ACA Draws Support From Physicians, but Also Conservative Medicaid Expansion States

A pair of commentaries published in the New England Journal of Medicine explored the popularity of the Affordable Care Act (ACA) among both US physicians and residents of red states that have expanded Medicaid. Legislators preparing to repeal the law will need to contend with the widespread support for some of its components, even in unexpected regions of the nation.

A survey of 1000 primary care physicians (PCPs) found that just a small fraction (15.1%) of respondents supported repealing the ACA in its entirety. Support fluctuated based on self-reported political party—no Democrats wanted it repealed and almost one-third of Republicans did. Support for repeal was slightly higher at 37.9% among physicians who had voted for President Donald Trump, who had emphatically promised to “repeal and replace” the ACA throughout his campaign.

These responses indicated that physicians are more averse to a full repeal than the general public. In a poll conducted shortly after the election by the Kaiser Family Foundation, 26% of Americans wanted to see the new administration completely repeal the law, including just over half of Republicans.

Just as the Kaiser poll found varying support for individual components of the law among Americans, PCPs also favored certain provisions of the ACA more than others. Support for the regulations preventing insurers from denying coverage based on preexisting conditions was near unanimous, as 95.1% said this step was “important” or “very important” for improving population health. The tax credits to small businesses and the provision allowing children to stay on parents’ plans until the age of 26 were also popular, but just under half approved of the individual mandate tax.

Almost three-fourths of the PCPs agreed that the law needs to be changed, but there was no clear consensus on what exactly these changes should look like. When asked about some ideas commonly found in GOP replacement plans, the increased use of health savings accounts was supported by 68.7% of respondents, but just 42% said private insurance should be deregulated, which Trump had suggested could be achieved by allowing insurance sales across state lines. Physicians were similarly split on more liberal proposals, as a public insurance option was supported by two-thirds of those polled, but the expansion of Medicaid to individuals as young as age 55 drew support from just 42.8%.

The researchers advised policy makers “to consider the views of PCPs, given their unique role in the US healthcare system.” They emphasized that the elements of ACA that drew the most consistent support were the ones that increased access to coverage for individuals.

A simultaneously published article examined consumer perceptions of Medicaid expansion, an ACA component that widely increased access to care. Specifically, the survey aimed to gauge the ACA’s perceived impact on low-income residents of 4 southern Republican-leaning states: 3 that had expanded Medicaid (Arkansas, Kentucky, and Louisiana) and 1 that had not (Texas).

While a plurality of respondents in all 4 states felt the ACA had not directly affected them, those who were affected were much more likely to feel positively towards the law if they lived in a Medicaid expansion state. On average, the proportion of expansion state residents who said the law had helped them was twice the amount saying it had hurt them, but more Texas residents said the law had hurt them, not helped them.

After multivariate analysis by demographics and other characteristics, the researchers found that race was a significant predictor of support for the law, as minorities were more likely than whites to feel the law had benefited them. Despite this correlation, white respondents in Kentucky and Arkansas were still more likely to report the ACA had helped rather than hurt them. The factors most strongly associated with positive perceptions of the ACA were living in a Medicaid expansion state and having Medicaid or ACA marketplace coverage, as opposed to being uninsured.

The authors of the study pointed to their findings to illustrate the law’s popularity, even in states politically unlikely to support the reforms enacted by former President Barack Obama. However, it remains unclear how the Republican-controlled Congress will reconcile this popularity with the legislative steps it has already taken to roll back large portions of the ACA, including Medicaid expansion.

“In states that have embraced coverage expansion despite their political leanings, the ACA’s Medicaid expansion has made a positive difference that is recognizable to the people whose lives have been most directly affected by it,” the authors wrote. “Now, the question is not whether many Americans—even those in thoroughly red states—have benefited from the ACA, but whether that will be enough to save it.”