Public Opinion about the Future of the Affordable Care Act

By Robert J. Blendon, Sc.D., and John M. Benson, M.A.
The New England Journal of Medicine, August 16, 2017

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.

Public values underlying the debate

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. 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.


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.…

In this highly credible review of public opinion on health care reform, one crucial finding really stands out above all else: “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… that the federal government should ensure coverage for them.”

So what is the response of the politicians and policy community? Some want to tweak ACA, and others want to walk away. If we were truly the democratic society we like to think we are, efforts would be underway to enact and implement policies that would take us down an affordable path to universal coverage. Such an approach would not be found in ACA but rather would be found in the enactment of a single payer national health program since it would establish truly universal coverage in a model that would be affordable for each of us.

So are we ready to put democracy to work to benefit us all? If we want a better health care system, the people are going to have to demand it.

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