special report 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? e31(1)
Washington Montana North Dakota Minnesota Maine Vermont Oregon Nevada California Idaho Utah Wyoming Colorado South Dakota Nebraska Kansas Wisconsin Michigan New York Iowa Pennsylvania Illinois Indiana Ohio West Virginia Missouri Virginia Kentucky New Hampshire Massachusetts Rhode Island Connecticut New Jersey Delaware Maryland Arizona New Mexico Oklahoma Arkansas Tennessee North Carolina South Carolina Texas Louisiana Mississippi Georgia Alabama 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 Report 3 and Real Clear Politics 4 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.* Variable Approval of the ACA ACA Enactment, 2010 2012 2014 % of respondents Favor 42 44 40 Oppose 45 45 51 President Obama s handling of health care Approve 43 43 41 Disapprove 52 51 57 * 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). National Support for the ACA 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 e31(2)
special report Table 2. Most Important Issues among Registered Voters in the 2014 Congressional Elections, According to Polling Results.* Rank ABC News Washington Post CBS News New York Times Issue % of Respondents Issue % of Respondents 1 Economy and jobs 35 The economy 38 2 The way things are working 15 Terrorism 17 in Washington 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 Health Care and the 2014 Election 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 e31(3)
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 56 86 26 60 government Trust in the federal government to handle domestic problems Great deal or fair amount 40 28 63 34 Not very much or none at all 59 NA NA NA 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 What effect has the health care law had on the country to date? Mostly positive 33 12 56 28 Mostly negative 45 73 22 46 Not much of an effect 18 13 17 21 Approval of the Affordable Care Act Support 41 11 71 36 Oppose 51 83 19 55 If a candidate for Congress supports the 2010 health care law passed by President Obama and Congress (ACA) You would be more likely to vote for a 31 9 60 25 candidate who held this position You would be less likely 40 69 10 43 Wouldn t make a difference 27 21 28 30 What you would like to see Congress do with the ACA 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 * 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 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 e31(4)
special report 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. e31(5)
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). Implications of Survey Results 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 e31(6)
special report 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. Infoplease, 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. e31(7)