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Review| Volume 128, ISSUE 8, P807-810, August 01, 2015

Why do so Many Americans Oppose the Affordable Care Act?

Published:February 28, 2015DOI:https://doi.org/10.1016/j.amjmed.2015.01.032
Why do so Many Americans Oppose the Affordable Care Act?
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      Abstract

      The Patient Protection and Affordable Care Act (ACA) was passed by a Democratic Congress and signed into law by a Democratic president in 2010. Republican congressmen, governors, and Republican candidates have consistently opposed the ACA and have vowed to repeal it. Polls have consistently shown that it is supported by <50% of Americans. The most important goal of the ACA is to improve the health of Americans by increasing the number covered by health insurance. In the first year of its implementation, more than 10 million citizens gained health insurance. The percentage of Americans without health insurance decreased from 18% in July 2013 to 13.4% in June 2014. In addition, the ACA has eliminated many of the negative features of private insurance such as the denial of coverage for those with “prior conditions.” The benefits of Medicare have been enhanced to decrease the cost of prescription drugs and to eliminate co-pays for preventive services. Despite these positive changes, a near majority of Americans still oppose the ACA, even though they approve of most of its features. They oppose the mandate that all Americans must have health insurance (the individual mandate), and they oppose a government role in health care. Yet Medicare, a mandatory insurance for seniors administered by the federal government since 1965, is overwhelmingly approved by the American public. The opposition to a government role in health care is based on the fact that that the vast majority of our citizens do not trust their government. Republicans are much less trusting of the federal government and much less supportive of a government role in health care than Democrats. The overwhelmingly negative TV ads against the ACA by the Republican candidates in the elections of 2012 and 2014 have had a major impact on Americans' views of the ACA. More than 60% of Americans have stated that most of what they know about the ACA came from watching TV. Opposition to a government role in health care and to mandatory health insurance makes it unlikely that the US will be able to insure that all of its citizens have ongoing access to health care in the near future.

      Keywords

      Clinical Significance
      • •
        Many Americans oppose the Patient Protection and Affordable Care Act (ACA) because they do not trust their government, and they oppose a government role in health care.
      • •
        Republicans are less likely to trust their government than Democrats, and are far more likely than Democrats to oppose the ACA.
      • •
        Public opposition to the ACA has been increased by the flood of negative ACA TV ads during the elections of 2012 and 2014.
      After a bitter partisan debate, the Patient Protection and Affordable Care Act (ACA) was passed by the Democratic majorities in the House and Senate and was signed into law by the Democratic President on March 23, 2010. No Republicans in the House or Senate voted yes and only 34 of 253 Democrats in the house voted no.
      When asked why Republicans oppose the ACA (dubbed “Obamacare“ by the Republicans), Republican Majority Leader John Boehner said: “Because it will destroy the best health care delivery system in the world.”

      NBC News. November 14, 2013. Boehner: Affordable Care Act ‘can't be fixed'. Available at: http://www.nbcnews.com/video/nbc-news/53554389. Accessed December 12, 2014.

      The US health care system is not the best health care system in the world. The US is one of the few industrial nations that does not ensure that all of its citizens have ongoing access to health care. As a result, our health care outcomes such as infant mortality, maternal mortality, and life expectancy are worse than those in other Western nations.

      OECD. OECD health statistics 2014. How does the United States compare? Available at: http://oecd.org/unitedstates/Briefing-Note-UNITED-STATES-2014.pdf. Accessed December 11, 2014.

      Eighteen percent of our citizens did not have health insurance in 2013,

      Gallup. In U.S., uninsured rate sinks to 13.4% in second quarter. Available at: http://www.gallup.com/poll/172403/uninsured rate sinks second quarter.aspx. Accessed December 12, 2014.

      and as a result, they did not have ongoing access to primary and preventive care. Our uninsured citizens have an annual mortality that is 25%-40% higher than individuals with health insurance.
      • Franks P.
      • Clancy C.M.
      • Gold M.R.
      Health insurance and mortality.
      JAMA. 1993; 270: 737-741
      , 
      • Wilper A.P.
      • Woolhandler S.
      • Lasser K.E.
      • et al.
      Health insurance and mortality in US adults.
      Am J Public Health. 2009; 99: 2284-2295
      The US certainly does not have the best health care system in the world, even though we spend about twice as much on health care as other Western countries!
      • Anderson G.F.
      • Frogner B.K.
      Health spending in OECD countries: obtaining value for dollar.
      Health Aff (Millwood). 2008; 27: 1718-1727
      When the ACA was passed in 2010, one of the first polls found that 45% of Americans were opposed to the law.
      • Blendon R.J.
      • Benson J.M.
      Voters and the Affordable Care Act in the 2014 election.
      N Engl J Med. 2014; 371: e31
      It is a very complex document, and many were confused by it. Americans continued to be confused in 2011; many were not certain how it would affect them and their family members.

