‘Stable Condition’

In a new book, Penn political scientist Daniel J. Hopkins offers a detailed study of Americans’ opinions about the Affordable Care Act and examines to what extent political elites can reshape public opinion through their words or policies.

President Barack Obama signs the Affordable Care Act surrounded by lawmakers and a young child standing by the table.
On March 23, 2010, President Barack Obama signed the Affordable Care Act in the East Room of the White House in Washington, D.C. (Image: AP Photo/J. Scott Applewhite)

The following is an excerpt from “Stable Condition: Elites’ Limited Influence on Health Care Attitudes” by Penn political scientist Daniel J. Hopkins. (©2023 Russell Sage Foundation)

In 1993, newly elected Democratic president Bill Clinton was trying to push comprehensive health care reform through Congress, while another Bill—Bill Kristol—circulated a memo to his fellow Republicans. Kristol argued that Republicans needed to do everything in their power to kill Clinton’s bill. He was alarmed about its potential political impacts. “Because the initiative’s inevitably destructive effect on American medical services will not be practically apparent for several years,” he wrote, “its passage in the short term will do nothing to hurt (and everything to help) Democratic electoral prospects.” A conservative and a former chief of staff to GOP Vice President Dan Quayle, Kristol worried that voters would reward the Democrats for passing health care reform, making it harder for Republicans to retake the White House. In his view, the long-term impacts of the bill’s passage were even more concerning: the legislation, he argued, would “relegitimize middle-class dependence for security on government spending and regulation.” Like the New Deal before it, comprehensive health care reform would become entrenched over time, transforming politics by permanently shifting the relationship between citizens and government.

Embedded in Kristol’s advice was a theory of how public opinion works: if policies today can reconfigure public opinion tomorrow, those in power may be able to propagate their own worldview, possibly for decades to come. In the period after Kristol’s 1993 memo, a fast-growing body of political science research on policy feedback effects concluded that policies sometimes can reshape public opinion.

Bill Clinton’s efforts at comprehensive health care reform ended in failure, as Congress did not even seriously consider his plan. But years later the political world would get to see if Kristol’s prediction about public opinion and health care reform was right. In 2010, the Democrats managed to enact sweeping health insurance reform through the vehicle of the Patient Protection and Affordable Care Act (ACA), or “Obamacare.” The widest-ranging social policy reform in a generation, and the signature legislative achievement of Barack Obama’s 2009-2017 presidency, the ACA was a complex bundle of public spending, taxes, and regulatory policies that sought to increase access to comprehensive health insurance.

In theory, the ACA seemed to be precisely the kind of law that should bolster the fortunes of the party and ideology behind it, just as Kristol had feared. It created substantial new benefits. Its Medicaid expansion alone provided health insurance to 14.8 million additional people in 2019. Its separate insurance subsidies were also substantial—in 2016, for example, the federal government spent $46 billion via the law’s Premium Tax Credit, meaning that the average policyholder’s subsidy amounted to just over $4,000. That’s not to mention the other avenues through which the ACA provided sizable benefits, such as by prohibiting discrimination against customers with preexisting conditions, ending higher premiums for women, and removing caps on lifetime insurance payments. The ACA was an inherently redistributive policy that used taxes on high earners to extend health insurance primarily to Americans with low incomes. Research on other policy areas has found that more modest government benefits can bolster the incumbent or enacting party. Given the size of its outlays and their impacts on people’s lives, the ACA appeared likely to do so as well.

Yet far from fulfilling Kristol’s prediction, the ACA seemed to be a major political liability for the Democrats in the years after its enactment. In 2010 and 2014, Republican congressional candidates campaigned primarily on the basis of their opposition to the ACA, which they tagged as an unnecessary expansion of governmental authority—and they swept those years’ most contested elections. Researchers estimate that in 2010 Democratic members of Congress who voted for the ACA lost a whopping 8.5 percentage points when running for reelection relative to Democrats who did not. Overall, in 2010 the Democrats dropped a historic 63 seats in the House of Representatives along with six Senate seats; in 2014 they gave up 13 House seats and another nine Senate seats. Presidential scholar George Edwards titled his book on Obama’s early years Overreach, and the politics of the ACA was a major reason why.

Cover of new book by Daniel J. Hopkins called "Stable Condition."
Daniel J. Hopkins’ new book, “Stable Condition: Elites’ Limited Influence on Health Care Attitudes.” (Image: Courtesy of the Russell Sage Foundation)

One explanation for the ACA’s unpopularity centers on a second pathway through which political elites are thought to influence public opinion: messaging. The New York Times stated the conventional wisdom in reporting that “the Obama administration and Democrats…largely lost the health care message war in the raucous legislative process.” Scholars have joined commentators in contending that politicians’ rhetorical choices influenced public views of health care reform, singling out former Alaska governor Sarah Palin’s use of the phrase “death panels” in a 2009 Facebook post as especially memorable and effective anti-ACA rhetoric.

