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Monday, June 2, 2014

What's Behind the Negative Views of the Affordable Care Act?

A key question for proponents of the Affordable Care Act is why the American public’s attitudes appear so negative -- and so immutable. Our latest update shows an eight-percentage-point negative gap in the approve-disapprove ratio for the ACA: 51% disapprove and 43% approve. There has been some fluctuation on this measure, but there is certainly no sign that, after the completion of the first exchange enrollment period, Americans are becoming significantly more positive about the new healthcare law.

Those who favor the ACA can write off Americans’ majority disapproval of the law by claiming that those who disapprove are ill-informed or irrational. But if people define the situation as real, the consequences are real. That is, these attitudes matter. The fact that over half of Americans still say they disapprove of this massive legislation should be a focus point for the attention of its proponents. What are possible underlying reasons for these negative views?

One answer revolves around the fact that the law isn't a consequential factor for many Americans -- the majority of whom claim that they are unaffected by it. About two-thirds of Americans say they are satisfied with the way the healthcare system is treating them. Thus, many Americans have no personal stake in the law at the moment, and, in theory, may find it easy to let the negative aspects of the law influence their views because there is no compensating personal benefit.

There is, however, some evidence that Americans who took advantage of the provisions in the healthcare law to get insurance are in fact much more positive than average about the law. The sample sizes involved in our latest update are small, but I estimate that roughly two-thirds of Americans who got a new insurance policy through a federal or state exchange in 2014 approve of the Affordable Care Act. Plus, between 55% and 65% of those who say they have a new insurance policy this year -- and did not have one in 2013 -- approve of the ACA. We can’t establish causality, but certainly it appears that acquiring new insurance this year is correlated with a positive view of the law. The problem is that this is a quite small percentage of the population, and thus these more positive attitudes don’t move the overall needle much.

Interestingly, Americans who at the time of our May 21-25 survey said they didn’t have insurance are slightly less positive about the ACA than those who have insurance. I say that’s interesting because the inference is that these individuals -- who in essence voted with their feet not to go along with the individual mandate and thus to remain uninsured -- perhaps did so because they were not so positively inclined toward that individual mandate to begin with.

So one argument is that the ACA has benefited a relatively small number of people (from a percentage rather than a raw numbers perspective) who got new insurance through an exchange, but the majority of Americans who have health insurance and are satisfied with their healthcare coverage aren’t directly affected, and therefore have less of a practical reason to favor the law. This latter group is the big group -- the group that drives the population averages.

Of course, many ACA proponents argue that support for the new law should be based on the fact that it helps others -- rather than on a purely self-interest perspective. Apparently, that shift in viewpoint hasn't happened yet to any great extent. 

A second reason many Americans may have a negative view of the healthcare law is based on its perceived connection to big government. Although the law certainly does not create a single payer system, it presumes a great deal of government involvement and government rules and regulations and requirements and government penalties. Thus, for some Americans, the law becomes a symbol of big government and government control. This creates controversy because the appropriate role of the federal government in our society is, as it has been for the most part since the nation’s founding, one of the central political dialogues of our time.

We know from previous research that Americans currently do not want government to be in charge of healthcare. To be specific, 56% of Americans say it is not the responsibility of the federal government to make sure all Americans have healthcare coverage, while 42% say it is.

Further, Americans remain distrustful of government in general, rate the federal government quite negatively, and have low levels of trust in government. Distrust in the government is highest among Republicans and conservatives, the groups that are most negative about the ACA. In this sense, those who oppose the ACA are not necessarily reacting to the law’s many individual provisions, but rather to the symbolic totality of the law. That shows up in surveys that find that the one provision of the law that Americans react most negatively to is the individual mandate, which carries with it a government requirement that Americans who do not have insurance must pay a fine.

To be sure, Americans actually like a number of elements of the law when these are tested one by one. The Kaiser Family Foundation’s monthly surveys about healthcare have included tests of various provisions of the law, and have found that the majority of the public supports many of them -- including prohibiting insurance companies from denying coverage because of a person’s medical history, providing financial aid to low- and moderate-income Americans so they can get insurance, allowing young adults to stay on their parents’ plans until age 26, and eliminating out-of-pocket costs for preventive services.

But Americans do perceive negative aspects of the law, one of which is the individual mandate I mentioned earlier. Additionally, there is the perception among some of higher costs for medical care and the perception that people lose their healthcare coverage as a result of the law.

Finally, it is important not to gainsay the dramatic way in which views of the law are intertwined with politics. Party identification is the No. 1 predictor of one’s attitudes about the law, and partisanship pervades almost any question asked about it. This politicization of the law is nowhere better exemplified than in the responses to a set of questions we asked last year about Barack Obama’s greatest achievement and his greatest failure. The Affordable Care Act was at the top of both lists. That is, a segment of society sees Obamacare as a great achievement, and another segment sees it as a great failure. Any attempt to increase acceptance of the law must take these political factors into account.

So, what for the future? Proponents hope that over time, more and more Americans will see the virtues of the law and will come to view it positively. But that hasn’t happened so far. Opponents hope for just the opposite -- that negative views of the law will increase until the powers that be are forced to repeal it or make dramatic changes in its provisions. The results of this fall's midterm elections will have a significant impact on what happens in regard to the ACA going forward.


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