Replacing Obamacare Will Not Be Easy Contemporary Pediatrics

Special Report

Public Opinion about the Future of the Affordable Care Act

Robert J. Blendon, Sc.D.,
and John M. Benson, M.A.

Introduction

In the early hours of Friday, July 28, the U.S. Senate closed debate on repealing and replacing the Affordable Care Act (ACA) without the passage of any piece of legislation and after rejecting the replacement bill previously passed by the House of Representatives. This public-opinion analysis offers a framework for looking at how the public as a whole saw the issues in this most recent debate.

Our analysis of 27 national opinion polls by 12 survey organizations provides background on four critical issues relevant to the previous House and recent Senate health care decisions: the public favorability of the current law, the public values underlying the debate about the future, support for various health policy changes in the proposed Republican legislation, and support for the overall Republican proposals debated in the House and Senate. Throughout the recent debate, polling organizations have used slightly different samples (either the total number of adults or the total number of registered voters).

Recent studies have shown that the adherents to each of the two political parties have become more divided and polarized in their views of many domestic policy issues, including health care. The divisions in policy preferences between Republicans and Democrats have become so wide that studies of congressional voting behavior often show more congruence with the views of a congressional member's party adherents than with the views of the general public.^1,2 Because Republicans are the majority party in Washington, our analysis pays particular attention to the views of Republicans.

Public Attitudes about the ACA

Table 1.

Table 1. Public Approval of the Affordable Care Act (ACA), 2010–2017.

Results from polls on the views of the public about the ACA varied somewhat between the various survey organizations, so we looked at the average of recent polls. This average of polls showed that as of June and July 2017, the public remained split in its assessment of the ACA, but more people approved than disapproved of the law (49% vs. 44%).^3-7 Approval of the ACA increased 5 percentage points between 2012 and the time of the 2017 House and Senate debates^8,9 (Table 1).

Table 2.

Table 2. Public Assessment of the ACA and Underlying Values, According to Party Identification.

Much of the controversial debate in Congress over the need to repeal and replace the ACA (Obamacare) centered on the view by Republican leaders that the law directly hurts many Americans and the position of Democratic leaders that the law needs to be maintained because it directly helps so many Americans. Neither of these positions reflected the point of view of the general public as a whole (Table 2). More respondents reported being helped by the law than hurt by it (24% vs. 16%).¹⁰ The results of the surveys represent the views of millions of people. However, the majority of the public as a whole (58%) and both Republicans (60%) and Democrats (60%) believed that the law had not had a direct effect on them. This suggests that most people's views about the ACA debate were not based on personal experience but on their beliefs and values about the role of the federal government in extending insurance coverage to those who do not have it.

Public Values Underlying the Debate

Figure 1.

Figure 1. Respondents' Views about Whether the Federal Government Should Provide Universal Health Insurance Coverage, 2013–2017.

Data are from the responses of 1039 U.S. adults, as reported by Gallup, November 2013¹⁵; 3341 U.S. adults, as reported by Pew Research Center, March 2014¹⁶; 1021 U.S. adults, as reported by Gallup, November 2015¹⁷; 1130 U.S. adults, as reported by Pew Research Center, March 2016¹⁸; and 2504 U.S. adults, as reported by Pew Research Center, June 2017.¹¹

Two underlying public values were particularly important here: support for universal coverage and the preferred role for the federal government in health care. When it came to the question of whether the federal government should ensure that all Americans have health care coverage, 6 in 10 respondents (60%) said that it should be the responsibility of the federal government. More than 8 in 10 Democrats (85%) believed this should be the responsibility of the federal government, whereas only 30% of Republicans agreed.¹¹ As shown in Figure 1, the percentage of the general public who said that they believed it was the responsibility of the federal government increased from 42% in 2013 to 60% in June 2017.^11,15-18

In addition, a majority of persons surveyed (57%) believed that the federal government should play a major role in improving the U.S. health care system, whereas 26% thought it should play a minor role and 15% thought it should play no role at all. Nearly 9 in 10 Democrats (87%) believed the federal government should play a major role in this area, as compared with only 28% of Republicans.¹²

When asked which of two options they would rather see lawmakers choose in the current health care debate, a majority of respondents (63%) preferred that lawmakers make changes so that more people would have health insurance, even if it cost the government more money. Approximately one in four respondents (27%) preferred changes to reduce government spending, even if it meant fewer people would have health insurance. Democrats overwhelmingly preferred more people having health insurance (89%), whereas a majority of Republicans (56%) preferred reducing government spending.¹³

When asked what Congress should do about the ACA, 7% of the public said the ACA should be kept as it was and approximately half (51%) said that the law should be kept in place and that Congress should work to improve it. Approximately 4 in 10 respondents believed Congress should repeal the ACA and either replace it with an alternative (31%) or not replace it at all (8%). Overall, nearly two thirds of Republicans thought the law should be repealed, with half (50%) wanting it repealed and replaced and 14% wanting it repealed and not replaced.¹⁴

Public Views about the Components of a Repeal-and-Replace Bill

Table 3.

Table 3. Public Attitudes about Repeal-and-Replace Legislation, According to Party Identification.

The views of the public about a general principle often differ from their views about specific policy proposals. When we looked at specific aspects of the Republican replacement proposals, some different patterns of public opinion emerged. The Republican replacement proposals in both the House and the Senate tended to focus on seven types of changes, shown in Table 3. There were very wide differences between Republicans and Democrats in the general public on nearly every component of the Republican repeal-and-replace proposals.