      The Henry J. Kaiser Family Foundation. Kaiser health tracking poll: March 2011. Available at: http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8166-c.pdf. Accessed December 12, 2014.

      Sixty percent of citizens in one poll reported that most of what they knew about the ACA came from cable TV.

      The Henry J. Kaiser Family Foundation. Kaiser health tracking poll: December 2011. Available at: http://kaiserfamilyfoundation.files.wordpress.com/2013/03/8265-c.pdf. Accessed December 11, 2014.

      Polls in 2014, after the ACA had been implemented, demonstrated that 51% of Americans were opposed to the law
      • Blendon R.J.
      • Benson J.M.
      Voters and the Affordable Care Act in the 2014 election.
      N Engl J Med. 2014; 371: e31
      (Table 1).
      Table 1Public Attitudes About the ACA 2010-2014
      • Blendon R.J.
      • Benson J.M.
      Voters and the Affordable Care Act in the 2014 election.
      N Engl J Med. 2014; 371: e31
      201020122014
      Approve ACA42%44%40%
      Oppose ACA45%45%51%
      ACA = Patient Protection and Affordable Care Act.

      How Has the ACA Affected the American Population 1 Year After Its Implementation?

      One would expect that many Americans would have benefitted from the implementation of the ACA, including 41 million individuals who were uninsured in 2013, 200 million people with private health insurance, and 54 million seniors covered by Medicare.
      • Dalen J.E.
      Should the affordable care act of 2010 be repealed?.
      Am J Med. 2011; 124: 575-577

      Increased Number of Insured

      The key goal of the ACA was to increase the number of Americans having ongoing access to health care by increasing the number of insured individuals. More than 10 million Americans gained health insurance in 2014 because of the ACA.

      Gallup. In U.S., uninsured rate sinks to 13.4% in second quarter. Available at: http://www.gallup.com/poll/172403/uninsured rate sinks second quarter.aspx. Accessed December 12, 2014.

      Those with family incomes <138% of the federal poverty level were eligible for Medicaid in the 27 states that agreed to expand Medicaid as of December 2014.
      Many residents (exact number uncertain) with incomes from 138% to 400% of the federal poverty level have acquired subsidized health insurance through the federal or state health insurance exchanges. Young adults ages 19 to 26 years can now be covered by their parents' insurance.
      Many individuals who had been denied insurance or were forced to pay an exorbitant premium because of “prior conditions” can now gain insurance at the same premium price as those residents without such conditions.
      Due to these features of the ACA, the percentage of uninsured Americans decreased from 18% in July 2013 to 13.4% in June 2014.
      • Blendon R.J.
      • Benson J.M.
      Voters and the Affordable Care Act in the 2014 election.
      N Engl J Med. 2014; 371: e31

      Improvements in Private Health Insurance

      Americans with private insurance found that many of the negative features of their insurance policies had now been outlawed, as shown in Table 2.
      • Dalen J.E.
      Should the affordable care act of 2010 be repealed?.
      Am J Med. 2011; 124: 575-577
      Table 2Improvements in Private Health Insurance
      1. Retroactive rescission of insurance prohibited
      2. No denials or increased premiums for those with “prior conditions”
      3. No annual or lifetime limits on coverage
      4. No cost-sharing for preventive services
      5. Coverage of dependents until age 26 years
      The 54 million seniors covered by Medicare have seen their benefits increase. These individuals can now receive preventive services without a co-pay or deductible. These services include: colonoscopy, ultrasound examinations for abdominal aneurysms, bone mass measurement, smoking cessation and nutrition counseling, hepatitis B vaccine, and Pap smears.
      The ACA has decreased the cost of prescription drugs for seniors. There is a 50% discount on brand name drugs when patients are in the donut hole, and the donut hole will gradually close and finally be eliminated by 2020.
      Despite these enhanced benefits of Medicare, in one poll held during 2012,
      • Blendon R.J.
      • Benson J.M.
      • Brule A.
      Understanding health care in the 2012 election.
      N Engl J Med. 2012; 367: 1658-1661
      35% of seniors said they expected to be worse off with ACA.

