Over the past decade and a half, few if any policy issues have attracted as much political or scholarly attention as the Patient Protection and Affordable Care Act (ACA) signed into law by President Barack Obama in 2010. Although the real-world impacts of the law on health coverage and other important outcomes have been substantial, scholars, politicians, and commentators have given considerable attention (perhaps more attention) to what the public thinks of this important law, the most substantial health coverage law since the establishment of Medicare and Medicaid in the 1960s. Both academics and practitioners have considered the law as a prime example of the power of rhetoric and framing, the ability of policy to reshape politics (“policy feedback”), and the enduring importance of race to the politics of American social policy. In his new book, Stable Condition: Elites’ Limited Influence on Health Care Attitudes, which builds on some of his previously published research, Daniel J. Hopkins effectively asks, “What if it wasn’t?”
Drawing on a wealth of existing and original ACA public opinion data gathered between 2009 and 2020, Hopkins concludes that the efforts of political elites to reshape public opinion, whether through messaging (including racially charged rhetoric) or policy change, had little effect. Specifically, he demonstrates that policy feedback (chaps. 4 and 5), racial prejudice (chap. 6), and elite messaging or framing (chap. 7) are not comprehensive explanations for opinions about the ACA, even in combination. The book instead paints a picture of stable and durable public opinion on the law (established in chap. 3), both at the individual and aggregate level, with the only significant shift coming after the election of Donald Trump and Republican majorities in the 2016 election. This led to an immediate boost in ACA support, which Hopkins characterizes as a case of thermostatic public reaction against the priorities of leaders in office.
In response to a rhetorical question of why the book’s findings differ from the arguments of so much established scholarship, Hopkins offers “a straightforward, two-word answer: effect sizes. Prior research has often framed its core questions in binary ways, asking questions about the direction of effects such as ‘Are there positive policy feedbacks?’ or ‘Can framing move attitudes?’ Here we…ask not just about the existence of effects but about their substantive magnitude and political import” (p. 7). A related issue is that existing scholarship is focused on changes in attitudes, whether over time or in response to randomized experimental treatment on a survey, and thus is poorly positioned to explain the deeper roots of public opinion, particularly when it is stable. On the racial politics of the ACA for example, Hopkins concludes, “To the extent that racial divisions shape white Americans’ ACA views…these divisions operate at a distance, shaping ACA attitudes through their long-run influence on partisan divisions and on the narratives through which the public makes sense of social policies. Racial divisions set the stage more than they act the parts” (p. 143). When research is too narrowly focused on testing discrete causal hypotheses, particularly in a cross-sectional or short-term context, it is not well positioned to uncover and explain these foundational aspects of public opinion.
There is a lot to admire about Hopkins’s approach in this book. His focus on explaining the values of a key dependent variable (ACA support or opposition), rather than on testing specific causal hypotheses, allows for an appropriately broad view of a major case in policy opinion and makes the substantive size of effects a central concern rather than the usual afterthought. At the same time, the book presents a wide range of hypothesis tests, effectively engaging with the relevant literatures on their own terms even as the author takes a more comprehensive view. The result is a book that reads more like a good-faith attempt to engage with and understand the facts than an exercise in motivated skepticism. This is a book that scholars of health policy, political behavior, and policy feedback, me included, should take very seriously.
In terms of data and methods, Hopkins avoids the pitfalls of some prior work by considering a wide range of data gathered over the entire 12-year period covered by the book, including numerous original cross-sectional surveys through various firms, the Kaiser Family Foundation’s Health Tracking Poll (a repeated cross-sectional survey), and original panel survey data, as well as survey experiments and even a field experiment (pp. 172–74). He also makes use of thousands of open-ended survey responses captured over time, pairing them with data on press releases from politicians, to assess the relationship between elite and mass understandings of the ACA, a technique that has promise for the study of elites’ influence on mass opinion on issues beyond health policy.
The book is engagingly written and strikes a nice balance between being accessible to smart lay readers and speaking to a scholarly audience. Although the occasional regression table and discussion of p-values may puzzle readers unfamiliar with quantitative methods, this is a book that one could reasonably assign to an advanced undergraduate class on health politics or public opinion. At the same time, it is unmistakably a work of serious academic research.
My chief criticism of Stable Condition is that Hopkins continues the questionable tradition of studying overall favorability toward the ACA (also known as the “health reform bill…signed into law in 2010” in surveys) while knowing full well that this evaluation has little relationship with how Americans feel about the actual policies included in the legislation (pp. 59–60). This isn’t to say that a person’s overall impression of the ACA as a political symbol is not worth understanding, but I wish the book had given more attention to specific health policy beliefs as important dependent variables. After all, the notion of the ACA as a unified whole to be preserved or repealed has become more and more disconnected from real policy decisions as time has passed, with the ability of states (and, in some cases, voters themselves) to decide on Medicaid expansion as a stand-alone issue, the repeal of the hated individual mandate in 2017, and the expansion of ACA marketplace premium subsidies initiated during the COVID-19 pandemic and extended by the Inflation Reduction Act of 2022. Hopkins considers aggregate predictors of vote shares in favor of Medicaid-expansion ballot initiatives in Maine and Oklahoma (chap. 4) but only as a test of self-interest arguments about the ACA. Otherwise, the book is focused on understanding holistic evaluations of the law to the exclusion of more specific beliefs.
The good news is that Hopkins has demonstrated a solid model for future research on public opinion on all sorts of policy issues, whether related to the ACA or not. I recommend this book not only to my colleagues in the health politics and policy spheres but also to anyone seeking a better understanding of American public opinion on public policy.