Politicians and pundits commonly emphasize messaging as an explanation for a policy’s popularity. The journalist Michael Hiltzik wrote that “the Democrats’ problem wasn’t Obamacare so much as faulty messaging. Think of how things might have been different if every time a Republican … trotted out a purported Obamacare ‘victim’ (most of which cases were bogus), a Democratic organization produced an Obamacare winner from among those 10 million new insurance holders.” Such arguments presume that politicians’ choices about messaging play a key role in the success of their policy goals.

This belief in the impacts of messaging can be self-serving, since messaging is among the few things that politicians (and their consultants) can consistently control. But it’s also a belief with considerable grounding in political science. In fact, political scientist Cindy Kam describes this elite leadership model of public opinion—and above all John Zaller’s The Nature and Origins of Mass Opinion—as “arguably the dominant paradigm today of public opinion formation.” Framing, elite cues, and other forms of messaging have already generated extensive study, just as research on policy feedbacks has. But these two research literatures have proceeded largely in isolation. From the vantage point of political figures like Bill Kristol and Barack Obama, however, messaging and policy feedbacks are the primary tools through which they and other political elites can reshape public opinion and so tilt the landscape for future policy battles. To politicians, they are thus complementary, meaning that studying messaging and policy feedbacks jointly is key if we are to provide an overall assessment of the capacity for elite influence on public opinion.

Still, an initial look at the evidence suggests that neither messaging nor policy feedbacks were all that influential. For years post-enactment, the public’s overall response to the ACA was both stable and cool: between 2010 and 2016, surveys consistently found pluralities or majorities voicing opposition. (That was despite the fact that many of the law’s provisions were quite popular on their own, with 67% of American adults backing the creation of the exchanges and 62% wanting to expand Medicaid in 2010.) Shifts in messaging during the initial debate over the law left a shallow imprint on public opinion. Even the implementation of the law’s main provisions in January 2014 did surprisingly little to move attitudes. The Democrats still lost the 2014 midterms badly. And in January 2015, a year after the ACA’s main provisions went into effect, the Kaiser Family Foundation’s (KFF) Health Tracking Poll (HTP) found that just 40% of Americans held favorable opinions toward the ACA, while 46% held unfavorable opinions.

The general stability and negativity of Americans’ ACA attitudes for several years is a lingering puzzle: given the very real benefits it provided, why didn’t the law’s passage and subsequent implementation do more to shift public opinion or to generate political support for its Democratic architects and defenders? Why did the public like many of the law’s pieces but not the law itself? More starkly, what was wrong with Kristol’s theory of elite influence through policy?

The 2016 election of Republican Donald Trump only deepened the mystery. After Trump’s general election victory, a slew of pundits and scholars argued that the Democrats had lost partly because they had put too much emphasis on identity-based appeals related to race, ethnicity, and gender. In this view, key states like Michigan, Ohio, Pennsylvania, and Wisconsin backed Trump because the Democrats didn’t focus their campaign on the economic interests of white voters without college degrees. But such claims reflect a touch of political amnesia. The Democrats’ chief policy accomplishment of the preceding administration had been the ACA, a redistributive economic policy of precisely the kind that should have played to the Democrats’ advantage. In theory, the promise of health insurance not tied to employment might have been especially welcome in the hard-hit manufacturing towns of the Northeast and Midwest. By 2016, however, the Democrats saw themselves as having little reason to highlight their support of the ACA, while Republicans had little reason to conceal their strident opposition. In fact, Trump campaigned in 2016 partly on a commitment to repeal the law.

Still, the story does not end there. After Trump’s election, GOP politicians moved quickly to fulfill their repeated promise to roll back the ACA. But after having been stable for years, public opinion swung in the ACA’s favor as soon as its repeal became a real possibility. By November 2018, 53% of respondents to a KFF poll reported favoring the ACA, up thirteen percentage points from 2015—and in 2018’s midterm elections, it was the Democrats trumpeting their ACA position. Indeed, Republican House leader Kevin McCarthy blamed the GOP’s 2018 loss of control of the House of Representatives “on the GOP’s push to roll back health insurance protections for people with pre-existing conditions.” Enacting the ACA had proven unpopular, but repealing it was even more so. Far from influencing public opinion, political elites seemed to retreat in the face of it.

How do we explain these paradoxical post-enactment trends? And more generally, to what extent can political elites reshape public opinion through their words or policies? This book addresses these questions through a detailed study of Americans’ opinions about the ACA between 2009 and 2020. Researchers have produced a rich body of scholarship about the role of specific factors in shaping ACA attitudes, but this book departs from prior research by providing a competitive assessment of several credible explanations for Americans’ views on the ACA. These explanations range from personal experiences with the policy to messaging, partisanship, racial attitudes, status quo biases, and thermostatic responses to presidential policymaking.

The text above is excerpted from “Stable Condition: Elites’ Limited Influence on Health Care Attitudes,” by Daniel J. Hopkins, copyright ©2023 Russell Sage Foundation. Used by arrangement with the publisher.