Case Study 6.1: The ACA Opinion Reversal — What Changed and Why

Case Study 6.1: The ACA Opinion Reversal — What Changed and Why

Background

Few episodes in modern American public opinion better illustrate the theoretical frameworks of Chapter 6 than the trajectory of public attitudes toward the Affordable Care Act (ACA) between 2009 and 2018. In the space of less than a decade, the ACA went from a law that couldn't sustain majority support in most polls to one with comfortable majority approval — without any fundamental change in its policy content. Understanding why requires applying Converse's non-attitudes framework, Zaller's RAS model, and the thermostatic model simultaneously.

The Timeline

2009-2010: Passage and initial reception. The ACA passed in March 2010 on a party-line vote after nearly a year of contentious legislative debate. During that period, Republican leaders mounted an aggressive public campaign against the law — characterizing it as a "government takeover of healthcare," warning of "death panels," and framing it as an assault on individual liberty. Public opinion polls during this period showed majority opposition. Gallup found opposition ranging from 50-53% through most of 2010. The law was deeply unpopular with Republican voters and had only modest majority support among Democrats.

2010-2016: Persistent opposition under Republican attacks. For six years, Republicans voted repeatedly to repeal the ACA (over 60 House votes by some counts) without success. During this period, Republican elite communication about the law remained consistently negative. Democrats defended it but without the sustained messaging energy that had surrounded its initial passage. Public opinion remained divided: support fluctuated between 40% and 48% in most national polls.

Late 2016-2017: The repeal threat and the reversal. In November 2016, Donald Trump was elected president with a Republican Congress, making ACA repeal a genuine legislative possibility for the first time. Within weeks, public support for the ACA spiked dramatically. Polls showed support climbing to 50%, then 54%, then 57% in some surveys — levels it had never previously reached. By early 2017, the ACA had majority support for the first time in its history.

2017-2018: Sustained majority support. Despite continued Republican efforts to repeal the law — culminating in the failed Senate vote in July 2017 — public support for the ACA remained elevated. The law that could not sustain 50% approval through six years of full implementation now consistently polled above 50%.

Analysis: Three Frameworks

The Thermostatic Explanation

The most parsimonious explanation for the 2016-2017 reversal is thermostatic: the public was reacting against the threat of policy change, not expressing any newly discovered positive evaluation of the ACA itself. For six years, the ACA was the status quo. The thermostatic model predicts that when the status quo is threatened with reversal, public demand for its preservation increases.

This interpretation is supported by the timing. Support began rising immediately after the 2016 election — before any changes to the law had been made. The thermostat wasn't responding to the law itself but to the signal that the law might be removed. This is precisely the pattern Wlezien and Erikson's model predicts: public opinion reacts against the direction of policy change, not just the level.

The RAS Explanation

The RAS model offers a complementary account. For six years, Republican elites had provided a steady stream of negative ACA communication that made anti-ACA considerations highly accessible. Democratic elites were less actively counterweighting this with positive ACA messaging. The balance of accessible considerations among persuadable, moderate voters was tilted against the law.

After November 2016, the nature of elite communication changed dramatically. Democrats, now entirely out of power, had strong incentives to defend the ACA vigorously. Democratic elected officials, advocacy groups, hospital systems, and patient groups produced a torrent of messaging about what the ACA meant for millions of beneficiaries — the 20 million newly insured, the protection for pre-existing conditions, the elimination of lifetime caps. These considerations, now freshly accessible, led persuadable voters to draw on different mental content when answering "do you support the ACA?"

The law hadn't changed. The accessibility of considerations relevant to it had.

The Non-Attitudes Explanation

Some portion of the opinion shift reflects Converse's non-attitudes. Many respondents who answered ACA questions in 2010 and again in 2017 had not thought carefully about the law in either year. Their responses in both periods were largely constructed in the moment — shaped by the most recently accessed information, the question context, and the social pressure to have an opinion on a prominent political topic. For these respondents, "changing" from opposition to support didn't reflect a genuine reconsideration; it reflected different information being accessible on different occasions.

The Measurement Construction Problem

The ACA reversal also illustrates the construction problem: which questions pollsters asked shaped what "support" meant.

Many polls during this period asked about "the Affordable Care Act" or "Obamacare" — and got different results depending on which name they used. A 2017 poll by CNBC found that significantly more respondents said they preferred the ACA to the Republican replacement plan than said they preferred Obamacare to the Republican plan — even though the two are the same law. Respondents' opinions about "Obamacare" were contaminated by their feelings about Barack Obama; their opinions about the "Affordable Care Act" were more purely about the policy.

This is not a measurement error in any simple sense. It demonstrates that the object being measured — "public opinion on the ACA" — is not a fixed thing. It is a variable that depends on what cue is used to reference it.

Discussion Questions

If the ACA's popularity rose substantially without any change in the law's content, what does this suggest about what polls were measuring before and after 2016?
A Republican strategist argues that the post-2016 ACA support spike was "manufactured" by Democratic messaging and doesn't represent genuine public preferences. A Democratic strategist argues it represents citizens finally understanding what the law does. Using the chapter's frameworks, evaluate both claims. Is either right?
How would you design a survey that could distinguish between (a) thermostatic response to repeal threat, (b) elite cue-driven accessibility effects, and (c) genuine long-term attitude change in ACA opinions?
The ACA opinion trajectory has been called "the best argument for the thermostatic model." Do you agree? What evidence would be inconsistent with the thermostatic interpretation?
What does this case suggest about the reliability of "public opinion" as a guide for policy? If opinion on a major law can swing 10+ points based on the political context rather than the law's content, should policymakers rely on it? What's the alternative?