Since its passage, the public has been told repeatedly how it feels about the Affordable Care Act (ACA), namely, that most of us disapprove of the ACA and detest its “mandate” that we be insured. A closer look at the national opinion data reveals that on those and related issues, public opinion actually favors the ACA.
Let’s begin with the basic finding that has been repeated so often: public disapproval of the ACA outweighs approval by a gap averaging around 5 to 10 points. But very few polls ask why people disapprove. The answers to that question change the picture dramatically.
One study that did ask “why” found that quite a bit of the disapproval comes from people who want health care reform expanded. When asked what they want done with the ACA, only 38 percent of survey respondents want it replaced with a Republican alternative or simply repealed; 25 percent want it kept as is, and 28 percent want more than the ACA provides. These latter 28 percent doubtless are the remnants of the 46-65 percent of the public who wanted health care reform to include a “public option,” or the 35 percent who want a single-payer system. Put simply, most Americans (53 percent versus 38 percent) want either the ACA or something with a greater role for government.
Many who disapprove of the ACA say they disapprove because it “creates too much government involvement in the health care system” (54 percent). Yet the public supports Medicare by 95 percent to 3 percent, Social Security by 95 percent to 4 percent, and Medicaid by 92 percent to 6 percent. How can a public that so overwhelmingly supports those far more government-involved programs complain that the ACA “creates too much government involvement”? The incoherence is not difficult to explain. Large numbers of respondents have told pollsters that they are “confused about” (48 percent) or “don’t have a good understanding of” the ACA. Their lack of understanding is confirmed by the findings that more than a third think the ACA contains provisions that it does not contain (e.g., death panels) and barely half can identify provisions that are in it.
Many who oppose the ACA explain that their unfavorable views are entirely a reflection of their general dislike of Washington (38 percent), rather than anything in the ACA. For these folks, booing the ACA is nothing more than an expression of their distaste for government generally. On the other hand, now that the Supreme Court has spoken, only 38 percent of the public overall want opponents to continue fighting against the ACA.
Support For Specific ACA Provisions
Some surveys dig further and ask respondents about specific provisions of the ACA. At this point, negativity disappears almost entirely:
- 85 percent like the provision on pre-existing conditions
- 80 percent like the tax credits to small businesses for employee insurance
- 79 percent like requiring easy-to-understand plan summaries
- 77 percent like closing the Medicare prescription drug doughnut hole
- 71 percent like subsidy assistance to individuals
- 71 percent like the appeals process for unfavorable health plan decisions
- 70 percent like Medicaid expansion
- 69 percent like elimination of cost-sharing for preventive services
- 68 percent like covering children to age 26 on parents’ insurance
All of those provisions find favor not only with majorities of Democrats and Independents (who also support additional provisions), but also with a majority of Republicans. So, although we do not like the label on the package, we apparently love what is in it.
On Individual Mandate, Better Information Reverses Hostility
The sole exception to this cheerful picture is, of course, “the mandate.” The requirement to be insured is disapproved by margins of 51 percent-45 percent, 65 percent-33 percent, and points in between. But even those seemingly clear opinions about the mandate are misleading. When provided with some basic explanatory information, hostility morphs into support. To cite the most dramatic example: when the very same people who are against the mandate by 65 percent-33 percent are informed that people who receive health insurance through their employers have automatically satisfied the mandate, their attitudes reverse to 61 percent-34 percent in favor of the mandate.
Opposition to the mandate apparently ends the moment we realize it does not apply to us. Attitudes likely will turn around even more sharply once people figure out to whom the mandate does apply: the few percent of the population who can afford health insurance but prefer to let the rest of us pay for their medical care if and when they get unlucky. Once people understand that, support for the mandate probably will approach the levels of approval already enjoyed by other major provisions of the ACA. This prediction is based on the persistent finding that Americans across the political spectrum solidly endorse the view that people (who are capable of doing so) should take responsibility for themselves and their families, and not rely on others to do it for them.
Doubtless, there are larger lessons here about polling: questions that aren’t asked, answers that are overlooked, and the resulting headlines can create misleading impressions that quickly become “the facts.” On important issues, it’s worth digging deeper. When we look more carefully at the ACA’s polling numbers, we see that “Obamacare” is far more welcome to most of the public than the public has been led to believe.