Regional Variations in Public Opinion on the Affordable Care Act

Transcription

1 Journal of Health Politics, Policy and Law Advance Publication, published on September 26, 2011 Report from the States Regional Variations in Public Opinion on the Affordable Care Act Mollyann Brodie Claudia Deane Sarah Cho Kaiser Family Foundation Abstract One year after passage, the Patient Protection and Affordable Care Act (ACA) remains a divisive topic. Most publicly released polls on the law have focused on the views of Americans as a whole. But with much of the responsibility of implementation lying with the states, this essay explores whether opinion differs geographically. The analysis finds that views on the health reform law do differ by region and these differences are most likely driven by the political leanings of a given area. While opinion nationally differs by age and race, this pattern does not hold when looking by region. Areas that have a larger share of uninsured and are slated to receive greater federal funding under the ACA also do not differ in their opinions. These data suggest that regional variations in attitudes about the ACA are based less on the demographic structure of a region and more on the political ideologies of residents in a given region. As implementation of the law continues, this analysis shows that national opinion data mask important regional variations in views of the ACA. The health reform debate was born in the midst of a nationwide presidential campaign a national dialogue about the future of U.S. health care and coverage in an era of rising costs. At its one- year anniversary in March 2011, the Patient Protection and Affordable Care Act (ACA) perhaps surprisingly to its advocates continues to be a contentious topic in nationwide debate. As the national battle wages on, however, much of the practical action of implementation has begun, and much of this action is occurring at the state level. Across the country, individual jurisdictions are well into their consideration of what the law will Journal of Health Politics, Policy and Law, Vol. 36, No. 6, December 2011 DOI / by Duke University Press Copyright Published 2011 by Duke by Duke University University Press Press

2 1098 Journal of Health Politics, Policy and Law mean for them and what changes will need to be made within their own state bureaucracies in order to implement it or, in some cases, in order to prevent its implementation (Kliff 2011). Most analyses of public views on the ACA focus on the national picture, but with the real action on implementation centered in the states, the question to explore is whether opinion differs around the country. That is, do differences in the opinion climate exist that may affect implementation at the state level? The National Picture For the past two years, the Kaiser Family Foundation has been tracking American public opinion on health reform via monthly, cross- sectional, nationwide random- sample telephone surveys. 1 Looking across the twentyfour months of polls, we have found both real consistencies and real contradictions. The most striking characteristic of public opinion has been its relative stability during a volatile public debate. Immediately before passage, the American public was divided roughly in half in their views of the ACA, and they remain roughly divided in half now, more than a year later. There is a similar divide when it comes to whether it would be better to keep the law or to repeal it. Underlying these neat splits, however, is a vast and consistent partisan divide, with most Americans who identify as Democrats backing the law while most self- identified Republicans oppose it and Independents remain fairly divided. We have also found that America s senior citizens, those aged sixty- five and older, tilt negative on the law and have been consistently less likely to see it as beneficial to them. 2 A few other consistent findings: the proportion of Americans who believe they will benefit from the ACA has never risen substantially beyond one third, and many Americans continue to harbor false impressions of the law or to express confusion over how it might impact them. And although a majority of the public have never embraced the law as a whole, substantial majorities continue to back many of its individual pro- 1. These monthly surveys were conducted among a nationally representative random sample of about 1,200 adults aged 18 and older. Telephone interviews were conducted by landline and cell phone (including those who have no landline telephone) in English and Spanish. For more information on the survey methodology, see KFF n.d. 2. See, for example, the March 2011 Kaiser Health Tracking Poll (KFF 2011c). 3. See, for example, KFF/Harvard School of Public Health 2011.