      Which Elements of the ACA Do the Public Support?

      The features of the ACA that were considered to be favorable in a Kaiser poll in December 2011

      The Henry J. Kaiser Family Foundation. Kaiser health tracking poll: December 2011. Available at: http://kaiserfamilyfoundation.files.wordpress.com/2013/03/8265-c.pdf. Accessed December 11, 2014.

      and a NYT-CBS poll

      The New York Times. Results of The New York Times/CBS News poll. Available at: http://www.nytimes.com/interactive/2012/03/27/us/03272012_polling_doc.html. Accessed December 12, 2014.

      are shown in Table 3.
      Table 3Which Elements of the ACA Do You Approve?

      The Henry J. Kaiser Family Foundation. Kaiser health tracking poll: December 2011. Available at: http://kaiserfamilyfoundation.files.wordpress.com/2013/03/8265-c.pdf. Accessed December 11, 2014.

      , 

      The New York Times. Results of The New York Times/CBS News poll. Available at: http://www.nytimes.com/interactive/2012/03/27/us/03272012_polling_doc.html. Accessed December 12, 2014.

      Requiring coverage for prior conditions85%
      Health insurance exchanges79%
      Premium subsidies for low income families75%
      Medicaid expansion69%
      Parents' coverage of young adults68%
      Employer mandate61%
      Individual mandate45%
      ACA = Patient Protection and Affordable Care Act.
      The only element in the ACA that was not approved in these two polls was the mandate that all Americans must have health insurance or face a fine. Mandated health insurance is not new to the US; Medicare is mandated health insurance that has been administered by the federal government since 1965.
      Medicare is well accepted by the American public, as shown in Table 4.
      • Blendon R.J.
      • Benson J.M.
      The public and the conflict over future Medicare spending.
      N Engl J Med. 2013; 369: 1066-1073
      Table 4Public Views of Medicare: Six Polls in 2013
      • Blendon R.J.
      • Benson J.M.
      The public and the conflict over future Medicare spending.
      N Engl J Med. 2013; 369: 1066-1073
      All AgesAge 65+ Years
      Favorable view of Medicare72%88%
      Medicare is working well88%95%
      Medicare same quality as private insurance66%75%
      Medicare important to your family77%93%

      The Partisan Divide

      Democratic and Republican attitudes toward the ACA in a 2014 poll highlight the fact that the ACA continues to be a highly partisan issue. Eighty-three percent of Republicans opposed the ACA, and 56% said it should be repealed. In contrast, only 19% of Democrats were opposed, and only 4% wanted it to be repealed.
      • Blendon R.J.
      • Benson J.M.
      Voters and the Affordable Care Act in the 2014 election.
      N Engl J Med. 2014; 371: e31
      The debate surrounding the introduction of Medicare and Medicaid in 1965 was also highly partisan, as shown in Table 5. Medicare was passed by a Democratic Senate, a Democratic House, and signed by a Democratic President.

      Social Security Administration. Legislative history. Summary of party affiliation on Medicare vote. Available at: http://www.ssa.gov/history/tally65.html. Accessed December 10, 2014.

      Table 5The Vote to Enact Medicare and Medicaid, 1965

      Social Security Administration. Legislative history. Summary of party affiliation on Medicare vote. Available at: http://www.ssa.gov/history/tally65.html. Accessed December 10, 2014.

      YesNo
      Senate
       Democrats577
       Republican1317
      House
       Democrats23748
       Republicans7068

      Role of the Federal Government in Health Care

      In a 2014 poll,
      • Blendon R.J.
      • Benson J.M.
      Voters and the Affordable Care Act in the 2014 election.
      N Engl J Med. 2014; 371: e31
      only 41% of citizens agreed that “making sure all Americans have health care coverage is a responsibility of the Federal government.” Only 12% of Republicans agreed, compared with 70% of Democrats.

      Americans Do Not Trust the Federal Government

      One reason that so many Americans oppose the ACA and a government role in health care is that they don't trust the federal government. As shown in Table 6, the percentage of Americans who trust the Federal government has decreased from 78% in 1964 to 24% in 2014.

      Pew Research. Public trust in government: 1958-2014. Available at: http://www.people-press.org/2014/11/13/public trust in government/. Accessed December 9, 2014.

