NEJM Review of ACA Polls Finds Gap Between Congress and Country

The barrage of polls on the Affordable Care Act (ACA)—from news organizations to the Kaiser Family Foundation—offer snapshots of public opinion on the law, but taken together they tell us something more, say authors from Harvard’s T.H. Chan School of Public Health.

In a special report to the New England Journal of Medicine, Robert J. Blendon, ScD, and John M. Benson, MA, find that public values on healthcare have slowly shifted, but they are distinct from how people feel about the ACA itself. The trouble, the authors say, is that views among active members of political parties—especially members of Congress—are far more polarized than those of average Americans, making solutions hard to achieve.

In other words, tracking whether public opinion “for” or “against” the ACA is up or down misses the point. An average of 27 national polls from 12 organizations shows that approval of the ACA has moved just 5 points between 2012 and June 2017, to 49% support, the authors note. Barely half the public thinks the ACA should be retained with some improvements (51%), while 7% say it needs no changes.

That’s hardly a ringing endorsement of the law. In particular, Americans are split on the question of the individual mandate. Right now, 50% oppose it, and 48% support it.

The more important shift, the authors find, is the one in underlying values on healthcare. When asked if the federal government should ensure that people have health coverage, 60% say yes, up 4 points from 2013 and 10 points from its lowest point in 2014. However, there is a divide along party lines: 85% of Democrats favor a federal role, compared with 30% of Republicans.

Also interesting is the view of Medicaid: the authors find that 72% of Americans favor allowing those newly enrolled through Medicaid expansion to stay. Here, there was agreement among Republicans and Democrats, which played out on the Senate floor, as GOP senators withheld their votes specifically over the threat of Medicaid cuts.

In fact, Matt Salo, executive director of the National Association of Medicaid Directors, told news organizations that the recent debate had been the program’s moment in the sun. "The more people understand what Medicaid is and what it does for them, the less interested they are in seeing it undermined,” he told ABC News.

The authors note that the shift in underlying values has occurred even though 58% of Americans—including large majorities of both Democrats and Republicans—report that the ACA has had no 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 health insurance coverage to those who do not have it,” the authors said.

Why are healthcare solutions so difficult? On issue after issue, the authors write, views between Republicans and Democrats differ significantly, and divisions within the Republican Party are substantial. The authors explain that while 72% of all Americans want to keep Medicaid as it is, that only applies to 52% of Republicans. About half of Republicans (51%) favor decreased federal spending for Medicaid, and exactly half (50%) support letting insurers offer fewer health benefits than are now required. Slightly less than half (47%) favor ending funding for Planned Parenthood. The authors say they focused on variation of opinion within the Republican Party because they control both houses of Congress.

The debate this spring and summer confirmed a long-time concern of ACA opponents: “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,” the authors wrote.

Reference

Blendon RJ, Benson JM. Public opinion and the future of the Affordable Care Act [published online August 16, 2017]. N Engl J Med. DOI: 10.1056/NEJMsr1710032.