Support for the Affordable Care Act Breaks Down Along Racial Lines

Both parties thought health reform would make pro-government liberalism attractive to more white voters. It hasn’t worked that way.

U.S. President Barack Obama (C) signs the Affordable Health Care for America Act during a ceremony with fellow Democrats in the East Room of the White House March 23, 2010 in Washington, DC.
Win McNamee/Getty Images
March 31, 2015, 5:49 a.m.

Race re­mains an im­pen­et­rable di­vid­ing line in at­ti­tudes about the Af­ford­able Care Act five years after Pres­id­ent Obama signed it in­to law.

With Obama cel­eb­rat­ing the law’s fifth an­niversary last week—and House and Sen­ate Re­pub­lic­ans mark­ing the oc­ca­sion by vot­ing again to re­peal it—polls show that whites re­main much more du­bi­ous about the law than Afric­an-Amer­ic­ans, with His­pan­ics fall­ing in between.

In the latest monthly track­ing poll by the non­par­tis­an Kais­er Fam­ily Found­a­tion, 67 per­cent of Afric­an-Amer­ic­ans and 48 per­cent of His­pan­ics, com­pared with just 34 per­cent of whites, said they had a fa­vor­able im­pres­sion of the law. Among all minor­it­ies, 55 per­cent ex­pressed a fa­vor­able view of the law.

“There is a huge dif­fer­ence [in at­ti­tudes] about the im­port­ance of achiev­ing uni­ver­sal cov­er­age by race and by party, and this re­sent­ment of gov­ern­ment in­ter­ven­tion is just very high among [white] Amer­ic­ans,” says Robert J. Blendon, a pro­fess­or at the Har­vard School of Pub­lic Health who spe­cial­izes in pub­lic opin­ion about health care.

(RE­LATED: Where Do Un­doc­u­mented Im­mig­rants Go For Med­ic­al Care?)

This en­dur­ing ra­cial con­trast con­founds the ex­pect­a­tions of both parties. As far back as Pres­id­ent Clin­ton’s ef­fort to provide uni­ver­sal cov­er­age in 1993, key Demo­crat­ic strategists have viewed health re­form as an op­por­tun­ity to con­vince skep­tic­al middle-class voters (par­tic­u­larly whites) that act­iv­ist gov­ern­ment could tan­gibly be­ne­fit their lives. Again, ex­tend­ing back to that de­bate in the 1990s, key Re­pub­lic­an strategists long feared that they were right.

In a fam­ous memo that suc­cess­fully ral­lied Re­pub­lic­ans to op­pose Clin­ton’s health care plan, the con­ser­vat­ive thinker Bill Kris­tol warned that if Demo­crats suc­ceeded in provid­ing uni­ver­sal cov­er­age it “will re­le­git­im­ize middle-class de­pend­ence for ‘se­cur­ity’ on gov­ern­ment spend­ing and reg­u­la­tion. It will re­vive the repu­ta­tion of the party that spends and reg­u­lates, the Demo­crats, as the gen­er­ous pro­tect­or of middle-class in­terests. And it will at the same time strike a pun­ish­ing blow against Re­pub­lic­an claims to de­fend the middle class by re­strain­ing gov­ern­ment.”

Now that Obama has achieved the sweep­ing health re­form that Clin­ton (as well as Richard Nix­on and Harry Tru­man) could not, none of that has oc­curred. The law is build­ing in­sti­tu­tion­al sup­port among hos­pit­als, in­surers, and to a less­er ex­tent phys­i­cians that could make it tough­er to re­peal even if Re­pub­lic­ans win uni­fied con­trol of gov­ern­ment in 2016. But polls sug­gest the ACA has done more to re­in­force than re­solve the doubts about act­iv­ist gov­ern­ment that have been grow­ing in the white middle class for many years.

Part of the law’s prob­lem with whites is that it is in­ex­tric­ably bound up in at­ti­tudes about Obama, who won only 39 per­cent of white voters in his 2012 reelec­tion, and has faced de­pressed ap­prov­al rat­ings with that com­munity through his second term. “A lot of it is par­tis­an­ship that is col­or­ing everything,” says Guy Mo­lyneux, a Demo­crat­ic poll­ster who has stud­ied at­ti­tudes to­ward the health care law.

But Mo­lyneux, Blendon, and oth­er ana­lysts across the polit­ic­al spec­trum agree the law faces a more spe­cif­ic prob­lem with many whites as well. Polls have con­sist­ently found that most whites do not view the health care law as a uni­ver­sal pro­gram that will be­ne­fit them­selves or their fam­ily. In­stead, they per­ceive it primar­ily as a trans­fer pro­gram that will help the poor and un­in­sured. “A lot of white voters as­sume that what the ACA was go­ing to do was provide health in­sur­ance to very poor people, which they think of as be­ing largely minor­ity, and they just haven’t learned enough or heard enough to con­vince them to change that as­sump­tion they’ve had from the be­gin­ning,” says Mo­lyenux.

