The 2010 Affordable Care Act (ACA) was one of the most significant—and controversial—regulatory overhauls of health care coverage in U.S. history. The ACA affected millions of Americans by increasing access to Medicaid and reducing the costs of health insurance and health care in general.

While the ACA continues to shape U.S. health care policy at the highest levels, a new study from the Texas A&M University School of Public Health is one of the first to explore the public’s perceptions of the ACA more than a decade after its hotly debated implementation.

“Previous major health care reform bills such as Medicaid and Medicare were passed through highly partisan efforts, but as time passed after their implementation, the initial controversy died down,” said Simon Haeder, PhD, an associate professor with the Department of Health Policy and Management, who led the study. “We wanted to find out if this was the case with the ACA, as well as how far any conflict might reach into the ACA’s specific policies and whether threats to the ACA affected public opinion.”

For the study, Haeder and a colleague from Utah Valley University surveyed a demographically diverse population of 6,066 adults in the United States over a two-week period in July 2020. The survey built on previous studies by introducing the topic to respondents using one of three different labels: the 2010 health reform law, the ACA, or Obamacare. In addition, the survey for half of the respondents focused on the potential dismantling of the ACA through the California v. Texas lawsuit that was then in front of the Supreme Court. The lawsuit challenged the ACA’s constitutionality after the repeal of the individual mandate penalty.

An analysis of the survey experiment found that perceptions of the ACA are still greatly divided based on political partisanship and race, and that the threat posed by the California v. Texas lawsuit did not have much of an effect on public attitudes.

“Partisanship had the greatest effect regarding favorability of the ACA,” Haeder said. “In every case—for the ACA as a whole and also for its specific policies—the differences between Republicans and Democrats were statistically significant and substantial.”

Haeder noted that using different labels for the ACA also resulted in statistically significant differences based on partisanship, but these effects pertained only to assessments of the ACA as a whole.

In addition, the degree of respondents’ racial resentment (defined as “favoring” or “disfavoring” other races using a common survey approach) produced results similar to those for partisanship. Respondents with lower racial resentment showed substantially higher support for the ACA in general and for three of its components—Medicaid expansion, marketplace subsidies and coverage of young adults—but not for coverage for pre-existing conditions.

Finally, the threat to the ACA posed by the California v. Texas case was found to have little effect on public perceptions of the ACA. Any effects were relatively small, and the gap between political parties and racial attitudes remained the same across all aspects studied, Haeder said.

“Our study suggests that opinions in the public realm—like the political—remain sharply divided even more than a decade after the ACA was passed,” Haeder said.

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