In 2010, the last time Democrats controlled both houses of Congress and the presidency, they used the opportunity to pass sweeping health care reform legislation known as the Affordable Care Act, or Obamacare.
But that legislative push was hardly easy. It divided many Democrats, and it ultimately came with an electoral price. In the midterm elections that year, Republicans won their largest share of seats in the House of Representatives since the 1940s, while Democrats who backed the ACA saw their vote share drop by an extraordinary 8.5 percentage points on average.
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Now, though, Democrats are back in the driver’s seat, with unified control of the federal government thanks to their Senate wins in Georgia. So, what lessons from their 2010 signature accomplishment should they apply to their efforts to pass legislation in 2021, whether it’s on COVID-19 or climate change?
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As a political science professor studying public perceptions of the ACA, I see two core lessons for Democrats to keep in mind. First, to stop high-profile laws from becoming unpopular, it helps to keep them simple. And the ACA was anything but: It sought to increase access to health insurance through a complex patchwork of regulations and other policies, which included creating new health insurance exchanges, expanding Medicaid, adding new rules to guarantee insurance access regardless of preexisting conditions, and mandating that all Americans obtain health insurance.
Second, when the public evaluates a complex, multifaceted policy, like the ACA, there is a tendency to focus on its least popular parts. Most of the ACA’s major provisions were actually pretty popular. In a January 2010 Kaiser Family Foundation poll, for instance, 67 percent of respondents said that they were more likely to support health care legislation that created insurance exchanges, while 62 percent said the same about expanding Medicaid. Yet, Obamacare as a whole was viewed unfavorably from 2011 until 2017. That was, in large part, due to one unpopular provision in the law: the individual mandate. In that same 2010 KFF poll, 62 percent said that the health insurance mandate made them less likely to support the bill. And for millions of Americans, the ACA became synonymous with the individual mandate.
The complexity of the ACA also masked its impact to a degree. For instance, the ACA’s exchanges should have fostered support for the law — after all, they enabled millions of Americans to get insurance, often with subsidies averaging thousands of dollars. Yet, as Cornell University’s Will Hobbs and I find in our preprint, the 2014 rollout of the exchanges did not increase support for the ACA. In part, that’s because the exchanges relied on private insurers, and so the government’s role in facilitating the insurance was obscured. The exchanges were also designed to be bolstered by the individual mandate, but given the mandate’s unpopularity, it provoked a demonstrable backlash. We found, too, that exchange customers felt more negative toward the ACA if local premiums spiked. Once again, losses loomed larger than gains.
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Not all parts of the law were unsuccessful, though. Take the ACA’s expansion of Medicaid. It extended coverage to most low-income adults, including adults without children, and is a key source of support for the ACA. In fact, in a 2019 article I co-authored with then-University of Pennsylvania researcher Kalind Parish, we found that poorer residents in states where Medicaid had been expanded were notably more supportive of the ACA after its implementation. That’s evidence that tangible, positive experiences with the law had an effect, too.
Policy design clearly plays a role in a law’s popularity. And policies that impose clear costs or obscure benefits are likely to be less popular, as we saw with the ACA. That said, there is one more key lesson here: It’s really hard for politicians to control the messaging of any piece of legislation. According to research I conducted for a 2018 article, the messaging that the two parties used in the initial debates around the ACA did little to influence public opinion, or even the words Americans used to explain their attitudes toward the ACA. The rhetoric used by politicians — remember former Alaska Gov. Sarah Palin’s infamous Facebook post suggesting that the ACA would create “death panels” — corresponded very little with the language used by Americans when talking about the ACA. This echoes other research that has also found little evidence of opinions shifting in response to messaging. This holds true even among groups for whom the messaging is targeted (like older Americans). Rather, the key to successful legislation seems to hinge on how the policy is designed, not how it is discussed.
And that makes some sense, as the central goal of legislating is to shape policy, not public opinion. But this is not to say the two aren’t closely related. After all, the ACA’s initial unpopularity undermined the Democrats’ ability to defend it, leaving the law politically vulnerable for years. It also had very real electoral consequences when Democrats lost the House in 2010. So, as the Democratic Congress gets ready to pass its agenda, it may be wise to internalize these lessons from the ACA to avoid the same pitfalls.