What Health Reform Tells Us about American Politics.

The passage and initial implementation of the Affordable Care Act (ACA) were imperiled by partisan divisions, court challenges, and the quagmire of federalism. In the aftermath of Republican efforts to repeal the ACA, however, the law not only carries on but also is changing the nature of political debate as its benefits are facilitating increased support for it, creating new constituents who rely on its benefits and share intense attachments to them, and lifting the confidence of Americans in both their individual competence to participate effectively in politics and that government will respond. Critics from the Left and the Right differ on their favored remedy, but both have failed to appreciate the qualitative shifts brought on by the ACA; this myopia results from viewing reform as a fixed endpoint instead of a process of evolution over time. The result is that conservatives have been blind to the widening network of support for the ACA, while those on the left have underestimated health reform's impact in broadening recognition of medical care as a right of citizenship instead of a privilege earned in the workplace. The forces that constrained the ACA's development still rage in American politics, but they no longer dictate its survival as they did during its passage in 2010.

Affordable Care Act Moving to New Stage of Public Acceptance.

The Affordable Care Act (ACA) was enacted in a deeply polarized context, and it has endured multiple challenges to its implementation and its very existence that continue to this day. Yet, we find that the law is entering a new phase of acceptance among the American public, such that it presents political risks to politicians who would dare to weaken it. We have conducted a panel study of Americans' public opinion on the ACA since 2010, returning to the same respondents every two years to ask the same questions. This approach, which is essential for tracking change, reveals that support for the ACA is growing and the most intense opposition is receding. It also shows that Americans' sense of the law's impact on their lives is at least holding steady and in some respects growing. Most strikingly, those who feel favorably toward the law are more engaged politically than those who oppose it, and they are more likely to take it into account when they vote. These trends indicate that the law, despite the legal and political obstacles it still confronts, is becoming more firmly established in public opinion and through patterns of political participation.

Liking Health Reform But Turned Off By Toxic Politics.

Six years after the Affordable Care Act (ACA) became law, the number of nonelderly Americans with health insurance has expanded by twenty million, and the uninsurance rate has declined nearly 9 percentage points. Nevertheless, public opinion about the law remains deeply divided. We investigated how individuals may be experiencing and responding to health reform implementation by analyzing three waves of a panel study we conducted in 2010, 2012, and 2014. While public opinion about the ACA remains split (45.6 percent unfavorable and 36.2 percent favorable), there have been several detectable shifts. The share of respondents believing that reform had little or no impact on access to health insurance or medical care diminished by 18 percentage points from 2010 to 2014, while those considering reform to have some or a great impact increased by 19 percentage points. Among individuals who held unfavorable views toward the law in 2010, the percentage who supported repeal-while still high, at 72 percent-shrank by 9 percentage points from 2010 to 2014. We found that party affiliation and distrust in government were influential factors in explaining the continuing divide over the law. The ACA has delivered discernible benefits, and some Americans are increasingly recognizing that it is improving access to health insurance and medical care.

Why public opinion changes: the implications for health and health policy.

Research on stasis or change in public opinion toward health, health policy, and medical care tends to focus on short-term dynamics and to emphasize the impact of discrete messages communicated by individual speakers in particular situations. This focus on what we term "situational framing," though valuable in some respects, is poorly equipped to assess changes that may occur over the longer term. We focus, instead, on "structural framing" to understand how institutionalized public health and health care policies impact public opinion and behavior over time. Understanding the dynamics of public opinion over time is especially helpful in tracking the political effects of the Patient Protection and Affordable Care Act of 2010 as it moves from the debate over its passage to its implementation and operation.