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Voters and the Affordable Care Act in the 2014 Election Robert J. Blendon, Sc.D., and John M. Benson, M.A.

As we approach the 2014 election, we are witnessing an unusual situation. Poll results suggest a low level of public interest and a low projected voter turnout in this election. Only about half (52%) of the public say they are currently paying attention to the election (CBS News–New York Times [CBS-NYT] poll, 2014). On the basis of past nonpresidential-year elections, less than half of U.S. adults are expected to vote.1 At the same time, congressional candidates are raising a number of important national issues, including what should be the future of the Affordable Care Act (ACA) in the years ahead. Most Democratic candidates hold positions in favor of continuing the next phase of the ACA’s implementation mostly in its current form, whereas most Republican candidates have positions favoring some sort of major scaling back, repeal, or replacement of the legislation. For a number of different reasons, political forecasters see this election’s outcome as being very close. They give at least an even chance that the Republican Party will win majorities in both the House of Representatives and the Senate. The uncertain outcome of this election has importance for health care because of the polarized views held by each party’s candidates on the future of the ACA, federal health spending, and policies regarding federal health care regulation. Forecasters see the outcome of the 2014 Senate races as most uncertain, while projecting that the House of Representatives will maintain a Republican member majority.2 They also predict that the Senate majority will be determined by the outcome of races in 14 states that have either competitive races, as shown by state polls, or open seats without an incumbent senator. The 14 states — Alaska, Arkansas, Colorado, Georgia, Iowa, Kansas, Kentucky, Louisiana, Michigan, Montana, New Hampshire, North Carolina, South Dakota, and West Virginia —

are shown on the map in Figure 1. A Senate race is considered to be competitive if it was listed as such in both the Cook Political Report and Real Clear Politics as of October 1.3,4 The Gallup Poll’s rating of the political culture of these states shows that these 14 states are more politically conservative as a group than the country as a whole (Gallup, January 2–December 29, 2013). In addition, support for the ACA is lower in some of these states than in states that are often cited as leading in ACA implementation. Whereas support for the ACA is 57% in Massachusetts (Boston Globe–Harvard School of Public Health [HSPH] poll, 2014) and 56% in California (California Wellness Foundation [CWF]–Field poll, 2014), it is 40% in Colorado (Quinnipiac University, 2014), 38% in North Carolina (NYT–Kaiser Family Foundation [KFF] poll, 2014), 37% in New Hampshire (WMUR– University of New Hampshire [UNH] poll, 2014), 35% in Kentucky, 34% in Louisiana, and 29% in Arkansas (NYT–KFF, 2014), six states with Senate races that are projected to be close. This article, which is based on an analysis of data from 27 public opinion polls by 14 organizations, seeks to examine the role of the ACA in the 2014 election and the potential implications for health care depending on the outcome. It examines the following six questions: How important is health care, and specifically the ACA, as an issue in the 2014 election? If a congressional candidate supports the ACA, are voters more or less likely to vote for him or her? What is the current level of voter support for the ACA? How does this support vary according to voters’ partisan affiliation? Do voters currently support a core principle of the ACA that it is the responsibility of the federal government to make sure that all Americans have health care coverage? What do voters want the next Congress to do with the ACA?

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Washington North Dakota

Montana

Vermont

Minnesota

Maine

Oregon

New Hampshire

Idaho

South Dakota

Wisconsin

Nebraska

Nevada

Iowa

Pennsylvania

Utah

Illinois

Colorado

California

Kansas

Arizona

New Mexico

Oklahoma

Texas

Missouri

Indiana

Ohio West Virginia

Kentucky

Rhode Island Connecticut New Jersey Delaware Maryland

Virginia

North Carolina

Tennessee

South Carolina

Arkansas

Louisiana

Massachusetts

New York

Michigan

Wyoming

Georgia MissisAlabama sippi Florida

Alaska Hawaii

Figure 1. Battleground States for Senate Races in 2014, According to Political Analysts. As of October 1, analysts at the Cook Political Report3 and Real Clear Politics4 were predicting that the Senate majority will be determined by the outcome of races in 14 states — Alaska, Arkansas, Colorado, Georgia, Iowa, Kansas, Kentucky, Louisiana, Michigan, Montana, New Hampshire, North Carolina, South Dakota, and West Virginia — that have either competitive races (according to local polling) or open seats without an incumbent senator.