(RE­LATED: There’s a Race Gap in the Toughest Classes at Most High Schools)

Blendon agrees. Among whites, he says, the ACA “hasn’t caught on as a uni­ver­sal pro­gram where every­body feels they are get­ting something out of it.”

In prac­tice, the evid­ence sug­gests the law is be­ne­fit­ing as many whites as minor­it­ies. When the Health and Hu­man Ser­vices De­part­ment re­cently re­por­ted that the num­ber of Amer­ic­ans without health in­sur­ance had de­clined by about one-third since the law’s pas­sage, it cal­cu­lated that 6.6 mil­lion whites, com­pared with 6.5 mil­lion Afric­an-Amer­ic­ans and His­pan­ics, had gained cov­er­age. Whites are also be­ne­fit­ing from the slow­down in the growth of premi­um costs for em­ploy­er-provided cov­er­age, and the re­duc­tion in hos­pit­al ac­quired ill­nesses and in­fec­tions, that ex­perts link in part to the law.

But those re­ceiv­ing cov­er­age through the law rep­res­ent a smal­ler share of the pop­u­la­tion among whites than minor­it­ies. And while all Amer­ic­ans are be­ne­fit­ing from im­prove­ments in qual­ity and the mod­er­a­tion of health cost growth, those gains are dif­fuse and not easy for most people to con­nect back to the ACA. “It’s not like you get an Obama­care card in the mail, like you get a Medi­care card,” says Mo­lyneux. ” Even people who are be­ne­fit­ing in some way, it’s not ob­vi­ous to them that they are. Maybe their adult child is on their policy now and they don’t know that is why they can do that.”

The res­ult is a ra­cial gap in per­cep­tions about the law’s per­son­al im­pact. In the latest Kais­er sur­vey, the share of whites who said the law had hurt their fam­ily (27 per­cent) sig­ni­fic­antly ex­ceeded the por­tion (16 per­cent) who said it had helped them. Among non­whites the pro­por­tions were al­most re­versed: 24 per­cent of them said it had helped their fam­ily, while 11 per­cent said it had hurt them. (Three-fifths of minor­it­ies and 55 per­cent of whites said the law had not dir­ectly af­fected them.) The mea­ger 16 per­cent of whites in the latest Kais­er poll who said the law had helped their fam­ily was ac­tu­ally the highest num­ber re­cor­ded in the sev­en times the sur­vey has asked that ques­tion since May 2014.

More broadly, a 2013 Na­tion­al Journ­al poll found a stark ra­cial gulf in per­cep­tions about who be­ne­fits from the law. In that sur­vey, 60 per­cent of whites said the law be­nefited people who lack health in­sur­ance and 55 per­cent said it helped the poor. But only 30 per­cent of whites said it be­nefited the middle class and just one in four said it helped people like them and their fam­ily. Only 35 per­cent of whites said the law would be­ne­fit the coun­try over­all.

(RE­LATED: Demo­graphy Is Not Des­tiny for Demo­crats

Minor­it­ies were some­what more likely than whites to see be­ne­fits for the un­in­sured (71 per­cent) or the poor (66), but vastly more likely than whites to see be­ne­fits for the coun­try over­all (58 per­cent), the middle class (58 per­cent), and people like them (51 per­cent).

All these res­ults sug­gest that most whites see the law as more akin to an in­come-trans­fer pro­gram like food stamps or wel­fare than a uni­ver­sal be­ne­fit pro­gram like So­cial Se­cur­ity or Medi­care. “In fact, a lot of people are be­ne­fit­ing who earn more than $40,000 a year, so it does have a middle-class side,” said Blendon. “But it is seen as a trans­fer pro­gram, so the an­ger about taxes [as­so­ci­ated with the law] is the an­ger you see about trans­fer pro­grams. You don’t see that an­ger about So­cial Se­cur­ity or Medi­care. The people telling you taxes are too high, what they are really re­flect­ing is an at­ti­tude to­ward trans­fer pro­grams.”

Un­der­scor­ing that point, the law faces the most fer­vent hos­til­ity from blue-col­lar whites, usu­ally the most re­cept­ive audi­ence for cri­ti­cism of trans­fer pro­grams. In the Kais­er poll, whites hold­ing at least a four-year col­lege de­gree, now split fairly closely in their over­all at­ti­tudes to­ward the law: 45 per­cent said they are fa­vor­able and 50 per­cent say they are are un­fa­vor­able. But non­col­lege whites are over­whelm­ingly neg­at­ive, with 56 per­cent un­fa­vor­able and just 29 per­cent fa­vor­able.

A sim­il­ar gap was evid­ent in the latest poll when Kais­er asked what Con­gress should do next about the law. Col­lege-edu­cated whites split al­most ex­actly in half: While a com­bined 45 per­cent said Con­gress should scale back (17 per­cent) or re­peal the law (28 per­cent), a nearly equal 44 per­cent said it should move for­ward with im­ple­ment­a­tion, or even ex­pand the plan. But just one-third of blue-col­lar whites wanted to ex­tend or ex­pand the law; a ma­jor­ity wanted to either scale it back (10 per­cent) or re­peal it en­tirely (42 per­cent.)