3 Brodie, Deane, and Cho Report from the Field 1099 visions, including the coverage expansions, many of the insurance market protections, and tax credits. 3 Public Opinion on the ACA at the Regional Level Looking beyond the national findings, however, public views of the new health reform law do differ by geography. Table 1 shows opinion on some key attitudinal questions by the nine census divisions defined by the US Census Bureau. 4 Across items considering overall favorability, perceived personal benefit, and perceived national benefit, survey data suggest that residents of New England and those in the Pacific states are consistently the most likely to back the ACA while those in the East South Central division (which includes states such as Alabama and Mississippi) and the West North Central division (including states such as Kansas, Nebraska, and North Dakota) are the most likely to think poorly of the new law. For example, in New England, 50 percent have a favorable view of the law and 36 percent an unfavorable view. In the East South Central division, however, the proportions are almost reversed: 32 percent have a favorable view and 58 an unfavorable view. Exploring the Basis of Regional Differences in Opinion There are many possible explanations for geographical differences of opinion, but our research suggests that it is the political leanings of a region s residents that, at least at this point of the debate, are the greatest influence on their views. As noted above, the ACA debate began in a political season, and opinion on the law, which passed Congress on a party 4. Each state was categorized into the census division designated by the US Census Bureau (KFF 2009a,b,c,d). Analysis by individual states was not conducted due to insufficient sample size. Results from the 2008 and 2010 elections show that states within a census division, while not monolithic, tend toward political similarity (see, for example, the 2008 presidential electoral map [New York Times 2008]). The census divisions are as follows. Pacific (note that the public opinion data do not include residents of Alaska or Hawaii): Alaska, California, Hawaii, Oregon, Washington; Mountain: Arizona, Colorado, Idaho, Montana, New Mexico, Nevada, Utah, Wyoming; West North Central: Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota; West South Central: Arkansas, Louisiana, Oklahoma, Texas; East North Central: Illinois, Indiana, Michigan, Ohio, Wisconsin; East South Central: Alabama, Kentucky, Mississippi, Tennessee; South Atlantic: Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia; Middle Atlantic: New Jersey, New York, Pennsylvania; New England: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont.

4 Table 1 Public Opinion on the Affordable Care Act by Census Division... of residents... who say they living of non-... who have a or their families... who say the... who self-... of under elderly... of favorable/ will be better off/ country will be identify as residents the federal residents residents unfavorable view worse off better off/worse Democrat/ aged 65 poverty who are who are Percent... of ACA under ACA off under ACA Republican and older level uninsured white fav/unfav diff better/worse diff better/worse diff Dem/Rep diff United States 42%/47% 5 27%/30% 3 37%/37% 0 35%/23% 12 13% 20% 19% 65% New England 50%/36% 14 30%/26% 4 50%/22% 28 38%/13% 25 14% 14% 9% 82% Pacific 50%/39% 11 33%/27% 6 45%/29% 16 43%/17% 26 11% 20% 20% 49% East North Central 45%/44% 1 25%/29% 4 36%/40% 4 30%/22% 8 13% 18% 15% 77% Mountain 45%/47% 2 28%/32% 4 36%/36% 0 36%/27% 9 11% 19% 20% 67% Middle Atlantic 40%/49% 9 26%/28% 2 34%/38% 4 34%/25% 9 14% 18% 15% 66% West South Central 40%/50% 10 23%/30% 7 37%/38% 1 36%/22% 14 11% 22% 26% 50% West North Central 39%/49% 10 22%/36% 14 33%/42% 9 27%/24% 3 13% 15% 13% 85% South Atlantic 38%/49% 11 29%/31% 2 35%/40% 5 35%/26% 9 14% 19% 20% 63% East South Central 32%/58% 26 19%/38% 19 34%/43% 9 37%/34% 3 14% 23% 18% 74% Source: Kaiser Family Foundation (KFF) 2011b,c. Kaiser Health Tracking Poll (Polls were conducted February 8-13, 2011, and March 8-13, 2011),; Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on thedata from US Census Bureau s 2009, March 2009 and 2010 Current Population Survey (CPS: Annual Social and Economic Supplements) Note: diff = percentage point difference between the two percentages displayed in the cell immediately to its left. E.g., 42 percent of Americans have a favorable view of the ACA and 47 percent have an unfavorable view, creating a 5 percentage point difference between those with a favorable view and those with an unfavorable view.

5 Brodie, Deane, and Cho Report from the Field 1101 line vote, has been consistently and highly partisan among both political elites and the general public. In table 1, you can also see that the regions that are most supportive of the law at present are also those in which selfidentified Democrats have the largest advantage, while in the regions that are least supportive, Republicans draw nearly even with the Democrats as a share of the population. In fact, there are sizeable, statistically significant correlations between party identification and each of the opinion- related columns. It is also possible that other important demographic distinctions contribute to the geographical opinion divide on the ACA. For example, given that the nation s seniors are less likely to support the reform legislation, perhaps the share of each region s population that is aged sixty- five and over differs, and that is driving the divide. A look at the proportion of seniors across the nine regions turns up very little geographic variation, however (ranging between 11 and 14 percent of the regional populations), and no significant correlation exists between the share that is elderly and the opinion- related variables, making this hypothesis less likely. Given that opinion on reform differs by race, with whites least supportive, we might also expect the racial profile of a region to be a factor. However, there is no consistent pattern and no significant correlation between the proportion of a region s population that is white and support for the ACA. For example, the two most supportive regions the New England and Pacific divisions are at the opposite ends of this particular spectrum, with the New England region 82 percent white compared to 49 percent of the Pacific region. Given that the coverage expansions in the ACA are targeted at providing assistance to the uninsured and to those with lower incomes, one might also imagine that the income profile of a region roughly reflecting the proportion of those who might expect to be aided by the new provisions could influence overall sentiment toward health reform. In other words, perhaps self- interest is driving these opinions. There is no correlation, however, between the percentage of each division s population that is either uninsured or living below the federal poverty level and that region s support for the ACA. For example, the East South Central region is both the least supportive and the least likely to expect personal benefits (32 percent have favorable views and just 19 percent think they will be better off with the ACA). This region, however, has the highest percentage of residents living below poverty. On the flip side, New England, the most supportive region (50 percent have favorable views and 30 percent believe they will be better off with the ACA), has the lowest proportion of uninsured. Furthermore, of the sixteen states that expect to receive at

