Conservative opposition to the ACA is partly driven by fears that, once fully implemented, the program will prove popular and thus be difficult to roll back. My new research suggests that these fears may be justified.
The research, conducted with Princeton’s Katherine McCabe, builds on a long-standing finding from political science: Policies, once created, generate constituencies who benefit from those policies and will therefore oppose efforts to reform or repeal them. This “policy feedback” is what Republicans want to avoid and Democrats want to cultivate.
How can we know what effects the ACA will have? It is far too early to say, and national polling is unlikely to provide much insight right now. It is certainly possible that experience with the ACA could change minds — 55 percent of the currently uninsured say they do not have enough information to know how the legislation will affect them and their families — but only time will tell.
There is, though, another government-sponsored health insurance program that can shed some light on this question: Medicare. By understanding how receiving Medicare affects people’s attitudes toward government’s role in health care, we can get a sense of how receiving the ACA may affect them as well.
In our research, we use a nationally representative subsample of almost 6,000 Americans from the 2012 Cooperative Congressional Election Study. This subsample is very unusual: Roughly half were born in 1946 or 1947 and were eligible for Medicare at the time of the survey, and the other half were born in 1948 or 1949 and were not yet eligible for Medicare. That is, this is a sample of people who are between 63 and 66 years old.
Why focus only on this group? It helps us deal with a tricky problem: There are many ways in which people who receive Medicare are different from those who do not. Mostly obviously, they are older and, as they age, will become more likely to experience a variety of health conditions. This may affect their personal views about health care. However, within just this narrow group of 63- to 66-year-olds, we can more safely assume that individuals face similar physical health challenges. In fact, the data confirm that those ages 63 and 64 are similar on almost every dimension to those ages 65 and 66. The only significant exception is in their relationship to government: whether they are retired and get Social Security, and what type of health insurance they report.
The attitudes of these two groups show that experience with public insurance matters greatly. Compared to 63- and 64-year-olds, 65- and 66-year-olds become significantly less likely to support cutting Medicare. That is no surprise.
What is more surprising is that 65- and 66-year-olds who currently receive public insurance also become more supportive of the ACA. This is all the more remarkable given that older Americans have often been the most hostile to the president’s health-care reform package. In addition, the effects of personal experience with public insurance transcend the partisan boundaries that are so prominent in public opinion about the government’s role in health care. In fact, the effect of receiving public insurance on increased support for Medicare funding is most pronounced among Republicans, and personal experience with Medicare has the strongest effect on support for the ACA among political independents.
One potential criticism of our approach is that this shift in attitudes may not be attributable to Medicare but to other significant changes, such as receiving Social Security, that occur at age 65. But additional analysis suggests that receiving Medicare is important. For example, if we restrict our analysis to only those who are not yet retired, we still find these effects.
Our research also contradicts a key argument of some commentators, who have suggested that the ACA’s failure to garner widespread support is due to Obama’s failure to raise awareness of its benefits. While we do find that awareness about the ACA has a significant effect on Republicans and Democrats alike, we also find that partisans are mostly likely to hold information that bolsters their existing ideas. Put another way, partisans only seem to learn information about the ACA that helps support their current position, rather than learning information that challenges it. So while disseminating information may be important, it is not likely to help build enthusiasm among segments of the public where opposition is currently concentrated.
In contrast, our findings suggest that if the ACA can survive its admittedly rocky start, public opinion may change based on personal experiences — with the ACA or even with Medicare. Indeed, the most striking aspect of Medicare receipt is that the effects of experience accrue so quickly. Of course, we hurry to add that the quality of experience is also going to matter. Despite sensible concerns about its efficiency, Medicare recipients report being more satisfied with their coverage than do those with employer-sponsored insurance. It remains to be seen whether the ACA will likewise be perceived by participants as a well-administered and high-quality program. If so, then once the ACA is fully implemented we can expect its place in American social policy to be relatively secure.