Reducing the Number of People Receiving Subsidies to Purchase Health Insurance

A majority of the general public did not favor changing the law so that it either provided financial assistance for the purchase of health insurance to fewer persons or reduced the number of people to be covered by Medicaid. When asked about the extent of coverage to be provided by a replacement plan, 57% of the public as a whole preferred to provide financial assistance to purchase insurance to the same number of people as the ACA does now, whereas approximately one third preferred to provide assistance to somewhat fewer people (22%) or a lot fewer people (12%) but save taxpayer money.¹⁰

Reducing the Number of Medicaid Recipients and Spending

A majority of the public preferred to keep the number of people covered by Medicaid the same as it is now (72%), whereas 22% wanted to reduce the number receiving Medicaid to what it was before the ACA, reducing government spending and taxes.¹⁰

An average of polls showed that 31% of the public favored reducing federal funding for Medicaid.^7,19,20 In addition, less than 4 in 10 respondents (37%) favored giving states less federal money for Medicaid but increasing their flexibility in whom to cover and how to spend the money.²¹

Ending the Individual Mandate

On the issue of removing the requirement under the ACA that people obtain health insurance coverage or pay a penalty, the overall public was divided. A total of 48% favored removing this requirement, whereas 50% were opposed.²² In late 2016, before the start of the congressional debate, only 35% of the public had a favorable opinion of the individual mandate.²³

Allowing Insurers to Offer Health Plans That Cover Fewer Benefits

Approximately one third of the public (35%) believed that insurers should be allowed to offer health plans that cover fewer benefits than currently required.^20,21

Allowing Insurers to Charge More for People with Preexisting Conditions

On the issue of ending federal health insurance regulatory protections for people who have preexisting medical conditions, less than one fourth of the public believed that insurers should be allowed to charge more for people with preexisting conditions (24%).^10,20,24,25

Other issues in the debate included adding cost-reducing restrictions to the current Medicaid program^20,21 and ending all federal funding for Planned Parenthood.¹² Table 3 shows the results of polling on those issues.

Overall Public Assessment of the Republican Repeal-and-Replace Bills

Overall, only approximately one in four of the respondents (24%) approved of the congressional Republican plan (or plans, since they include both the plan that passed in the House and the proposals put forth in the Senate) to repeal and replace the ACA, whereas 56% disapproved. Fully one in five respondents did not have an opinion.^4,7,13,26-29

From the point of view of public opinion, the Republican replacement plans were extraordinarily unpopular. When Medicare was first enacted in 1964, it was supported by 61% of the public.³⁰ Support for the ACA was lower, but as Table 1 shows, the rate of support was 42% at the time of its enactment and in June and July it stood at 49%. By contrast, only 24% of the public approved of the Republican replacement plans, and more than twice as many disapproved. Even though a majority of Republicans favored repealing the ACA, only half (50%) approved of the replacement bills. Still, given a choice between the House replacement plan and Obamacare, nearly two thirds (64%) of Republicans preferred the replacement plan.²¹

The views of Republicans are particularly important here. As shown in Table 2, nearly two thirds of Republicans (64%) wanted to repeal the ACA.¹⁴ With regard to beliefs and values, only a minority of Republicans believed that it was the responsibility of the federal government to ensure that all Americans have health care coverage (30%) or that the federal government should play a major role in improving health care in the United States (28%).^11,12 Likewise, only a minority of Republicans preferred providing financial assistance to purchase health insurance to the same number of people as the ACA does now (27%)¹⁰ or making changes so that more people have health insurance if it costs the government more money (32%).¹³

Reflecting the difficulty in reaching a consensus among Republicans in Congress were the deep divisions among Republicans on many of the specific components of their own replacement proposals. A slight majority of Republicans (52%) wanted to keep the number of people covered by Medicaid the same as it is today rather than reducing the number to what it was before the ACA.¹⁰ Approximately half of Republicans (51%) favored decreased federal funding for Medicaid, allowing insurers to offer health plans that cover fewer benefits than are currently required (50%),^20,21 and ending all federal funding for Planned Parenthood (47%).¹²

In addition to these divisions, only 37% of Republicans favored allowing insurers to charge more for people with preexisting conditions.^10,20,24,25 However, one in seven Republicans (14%) still wanted to repeal the ACA without replacing it at all.¹⁴

Taken together, these fundamental divisions among Republicans point to an underlying reason why Republicans in Congress had such difficulty agreeing on a single repeal-and-replace plan. These divisions were not helped by the fact that President Donald Trump's role in the debate was seen so poorly by the general public, with only 28% approving of his handling of health care.³¹

Conclusions

What are the insights we can learn from polls during the recent congressional debate? The first insight is that the Republican Party, which is in the majority in Washington, is much more divided on health care issues than was recognized at the time of President Trump's election, so it is difficult to enact major legislation.

The second insight is how polarized Republicans and Democrats are about the overall future of the ACA. Throughout the debate, the majority of Republican adherents favored repealing the ACA, whereas Democrats did not. This made it very difficult to have any compromise legislation. Not widely recognized is that one of the reasons no bill was ultimately enacted was the split among Republicans between repealing and replacing the ACA or repealing it without a replacement.

On most specific policy issues in the debate, Republicans and Democrats disagreed, but there is one major exception. The two parties' adherents agree that the number of people covered by Medicaid should not be reduced in any replacement bill.

Finally, the most important change over time was not the increase in public approval of the ACA, but rather the increase in overall support for universal coverage. When confronted with millions of people losing coverage, the public became more supportive of the principle that the federal government should ensure coverage for them.

Funding and Disclosures

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

This article was published on August 16, 2017, at NEJM.org.

Author Affiliations

From the Harvard T.H. Chan School of Public Health, Boston (R.J.B., J.M.B.), and the John F. Kennedy School of Government, Cambridge (R.J.B.) — both in Massachusetts.

Address reprint requests to Dr. Blendon at the Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave., 4th Fl., Boston, MA 02115, or at [email protected].

Supplementary Material

References (31)

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