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Americans Don't Want Senate's Health Care Plan, But It's Unclear What They Do Want

Demonstrators protest changes to the Affordable Care Act on June 28, 2017, in Chicago, Illinois.
Scott Olson
Getty Images
Demonstrators protest changes to the Affordable Care Act on June 28, 2017, in Chicago, Illinois.

Americans really, really don't like the Senate bill to repeal and replace the Affordable Care Act.

Only 17 percent of U.S. adults approve of the health care bill, according to a recent NPR/Marist/PBS NewsHour poll. In fact, a majority of Americans now approve of the ACA, also known as Obamacare — but just nine months ago, that wasn't true.

So what do they want?

Maybe they want single-payer health care — a slight majority of Americans now say they would like that kind of system, according to the Kaiser Family Foundation. But then, they don't like it once they hear about the trade-offs. So maybe they simply want Obamacare to go further — that's what a plurality of respondents told NPR. Or to be more specific, they favor most Obamacare provisions...but not the individual mandate (which is needed to make the ACA work). Or they want to keep the Affordable Care Act but scrap Obamacare (or vice versa).

Some of this uncertainty is perhaps to be expected — as a certain president has pointed out, health care is "complicated." But if lawmakers are looking to Americans to know what their next move should be, they could be waiting a while. Messy, contradictory, easily swayable opinions on health care are a common theme in American politics, as it turns out.

Inconsistent, changeable opinions

Recent polls on health care show a few areas where Americans' views on health care are less than clear:

1) Single-payer

A slight majority of the population — 53 percent — approves of a single-payer system, according to a new Kaiser Family Foundation poll, up from 39 in the early 2000s.

But then, the Kaiser pollsters found that they could easily — and substantially — swing that 53 percent by presenting people with potential arguments for and against a single-payer system.

When people heard the argument that the system would "give the government too much control over health care," opposition rose from 40 to 62 percent. But on the other hand, when presented with the argument that a single-payer system would "reduce health insurance administrative costs," the share of Americans in favor swung from 55 to 72 percent.

...all of which makes logical sense (people can be swayed by arguments for and against a particular policy — who knew?). But it suggests that it may be a mistake to take Americans' support or opposition for a given health care policy at face value.

Moreover, in a more intense debate over single-payer, all of these arguments would be made at once, meaning many Americans could easily be swung from one side to another or simply left in a "don't know" place.

2) Obamacare is relatively popular now. It wasn't before.

Obamacare was never a super-popular policy. But it did suddenly become more well-liked just after President Obama left office. According to data from Gallup, the law hit its highest popularity ever in April, at 55 percent approval — the first time it ever had majority support in Gallup's polling (which began in 2012). And that swing was despite the fact that nothing major changed in Obamacare in recent months that would easily account for that swing.

3) Government responsibility for health care has also grown more popular

Relatedly, Americans during the Obama presidency were closely divided over whether the government is responsible for making sure "all Americans have healthcare coverage," and at times a majority believed it was not the government's responsibility.

But before the Obama presidency, a majority of Americans consistently said yes, and a majority once again do, according to data from the Pew Research Center and Gallup.

4) Only some of Obamacare is popular

When it comes to Obamacare, Americans tend to like many of the provisions: they like people being able to stay on their parents' insurance until age 26, and they like the idea of exchanges. But they don't like the individual mandate — the fact that people must buy insurance or pay a penalty. In fact, as the Kaiser Family Foundation found, out of seven Obamacare provisions, the individual mandate was the only one without majority support.

"The elements of the Affordable Care Act are more popular than the act itself," said Kathleen Weldon, director of data operations and communications at the Roper Center for public opinion. "And that's largely a political question."

Again, this isn't necessarily surprising — the threat of a penalty is understandably less appealing to many than the convenience and security of the age-26 provision. But it does show that what Americans want doesn't always match up with what is feasible — that individual mandate is a big part of what makes the Affordable Care Act work.

"It would be very hard to put together a functional health policy that wouldn't have some elements that people disliked," said Weldon.