Table 1. Public Attitudes about the Affordable Care Act (ACA) and President Barack Obama’s Handling of Health Care.* ACA Enactment, 2010

Variable

2012

2014

% of respondents Approval of the ACA† Favor

42

44

40

Oppose

45

45

51

Approve

43

43

41

Disapprove

52

51

57

President Obama’s handling of health care‡

* Data are the averages from available polls for each period. † Data in this category are from the following polls: for 2010–2012, Blendon et al.; for 2014, KFF (August–September), Pew (September), NBC–WSJ (September), ABC–WP (September), CBS–NYT (September), and HSPH– SSRS (September). ‡ Data in this category are from the following polls: for 2010, Gallup–USA Today (March), ABC–WP (April), Quinnipiac (April), Fox (April), Pew (April), CBS–NYT (April–May); for 2012, ABC–WP (July), Quinnipiac (July), and Fox (October); for 2014, Gallup (August) and Fox (September).

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National Supp or t for the AC A Before examining these questions, we provide some politically relevant background data on the ACA and the public. The ACA was enacted in 2010. Table 1 shows public support (in an average of polls) for the ACA at the time of its enactment and in connection with the 2012 and 2014 elections. We also show President Obama’s job approval on his handling of health care for the same years. What is striking is that despite major changes in health care since 2010 — including increased health insurance security protections and benefits, the expansion of Medicaid, and subsidized private insurance plans, which have reduced the proportion of Americans who are uninsured from 18.0% to 13.4% (Gallup, July 2013–June 2014) — public approval of the ACA has not increased since the law was enacted. Today, as was the case in 2010 and 2012,5 only a minority of Americans approve of either the ACA or the President’s handling of the health care

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Table 2. Most Important Issues among Registered Voters in the 2014 Congressional Elections, According to Polling Results.* Rank

ABC News–Washington Post† Issue

CBS News–New York Times‡

% of Respondents

Issue

% of Respondents

1

Economy and jobs

35

The economy

38

2

The way things are working in Washington

15

Terrorism

17

3

Health care

13

Health care

16

4

International conflicts

12

Immigration

10

5

Immigration

10

Federal budget deficit

8

6

Other

11

International conflicts

6

* Percentages reflect the percentage of respondents who identified the issue as the single most important issue affecting their vote. † Data are from the responses of 847 registered voters, as reported by ABC–WP, 2014. ‡ Data are from the responses of 854 registered voters, as reported by CBS–NYT, 2014.

issue (Table 1). They hold these views even though most respondents report that the law has had no direct impact on their own family (56%). About one in four (27%) believe the law has hurt their family, whereas 14% believe it has helped them (KFF, 2014). However, Americans are more divided over the impact of the ACA on the country as a whole. Nearly half (45%) believe that the law has had a mostly negative effect on the country to date, whereas 33% think it has had a mostly positive effect, and 18% do not think it has had much of an effect (Pew Research Center, September 2014). Over the past decade, there has been a cultural shift in Americans’ attitudes about the principle of universal health care coverage, one of the main rationales for the ACA. In 2007, during the presidential primary season, public support for the view that the federal government has a responsibility to make sure all Americans have health insurance coverage was at 64% (Gallup, 2007). By 2014, this number had declined to 47% (Pew, January–February 2014). In addition, there has been a decline in overall public trust in the federal government to handle domestic problems such as health care from 51% in 2012 to 40% in 2014, which may also play a role in depressing public support for the ACA (Gallup, September 2014). One often unrecognized factor that may be contributing to these overall findings is the extraordinary level of paid negative advertising opposing the ACA that has taken place since the

law was enacted. A recent study reported that $445 million had been spent for advertising related to the ACA through the beginning of 2014.6 Of that amount, 94% was expended on negative ad messages about this national law. Moreover, the large volume of advertisements against the ACA has continued throughout the campaign season, with 37,544 anti-ACA ads between August 1 and September 11, 2014.7