      Table 6Pew Research Polls 1964-2014

      Pew Research. Public trust in government: 1958-2014. Available at: http://www.people-press.org/2014/11/13/public trust in government/. Accessed December 9, 2014.

      Do You Trust the U.S. Federal Government?
      YesNo
      196478%22%
      197056%44%
      198035%65%
      199033%67%
      200034%66%
      201024%76%
      201424%76%
      Several polls have shown that Republicans are far less trusting of government compared with Democrats.

      CNN. CNN/ORC Poll July 2014. Available at: http://i2cdn.turner.com/cnn/2014/images/08/08/re17g.pdf. Accessed December 8, 2014.

      , 

      Pew Research Center. Trust in government nears record low, but most federal agencies are viewed favorably. Available at: http://www.people-press.org/2013/10/18/trust in government nears-record low but most federal agencies are viewed favorably/. Accessed December 13, 2014.

      In a CNN/ORC poll in 2014,

      CNN. CNN/ORC Poll July 2014. Available at: http://i2cdn.turner.com/cnn/2014/images/08/08/re17g.pdf. Accessed December 8, 2014.

      only 7% of Republicans said that they can “trust government to do the right thing most or all of the time,” compared with 23% of Democrats.
      A poll by Pew Research in 2013

      Pew Research Center. Trust in government nears record low, but most federal agencies are viewed favorably. Available at: http://www.people-press.org/2013/10/18/trust in government nears-record low but most federal agencies are viewed favorably/. Accessed December 13, 2014.

      found that 10% of Republicans “trust the government in Washington always or most of the time,” compared with 28% of Democrats.
      Because so many Americans, especially Republicans, distrust the federal government, it is not surprising that they also oppose the ACA. In a Pew poll in 2014,

      Pew Research Center. Chapter 2: Views of the Affordable Care Act and its future. Available at: http:www.people-press.org/2014/05/05/views-of-the-affordable-care-act-and-its-future. Accessed December 7, 2014.

      80% of those who opposed the ACA said a major reason was “too much government involvement in health care.”
      Yet as noted, most Americans have a favorable view about Medicare, which is administered by the federal government.
      • Blendon R.J.
      • Benson J.M.
      The public and the conflict over future Medicare spending.
      N Engl J Med. 2013; 369: 1066-1073
      Some Americans have suggested that the best health care delivery system for the US would be “Medicare for All.”
      • Dalen J.E.
      • Alpert J.S.
      National health insurance: could it work in the US?.
      Am J Med. 2008; 121: 553-554
      , 
      • Conyers J.
      A fresh approach to health care in the United States: improved and expanded Medicare for all.
      Am J Public Health. 2008; 98: S58

      The Impact of Television

      As noted, most Americans state that what they know about the ACA comes from watching television, particularily cable TV.

      The Henry J. Kaiser Family Foundation. Kaiser health tracking poll: December 2011. Available at: http://kaiserfamilyfoundation.files.wordpress.com/2013/03/8265-c.pdf. Accessed December 11, 2014.

      Television coverage of the ACA has been almost overwhelmingly negative from 2010 to the present.
      TV coverage of the presidential election in 2012 and the mid-term election in 2014 was intense and dominated by negative ads about the ACA. Ninety-four percent of $445 million spent on TV advertising in 2014 went for negative ad messages about ACA.

      Wilner B, West M. The Affordable Care Act's place in advertising history. Kantar Media, May 2014. Available at: http://thehill.com/sites/default/files/cmag_aca_deck_v4_embargoed_1.pdf. Accessed December 7, 2014.

      TV ads supporting the ACA were scarce.
      These televised attacks on the ACA would certainly have an impact on viewers who don't trust the federal government and who oppose mandatory health insurance. One would not expect them to embrace the ACA.
      The fact that the majority of Americans oppose a federal role in health care and oppose mandatory health insurance makes it unlikely that the US will achieve universal access to health care in the near future.

      References

      1. NBC News. November 14, 2013. Boehner: Affordable Care Act ‘can't be fixed'. Available at: http://www.nbcnews.com/video/nbc-news/53554389. Accessed December 12, 2014.

        View in Article

      2. OECD. OECD health statistics 2014. How does the United States compare? Available at: http://oecd.org/unitedstates/Briefing-Note-UNITED-STATES-2014.pdf. Accessed December 11, 2014.

        View in Article

      3. Gallup. In U.S., uninsured rate sinks to 13.4% in second quarter. Available at: http://www.gallup.com/poll/172403/uninsured rate sinks second quarter.aspx. Accessed December 12, 2014.

