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Obtaining consensus on competing health reform preferences

July 1, 2020

Topics: Quote of the Day

By Adrianna McIntyre, Robert J. Blendon, John M. Benson, Mary G. Findling, Eric C. Schneider
Journal of Health Politics, Policy and Law, Vol. 45, No. 5, October 2020


Ten years after its enactment, public support for the Affordable Care Act (ACA) still only reaches a scant majority. Candidates for the presidency—and the sitting president—have endorsed health reforms that would radically transition US health care away from the current system upon which the ACA was built. Few opinion surveys to date have captured dominant preferences among alternative health reform policies or characterized attitudes and experiences that might be associated with policy preferences. Using a 2019 nationally representative telephone survey, this article considers how variations in political values, attitudes toward government, and experiences with the health care system relate to competing health reform preferences. Differences between those who favor Medicare for All over building on the ACA largely reflect different levels of satisfaction with the status quo and views of private health insurance. By contrast, differences between ACA supporters and those who would favor replacing it with a state-based alternative reflect sharply different political values and attitudes. Key differences remain significant after controlling for demographic, health, and political characteristics. Overwhelming public support still eludes the ACA, and reaching consensus on future directions for health reform will remain challenging given differences in underlying beliefs.


The Affordable Care Act has become a fundamental part of the US health care system in its first ten years. However, public support remains middling, with approval at 50% in April 2020 (KFF 2020). Given a choice, only about one-third of Americans most favor keeping and improving on the law; the other two-thirds are split between supporting more expansive Medicare for All reforms and letting states take the lead. Results from this survey make evident that the views, values, and attitudes that comprise each of these groups different from those who support maintaining and strengthening the ACA are not the same. Respondents who favor Medicare for All share many common values and attitudes with respondents who want to build on the ACA—and most have a favorable view of the ACA itself — but tend to be more dissatisfied with their own experiences with the current health care system, including their health care costs. In contrast, those favoring a state-based option tend to have similar levels of satisfaction as those who want to build on the ACA, but starkly different opinions on taxation and the broader role of government in health care. A broad consensus on future directions for health reform will likely continue to be difficult to achieve given these differences in underlying beliefs. However, the one key thing those who support improving the ACA and those favoring Medicare for All agree on is the need to move toward universal coverage.



By Don McCanne, M.D.

In this study, survey participants were required to choose their preference of one of three alternative reform policies. The 11 percent who did not choose an option were excluded from the results. Of the three options, one-third of the remaining participants favored keeping and improving on the Affordable Care Act (ACA), one-third favored Medicare for All, and one-third favored replacing ACA with a state-based alternative. The study then attempted to define differences in values, attitudes and experiences that might explain the differing preferences.

Actually the groups favoring ACA and favoring Medicare for All had much in common, especially agreeing that the nation needs to move toward universal coverage. Those favoring state-based reform had distinctly different political attitudes, especially in their opposition to taxation and opposition to a broad role of government in health care. The other differences between the three groups were comparatively of such minor significance that it would be more accurate to say that the participants (presumably representing the nation) were divided into two groups – two-thirds supporting comprehensive reform with a broader role for government, and one-third rejecting a major role for government. The authors in their report state, “those favoring a state-based option held more negative attitudes toward government on every measure, including saying things run by the federal government are not run too well or not well at all.”

It seems that a consensus should be able to be reached between the pro-ACA and the Medicare for All groups. The most important differences between them demonstrated in this study were in the degree of satisfaction with the status quo and in their views on private health insurance. It is likely that the great majority of privately insured Americans who remain healthy and have little need for their insurance are satisfied. It is the minority who have been deprived of care they think they should have had or who have faced financial hardship that they thought their insurance should have prevented. They need to understand that the single payer model of an improved Medicare for All would remove such barriers to care for all of us, including those who reject social solidarity.

Although the one-third who are ideologically opposed to Medicare for All will likely remain inflexible, the one-third who believe that our private insurance system is working well for them need to be better informed. The few who learn each year through unfortunate personal experiences are not enough to swing the political pendulum. We have to do a better job of educating the public at large.

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About the Commentator, Don McCanne

Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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