He alth C are and the 2 014 Elec tion The 2014 election campaign has not been dominated by a single issue, with respondents highlighting multiple issues as important (Table 2). Health care was the third-ranked issue in two recent polls asking registered voters to identify the single most important issue influencing their vote in the upcoming congressional elections (ABC News–Washington Post [ABC–WP] poll, 2014; CBS–NYT, 2014). Polling results have highlighted the fact that voters do not see health care as a single issue. In one poll, 73% of respondents said that health care was an extremely or very important issue in their voting decision. When asked from a list what they meant by this statement, the ACA or Obamacare was the dominant health care issue (48%). Medicare was mentioned by 25%, and Medicaid by 14% (HSPH–Social Science Research Solutions [SSRS], 2014). In this shifting political environment, poll

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Table 3. Attitudes about the Affordable Care Act, According to Party Affiliation.* Variable

All Respondents

Republicans

Democrats

Independents

percentage of respondents Making sure all Americans have health care coverage is . . .† The responsibility of the federal government

41

12

70

39

Not the responsibility of the federal government

56

86

26

60

Great deal or fair amount

40

28

63

34

Not very much or none at all

59

NA

NA

NA

Trust in the federal government to handle domestic problems‡

The new health care law has  .  .  .§ Directly helped you and your family

14

2

27

11

Directly hurt you and your family

27

46

10

31

Not had a direct effect

56

50

63

55

Mostly positive

33

12

56

28

Mostly negative

45

73

22

46

Not much of an effect

18

13

17

21

What effect has the health care law had on the country to date?¶

Approval of the Affordable Care Act†§¶‖ Support

41

11

71

36

Oppose

51

83

19

55

You would be more likely to vote for a candidate who held this position

31

9

60

25

You would be less likely

40

69

10

43

Wouldn’t make a difference

27

21

28

30

Expand what the law does

27

9

44

26

Keep the health care law in place as it is

14

4

30

8

Scale back what the law does

23

27

14

27

Repeal the law entirely

31

56

4

34

If a candidate for Congress supports the 2010 health care law passed by President Obama and Congress (ACA)†

What you would like to see Congress do with the ACA†

* “Don’t know” or “Refused” responses are not shown. NA denotes not available. † Data are from the responses of 1596 likely voters, as reported by HSPH–SSRS, 2014. ‡ Data are from the responses of 1017 U.S. adults, as reported by Gallup, September 2014. § Data are from the responses of 1505 U.S. adults, as reported by KFF, 2014. ¶ Data are from the responses of 2002 U.S. adults, as reported by Pew, September 2014. ‖ Data are the averages of responses that were available according to party identification.

results show that support for the principle of universal coverage is lower among those who are likely to vote than among the public as a whole. About 4 in 10 likely voters (41%) support e31(4)

the principle of universal coverage provided by the federal government, as compared with 47% of the general public (HSPH–SSRS, 2014; Pew, January–February 2014). Among likely voters, a

