (Michener 2018; Patashnik and Oberlander 2018).

Still, there was reason to think that the ACA might produce positive policy feedback effects. It had direct impacts on tens of millions of Americans, whether by subsidizing their health insurance on the new exchanges, providing health insurance through Medicaid, removing lifetime and annual caps on insurance payments, prohibiting discrimination by insurers based on health status, or mandating that Americans without insurance pay a fine. Even Romney, an ardent opponent of the ACA, conceded that it was a “gift” likely to win voters’ loyalties. But did it?

Building on earlier work (Jacobs and Mettler 2018; Lerman 2019; Lerman and McCabe 2017; Michener 2018; Patashnik and Oberlander 2018; Sances and Clinton 2021), Stable Condition examines the impacts of Americans’ concrete experiences with key ACA policies on their attitudes toward the law. The Medicaid expansion did influence low-income Americans’ ACA attitudes: low-income Americans in expansion states were more positive toward the ACA after the expansion's implementation (see also Hopkins and Parish 2019; Sances and Clinton 2021). But these effects are limited to a small fraction of the population, one with lower levels of voter turnout on average.

Another key aspect of the ACA was its creation of subsidized health exchanges for Americans with incomes higher than the Medicaid threshold. While the exchanges and the subsidies had positive effects on the attitudes of some, those attitudinal changes were offset by the negative impact the mandate and other policies had on many others, meaning that attitudes overall were largely unchanged (see also Hobbs and Hopkins 2021; Oberlander and Weaver 2015). For example, among those most likely to be uninsured after the law's implementation, ACA attitudes actually became more negative, in part because of the imposition of the individual mandate. The billions of dollars spent under the ACA did not move aggregate public opinion much and left the ACA in a precarious political position even years after its implementation (Hacker and Pierson 2018). When studying public opinion, estimating the precise effect sizes allows researchers to not only assess the statistical significance of various effects but also their political relevance. The ACA is a case study illustrating the limits of politicians’ capacity to influence public opinion at a time of high polarization, whether through messaging or policy making (see also Patashnik and Oberlander 2018).

Conclusion

The politics of the ACA were a study in contrasts. At the elite level, the politics of the ACA were dramatic, with twists and turns as a long list of politicians fought to advance, alter, or repeal the ACA. This drama was partly a product of elite-level polarization as the law's architects passed a landmark social reform through an unusual congressional procedure on party-line votes and were then largely unable to fix the law through subsequent legislation for years. With unwavering Republican opposition, the law's fate hinged on the individual decisions of several institutionalists or relative centrists, from John Roberts to John McCain.

At the mass level, the story of the ACA was one of stability rather than drama. Although the public polarized after the initial debates over the law, public opinion remained largely unmoved in the aggregate after that, even as the ACA was implemented and its tangible impacts came to be felt by millions. To pass the ACA through a polarized Congress, the Democrats designed a complex, patchwork policy. Yet the very features that helped the ACA pass also undermined its capacity to reshape public opinion through policy feedbacks. For one thing, the majority of Americans did not gain or lose health insurance—or change insurers—as a consequence of the law. In aggregate, public opinion was driven by the majority of Americans who were not the law's primary beneficiaries rather than the minority of Americans who were. Even the minority of Americans who were directly affected did not unambiguously benefit. For many, the benefits were concealed by the law's market-based delivery and its use of sticks alongside carrots (see also Morgan and Campbell 2011). It turned out that some of the very features that helped ease the ACA's passage through a polarized Congress also limited its capacity to reshape public opinion.

Acknowledgments

The author acknowledges Gall Sigler's excellent editing and research assistance.

References