Minor­it­ies showed much less en­thu­si­asm about un­do­ing the law. Among non­whites, just 15 per­cent sup­por­ted re­peal, while 7 per­cent said they would scale it back. Fully 65 per­cent said they would con­tin­ue im­ple­ment­ing or ex­pand the law.

(RE­LATED: Should Obama­care Help Pay for Hous­ing?)

Those at­ti­tudes point to­ward an­oth­er key polit­ic­al ques­tion sur­round­ing the ACA: Will the con­tin­ued Re­pub­lic­an push for re­peal ali­en­ate minor­ity com­munit­ies re­ceiv­ing sig­ni­fic­ant be­ne­fits from the law? The re­cent HHS re­port, for in­stance, found that since the first open-en­roll­ment peri­od in 2013, the un­in­sured rate has ex­per­i­enced un­pre­ced­en­ted de­clines among both Afric­an-Amer­ic­ans (down 9.2 per­cent­age points) and His­pan­ics (down 12.3 points.)

Mo­lyneux says that while the re­peal push will likely ant­ag­on­ize Afric­an-Amer­ic­an voters who are the most sup­port­ive of the law, that would have re­l­at­ively little polit­ic­al im­pact since that com­munity is so re­li­ably Demo­crat­ic to be­gin with. In­stead, he says, “the key ques­tion is the Latino com­munity.”… Will the His­pan­ic com­munity come to see the health care law as an im­port­ant Demo­crat­ic ac­com­plish­ment?”

A na­tion­al sur­vey of His­pan­ics sponsored by the Robert Wood John­son Found­a­tion Cen­ter for Health Policy at the Uni­versity of New Mex­ico and con­duc­ted by Latino De­cisions offered mixed sig­nals on that front. The sur­vey, re­leased last week, found that the share of His­pan­ics with health in­sur­ance jumped from 72 per­cent as re­cently as 2013 to 82 per­cent now.

Yet the poll found only a mod­estly pos­it­ive as­sess­ment of the ACA among His­pan­ics. Ex­actly one-third of His­pan­ics said the law would im­prove their abil­ity to ob­tain in­sur­ance while only about one-fifth said it would hurt their ac­cess to in­sur­ance. The largest group—43 per­cent—said they did not ex­pect the law to change their ac­cess to cov­er­age. The res­ults were al­most identic­al when re­spond­ents were asked about the qual­ity of care they re­ceive: 34 per­cent of His­pan­ics said the law would im­prove their care, 18 per­cent said it would hurt it, and 43 per­cent said they did not ex­pect the ACA to af­fect it either way. Those sur­veyed re­turned the least en­thu­si­ast­ic ver­dict on cost: 28 per­cent said the law would im­prove the cost of health care for their fam­ily, while 29 per­cent thought it would make it worse. (An­oth­er 38 per­cent ex­pec­ted no change.)

Fi­nally, the poll un­der­scored the sheer dif­fi­culty of reach­ing this com­munity: Even after two open-en­roll­ment peri­ods, just over half of His­pan­ics still said they had either heard not much or noth­ing at all about the new health care ex­changes.

Gab­ri­el Sanc­hez, ex­ec­ut­ive dir­ect­or of the Uni­versity of New Mex­ico Cen­ter, said that among those res­ults, he viewed the key fig­ure as the 76 per­cent who be­lieve the law will either main­tain or im­prove their ac­cess to in­sur­ance. “There’s a high­er seg­ment of the Latino pop­u­la­tion who per­ceive that the situ­ation is ac­tu­ally go­ing to get bet­ter,” he told re­port­ers dur­ing a con­fer­ence call this week. “Over­all, you see a much smal­ler seg­ment that think it’s go­ing to get worse.”… This data sug­gests that Lati­nos at least are pretty op­tim­ist­ic about mov­ing for­ward in the con­text of the ACA.”

Demo­crats are hop­ing he’s right, be­cause there are no signs that white skep­ti­cism about the law is dis­sip­at­ing, des­pite the en­cour­aging news in cov­er­age and costs. In the monthly Kais­er track­ing poll, the share of whites ex­press­ing fa­vor­able views about the law has ex­ceeded 36 per­cent only two times since Janu­ary 2011; since Janu­ary 2013, white sup­port has os­cil­lated only between a low of 26 per­cent and a mea­ger high of 34 per­cent (the fig­ure in the latest poll).

Giv­en such sta­bil­ity, Mo­lyneux says that while the law could be­come “a policy boon for the coun­try” it re­mains un­likely to “be a great polit­ic­al boon for the [Demo­crat­ic] Party.”

“I hope I am wrong,” Mo­lyneux con­tin­ued, “but I don’t see it all con­geal­ing in the pub­lic aware­ness in­to some single en­tity, wheth­er it’s called Obama­care or the Af­ford­able Care Act, that gets some big cred­it in the pub­lic mind.”

Janie Boschma contributed to this article.
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