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Opinion Polls on Voters and the Affordable Care Act in the 2014 Election ABC News–Washington Post (ABC–WP) polls April 22–25, 2010 (http://abcnews.go.com/images/PollingUnit/1109a22010Politics.pdf) July 5–8, 2012 (http://www.langerresearch.com/uploads/1138a1The2012Election.pdf) September 4–7, 2014 (http://s3.documentcloud.org/documents/1286547/2014-09-07-trend-for-release.pdf) Boston Globe–Harvard School of Public Health (Boston Globe–HSPH) poll May 27–June 2, 2014 (http://cdn1.sph.harvard.edu/wp-content/uploads/sites/21/2014/06/Poll-Public-Perceptions-of-MA-Health-Law.pdf) California Wellness Foundation–Field (CWF–Field) poll June 26–July 19, 2014 (http://www.field.com/fieldpollonline/subscribers/Rls2477.pdf) CBS News–New York Times (CBS–NYT) polls April 28–May 2, 2010 (http://s3.amazonaws.com/nytdocs/docs/330/330.pdf) September 12–15, 2014 (http://s3.documentcloud.org/documents/1302290/sept14b-politics-trn.pdf) Fox News polls April 6–7, 2010* October 7–9, 2012* September 7–9, 2014 (http://www.foxnews.com/politics/interactive/2014/09/11/fox-news-poll-gop-has-advantage-in-upcoming-midterm-election/) Gallup polls January 2–December 29, 2013 cumulative data (http://www.gallup.com/poll/167144/wyoming-residents-conservative-liberal.aspx#2) July 1, 2013–June 30, 2014 (http://www.gallup.com/poll/172403/uninsured-rate-sinks-second-quarter.aspx) November 11–14, 2007* August 7–10, 2014* September 4–7, 2014 (http://www.gallup.com/poll/175697/trust-federal-gov-international-issues-new-low.aspx) Gallup–USA Today poll March 26–28, 2010 (http://www.gallup.com/poll/127190/Obama-Approval-Healthcare-Recovers.aspx) Harvard School of Public Health–Social Science Research Solutions (HSPH–SSRS) poll September 10–28, 2014 (http://cdn1.sph.harvard.edu/wp-content/uploads/sites/94/2014/10/HSPH_Election_2014_Topline.pdf) Kaiser Family Foundation (KFF) poll August 25–September 2, 2014 (http://kaiserfamilyfoundation.files.wordpress.com/2014/09/8628-t.pdf) NBC News–Wall Street Journal (NBC–WSJ) poll September 3–7, 2014 (http://online.wsj.com/public/resources/documents/WSJNBCpoll09092014.pdf) New York Times–Kaiser Family Foundation (NYT–KFF) poll April 8–15, 2014 (http://kaiserfamilyfoundation.files.wordpress.com/2014/04/8580-t2.pdf) Pew Research Center for the People and the Press polls April 21–26, 2010 (http://www.people-press.org/files/legacy-pdf/608.pdf) January 23–February 9, 2014 (http://www.people-press.org/files/2014/06/6-12-2014-Political-Polarization-Release.pdf) September 2–9, 2014 (http://www.people-press.org/files/2014/09/09-12-14-Midterms-Release.pdf) Quinnipiac University polls April 14–19, 2010* July 1–8, 2012 (http://www.quinnipiac.edu/news-and-events/quinnipiac-university-poll/national/release-detail?ReleaseID=1770) July 10–14, 2014 (http://www.quinnipiac.edu/news-and-events/quinnipiac-university-poll/colorado/release-detail?ReleaseID=2060) WMUR–University of New Hampshire (WMUR–UNH) poll April 1–9, 2014 (http://cola.unh.edu/sites/cola.unh.edu/files/research_publications/gsp2014_spring_presapp041414.pdf) * These data are available from the iPOLL database, Roper Center for Public Opinion Research, University of Connecticut.

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majority (56%) do not believe it is the responsibility of the federal government to make sure all Americans have health care coverage (HSPH– SSRS, 2014). Those who are likely to vote in the 2014 election are highly polarized on the basis of their party identification. Democratic voters are the most likely to support both the ACA (Pew, September 2014; KFF, 2014; HSPH–SSRS, 2014) and the principle of universal coverage (HSPH–SSRS, 2014), whereas Republican voters are the least likely (Table 3). There are also major differences in policy views between the adherents of the two parties on a whole range of other issues relating to the ACA and the future role of the federal government in health care. Of significance for this election and its aftermath, a larger proportion of likely voters say they are less likely to vote for a congressional candidate who supports the ACA (40%) than say that they are more likely to vote for such a candidate (31%). About one in four (27%) report that a candidate’s stand on the ACA will not matter to their vote. More than two thirds of Republican voters (69%) say they are less likely to vote for a pro-ACA candidate, whereas only 9% say they are more likely. Among independent likely voters, those who say they are less likely to vote for a pro-ACA candidate outnumber those who say they are more likely to vote for such a candidate, 43% to 25%. Only among Democratic likely voters was this pattern reversed: 60% say they would be more likely to vote for a candidate who supports the ACA, whereas 10% say they would be less likely (HSPH–SSRS, 2014). Finally, as to voters’ preferences for the future, polling results show that a majority of likely voters nationally do not support repealing the ACA. However, a majority do support either repealing or scaling back the ACA (31% repeal entirely and 23% scale back) (Table 3). In contrast, a majority (74%) of Democratic likely voters support keeping the law in place as it is (30%) or expanding what it does (44%), whereas only 18% prefer scaling it back or repealing the law. On the other side, a majority of Republican likely voters (56%) support repealing the law, with 27% favoring scaling back the existing program. Few Republicans support future implementation or expansion (13%) (HSPH–SSRS, 2014).