6 1102 Journal of Health Politics, Policy and Law least 30 percent more federal dollars under the ACA, nine are located in the three southern regions that hold the least positive opinions of the law (Kaiser Family Foundation [KFF] 2011a). Discussion: Waiting for an Ideological Debate to Land on the Ground There are certainly limitations to what one can conclude based on comparisons made at such an aggregate level. But even given those limitations, the data suggest that current attitudes toward the ACA are based less on the sociodemographics of a region or its potential to benefit from an infusion of federal dollars and more on the current political cast of that region s residents. With most of the law s more impactful provisions expansion of Medicaid, the individual mandate, the provision of subsidies, and the creation of insurance exchanges not scheduled to be realized until 2014, health reform seems for many Americans to be an issue evaluated more through the lens of political ideology and partisan affiliation and less through the lens of real- world experience, at least for the moment. How opinion develops over the next several years depends on many factors, perhaps first among them presidential politics. As we enter the 2012 presidential campaign, the extent to which the ACA remains a political football and the subject of rhetorical wars will certainly impact the extent to which Americans continue to see health reform through a political lens. And of course if party control of the White House changes hands and Republicans gain a firmer hand on the Congress, then the law s continued existence could even be in question. But a second major factor is the pace and quality of the ACA s ongoing implementation, both at the federal and, perhaps even more important, at the state level. As an abstract law turns into a concrete change in Americans health care arrangements, as greater numbers of real people have, and see others have, real experiences with the law, we might expect opinion to shift and the current geographic patterns to change in ways that are hard to predict. What is clearly evident from the data is that national opinion results mask important regional (and state- level) distinctions in views. It is likely that these local views may be most salient to governors, their staffs, and

7 Brodie, Deane, and Cho Report from the Field 1103 the state legislatures as they make key decisions and choices about whether and how to implement the ACA in their states. References Kaiser Family Foundation (KFF). n.d. Kaiser Health Tracking Poll. kaiserpolls/trackingpoll.cfm (accessed July 29, 2011) a. Data Source: Population Distribution by Age, States ( ), U.S. (2009) US Census Bureau 2009 and 2010 Currently Population Survey: Annual Social and Economic Supplements. table.jsp?ind=2&cat=1&sub=1&yr=199&typ=2 (accessed May 18, 2011) b. Distribution of Total Population by Federal Poverty Level, States ( ), U.S. (2009) US Census Bureau 2009 and 2010 Currently Population Survey: Annual Social and Economic Supplements. (accessed May 18, 2011) c. Population Distribution by Race/Ethnicity, States ( ), U.S. (2009) US Census Bureau 2009 and 2010 Currently Population Survey: Annual Social and Economic Supplements. =6&cat=1&sub=1&yr=199&typ=2 (accessed May 18, 2011) d. Health Insurance Coverage of Nonelderly 0 64, States ( ), U.S. (2009) US Census Bureau 2009 and 2010 Currently Population Survey: Annual Social and Economic Supplements. table.jsp?ind=126&cat=3 (accessed May 18, 2011) a. Key Questions About Medicaid and Its Role in State/Federal Budgets and Health Reform, January b. Kaiser Health Tracking Poll, February c. Kaiser Health Tracking Poll, March. Kaiser Family Foundation/Harvard School of Public Health The Public s Health Care Agenda for the 112th Congress, January. uploa d / T.p d f. Kliff, S Waivers at Center of Health Debate. Politico, March New York Times Election Results 2008 President Map. December 9. elections.nytimes.com/2008/results/president/map.html.

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