5) Obamacare vs. ACA

As of February, 35 percent of Americans didn't know the Affordable Care Act and Obamacare were the same, according to polling organization Morning Consult...a fact famously hammered home when late-night TV host Jimmy Kimmel asked people on the street of Los Angeles whether they favored the Affordable Care Act or Obamacare.

None of this is new

Inconsistent opinions on health care have been around for a long time. In one 2001 review of 50 years of public opinion data, for example, experts remarked that "it is striking to see how many conflicting views the public holds on health policy issues," before laying out an array of messy public views:

"On the one hand, Americans report substantial dissatisfaction with our mixed private/public health care system and with the private health insurance and managed care industries. A majority of Americans indicate general support for a national health plan financed by taxpayers, as well as increased national health spending. On the other hand, these surveys portray a public that is satisfied with their current medical arrangements, in many years does not see health care as a top priority for government action, does not trust the federal government to do what is right, sees their federal taxes as already too high, and does not favor a single-payer (government) type of national health plan."

Much of this sounds familiar today — indeed, a majority of Americans now believe that it's government's responsibility to make sure people have care, but an overwhelming majority of Americans also distrusts the government.

"Over the years these conflicts in beliefs have been difficult to resolve in legislative debates, particularly around the issues of large-scale national health care reform. This is likely to remain the case in the years ahead" they wrote — something lawmakers on Capitol Hill know all too well.

So what do Americans want?

Americans' views on health care are hard to understand for a number of reasons. One is a lack of knowledge. Some of that knowledge is basic — not knowing there is no difference between the ACA and Obamacare, for example — but many Americans may also not understand how the individual mandate makes other parts of Obamacare work.

Another reason is fear.

"There are some things we do know. Americans fear big changes on something that is an acutely sensitive subject," said Karlyn Bowman, an expert on public opinion at the right-leaning American Enterprise Institute.

She compares it to another policy area Congress continually talks about overhauling.

"In tax reform, change is not at all concerning. It's just so interesting," said Bowman. "[Tax policy] is so much less sensitive than health care, which scares the heck out of us because we don't understand it."

But that fear is nuanced. People like the broad idea of change, said Ashley Kirzinger, senior survey analyst at the Kaiser Family Foundation, a health policy research organization. But it's the particulars that scare people off.

"People kind of have this enthusiasm for health reform," she said. She points to the Affordable Care Act. "Once it became a plan that had pros and cons and winners and losers, favorability tends to fall off rather dramatically."

But then, it's those very particulars that may have made more Americans suddenly decide they approve of Obamacare.

"A lot of the attitudes towards the ACA and why we're seeing this trend upwards in favorability is because people weren't quite sure what was in it, and once they're hearing about benefits being taken away, then it's really like, 'Oh, but we really liked that.'"

And then there's politics. On all of these questions, there are, of course, sharp political divides driving people's opinions. The Affordable Care Act became widely known as Obamacare, meaning that many Americans (that is, those who know the two are synonymous) may have linked their approval of the act with their approval of Obama.

Given all this, there are still at least a couple of constants in Americans' views on health care. Kinzinger says one pops up over and over again.

"Always lower costs," she said. "When individuals say they want health care reform, what they mean is they want to reduce their own costs when it comes to health care. Premiums, deductibles, any of that. It's all about cost."

But most Americans have a more selfless instinct as well, Bowman added.

"[Americans] generally want us to try to cover more people, to give more, because we're such a generous people," she said. "We really want to move to that end. But I don't think we're very knowledgeable about specifics."

It's not that people's opinions don't matter or that they're always unclear — clearly, Americans dislike the Senate bill (according to an Axios analysis, it's the most unpopular major legislation in 30 years).

But what they want is also hard to deliver — plenty of politicians would certainly like to know how to bring down America's extremely high health care costs once and for all, and to make sure all Americans can get health care coverage if they want it. But doing so without scaring voters too much, whether it's by trade-offs or the simple act of overhauling the system, may well be impossible.

Copyright 2021 NPR. To see more, visit https://www.npr.org.

Danielle Kurtzleben is a political correspondent assigned to NPR's Washington Desk. She appears on NPR shows, writes for the web, and is a regular on The NPR Politics Podcast. She is covering the 2020 presidential election, with particular focuses on on economic policy and gender politics.