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Implic ations of Sur ve y Re sult s Although the election of 2014 is not of wide public interest, the outcome matters in terms of health care. This is the case because Republican and Democratic voters are so separated in their views on the future of the ACA that these divisions will have an impact after the election. The leaders of the majority party in the House and Senate are likely to reflect the views of their party’s adherents. On one side, Republicans favor scaling back or repealing the legislation, positions that have been shown by other studies to have been taken by a majority of Republican candidates in 2014 primary races.8 On the other side, Democrats favor moving ahead with this law. Of important note for the 2016 election, the plurality of Democratic likely voters favor expanding the current scope of the ACA, rather than just implementing the current law. Regardless of the outcome of the election, the ACA cannot be repealed unless President Obama concurs, which is highly unlikely. However, what a Republican majority could possibly accomplish through multiple budgetary bills is to reduce federal support for health insurance subsidies, Medicaid expansions, public health grants, innovation investments, program administrative information, and outlays for outreach. Also, honoring Republican candidates’ commitments, substantial efforts would probably be made to postpone employer and individual health insurance mandates and reduce the ACA’s taxes on employers, insurers, and health care companies. The budgetary process would provide the focus for these efforts. Though proposals to provide a new Republican substitute for the ACA are likely to be debated, it is unlikely that one could be passed in the Congress and signed by the President after the election. However, a Democratic majority in the Senate would probably result in the implementation of the next phase of the ACA with more resources being available. Such an outcome would be likely to create a political environment in which more of the 23 states that are not participating in the optional Medicaid expansion component of the law would agree to move ahead. It would also provide encouragement for 2016 Democratic presidential hopefuls who are presenting their views on an expanded ACA. Even though health

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care is only one of a number of top issues in the 2014 election, the majority party in Congress will claim it has a mandate for its priorities on what is still a controversial national health care issue. Of the most importance in the health care field, these deep divisions foretell continuing conflicts over the shape and direction of U.S. health care policy in the future. The views expressed in this article are those of the authors and do not necessarily reflect those of the Robert Wood Johnson Foundation. Supported by a grant from the Robert Wood Johnson Foundation. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. From the Harvard School of Public Health, Boston (R.J.B., J.M.B.), and the John F. Kennedy School of Government, Harvard University, Cambridge (R.J.B.) — both in Massachusetts. This article was published on October 29, 2014, at NEJM.org. 1. National voter turnout in federal elections: 1960–2012. Info-

please, 2013 (http://www.infoplease.com/ipa/A0781453.html). 2. Democrats currently have a 1 percent chance of retaking

the House. Washington Post. December 20, 2013 (http://www .washingtonpost.com/blogs/monkey-cage/wp/2013/12/20/ democrats-currently-have-a-1-percent-chance-of-retaking-the -house/). 3. Cook Political Report. 2014 Senate race ratings for September 29, 2014 (http://cookpolitical.com/senate/charts/race-ratings). 4. Real Clear Politics. Battle for the Senate (http://www .realclearpolitics.com/epolls/2014/senate/2014_elections_senate _map.html). 5. Blendon RJ, Benson JM, Brulé A. Understanding health care in the 2012 election. N Engl J Med 2012;367:1658-61. 6. Wilner E, West M. The Affordable Care Act’s place in advertising history. Kantar Media, May 2014 (http://thehill.com/sites/ default/files/cmag_aca_deck_v4_embargoed_1.pdf). 7. Wesleyan Media Project. 2014 general election advertising opens even more negative than 2010 or 2012. September 16, 2014 (http://mediaproject.wesleyan.edu/releases/2014-general-election -advertising-opens-even-more-negative-than-2010-or-2012//). 8. Kamarck EC, Podkul AR. The 2014 congressional primaries: who ran and why. Washington, DC: Center for Effective Public Management at Brookings, September 2014 (http://www .brookings.edu/~/media/research/files/reports/2014/09/30%20 congressional%20primaries%20kamarck%20podkul/primaries5 .pdf). DOI: 10.1056/NEJMsr1412118 Copyright © 2014 Massachusetts Medical Society.

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Voters and the Affordable Care Act in the 2014 election.

In this analysis of data from 27 public opinion polls, the authors examine the role of the Affordable Care Act in the 2014 congressional elections. Th...
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