        View in Article
        • Franks P.
        • Clancy C.M.
        • Gold M.R.
        Health insurance and mortality.
        JAMA. 1993; 270: 737-741
        View in Article
        • Wilper A.P.
        • Woolhandler S.
        • Lasser K.E.
        • et al.
        Health insurance and mortality in US adults.
        Am J Public Health. 2009; 99: 2284-2295
        View in Article
        • Anderson G.F.
        • Frogner B.K.
        Health spending in OECD countries: obtaining value for dollar.
        Health Aff (Millwood). 2008; 27: 1718-1727
        View in Article
        • Blendon R.J.
        • Benson J.M.
        Voters and the Affordable Care Act in the 2014 election.
        N Engl J Med. 2014; 371: e31
        View in Article

      8. The Henry J. Kaiser Family Foundation. Kaiser health tracking poll: March 2011. Available at: http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8166-c.pdf. Accessed December 12, 2014.

        View in Article

      9. The Henry J. Kaiser Family Foundation. Kaiser health tracking poll: December 2011. Available at: http://kaiserfamilyfoundation.files.wordpress.com/2013/03/8265-c.pdf. Accessed December 11, 2014.

        View in Article
        • Dalen J.E.
        Should the affordable care act of 2010 be repealed?.
        Am J Med. 2011; 124: 575-577
        View in Article
        • Blendon R.J.
        • Benson J.M.
        • Brule A.
        Understanding health care in the 2012 election.
        N Engl J Med. 2012; 367: 1658-1661
        View in Article

      12. The New York Times. Results of The New York Times/CBS News poll. Available at: http://www.nytimes.com/interactive/2012/03/27/us/03272012_polling_doc.html. Accessed December 12, 2014.

        View in Article
        • Blendon R.J.
        • Benson J.M.
        The public and the conflict over future Medicare spending.
        N Engl J Med. 2013; 369: 1066-1073
        View in Article

      14. Social Security Administration. Legislative history. Summary of party affiliation on Medicare vote. Available at: http://www.ssa.gov/history/tally65.html. Accessed December 10, 2014.

        View in Article

      15. Pew Research. Public trust in government: 1958-2014. Available at: http://www.people-press.org/2014/11/13/public trust in government/. Accessed December 9, 2014.

        View in Article

      16. CNN. CNN/ORC Poll July 2014. Available at: http://i2cdn.turner.com/cnn/2014/images/08/08/re17g.pdf. Accessed December 8, 2014.

        View in Article

      17. Pew Research Center. Trust in government nears record low, but most federal agencies are viewed favorably. Available at: http://www.people-press.org/2013/10/18/trust in government nears-record low but most federal agencies are viewed favorably/. Accessed December 13, 2014.

        View in Article

      18. Pew Research Center. Chapter 2: Views of the Affordable Care Act and its future. Available at: http:www.people-press.org/2014/05/05/views-of-the-affordable-care-act-and-its-future. Accessed December 7, 2014.

        View in Article
        • Dalen J.E.
        • Alpert J.S.
        National health insurance: could it work in the US?.
        Am J Med. 2008; 121: 553-554
        View in Article
        • Conyers J.
        A fresh approach to health care in the United States: improved and expanded Medicare for all.
        Am J Public Health. 2008; 98: S58
        View in Article

      21. Wilner B, West M. The Affordable Care Act's place in advertising history. Kantar Media, May 2014. Available at: http://thehill.com/sites/default/files/cmag_aca_deck_v4_embargoed_1.pdf. Accessed December 7, 2014.

        View in Article

      Article Info

      Publication History

      Published online: February 28, 2015

      Footnotes

      Funding: None.

      Conflict of Interest: None.

      Authorship: All authors contributed to and reviewed this manuscript.

      Identification

      DOI: https://doi.org/10.1016/j.amjmed.2015.01.032

      Copyright

      © 2015 Elsevier Inc. Published by Elsevier Inc. All rights reserved.

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      Linked Article

      • Why Do So Many White Americans Oppose the Affordable Care Act?
        The American Journal of MedicineVol. 129Issue 5
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          Dalen et al1 offer plausible explanations for opposition to the Affordable Care Act (ACA). Yet, although 50% of whites report unfavorable views, only 20% of blacks and 27% of Latinos do so.2 These national polling data suggest a narrower, but unsettling question: why do so many white Americans oppose the ACA?
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