Most Americans may be too politically biased to fairly rate the effectiveness of the Affordable Care Act, even when they are generally aware of prices in their local insurance market, according to a recent survey study that helps provide a more nuanced understanding of how polarization can erode democratic accountability.

In a paper published late last month in Public Opinion Quarterly, authors Amy Lerman and Samuel Trachtman, based at the University of California, Berkeley, found that partisan leanings “overwhelmed” most voters’ ability to accurately assess how their local ACA markets are performing, though some exceptions exist. 

For example, patients who rely on the individual ACA markets for health insurance, as well as political independents, were more likely to make objective assessments of their local marketplace, though this effect was “quite small compared to the role of partisanship,” according to Trachtman, a doctoral candidate at UC Berkeley.

“Our study highlights how polarization can dominate links between public policy performance and political attitudes that are so important to democratic accountability,” Trachtman told The Academic Times. “But it also shows that this link can be achieved — even despite high polarization — when people have direct experience with what the government is doing,” or when they do not identify as a Democrat or Republican.

These findings emerge as congressional Democrats mull plans to expand federal subsidies for ACA insurance plans. On Monday, President Joe Biden reopened enrollment in the federal health insurance marketplace for three months in a bid to get more people insured during the COVID-19 pandemic. 

The researchers' work builds on a growing body of work suggesting American voters are largely ineffective at holding their officials to account.

According to Lerman and Trachtman, individuals respond to a policy's objective conditions in three key steps: becoming aware of conditions; assessing the link between conditions and public policies; and attributing credit or blame for a policy. Prior studies had only explored one of these stages at a time, they wrote, whereas Lerman and Trachtman examined the whole picture.

“It is important to trace this entire process to fully understand the real complexity of the potential feedback loop between public policy experience and political behavior, and just how many points there are for that healthy loop to be obstructed,” Trachtman explained.

To establish objective conditions of ACA markets, the authors examined data on premiums and the number of insurers per county in 49 states plus Washington, D.C., in 2017. In a web survey conducted in June of that year, more than 2,200 people in 196 counties across 18 states were asked to guess the objective conditions of their local market. Respondents were then asked to rate the performance of their local ACA marketplace and to rate the health care law overall on a five-point scale.

Across the board, variation in actual premiums and competition by counties had no effect on individuals' assessment of their local ACA marketplace, demonstrating that most voters are unable to translate their general awareness of market conditions into an accurate objective assessment of market performance. Partisanship, however, had a strong effect on attitudes toward both the local market and the Affordable Care Act overall, and most voters gave credit for a successful health care exchange to federal leaders of their party, rather than state politicians who are often administering those markets.

When examining the link between actual premiums and voter estimates, the authors found a full-sample coefficient of 0.24, meaning that a real premium difference of $100 corresponded with an increased price estimate of around $24. This indicates that individuals generally have “some basic level of awareness” when it comes to local price levels, the researchers wrote. Coefficients for independents and those who had insurance through the ACA were 0.14 and 0.61, respectively.

The impact of partisanship on estimates was much stronger: Democrats’ and Republicans’ premium estimates differed by around $75.50, the authors found through a statistical analysis, with Republicans estimating considerably higher premiums and Democrats estimating lower premiums compared to the real prices in their respective area.

“Partisanship just played an overwhelming role in driving marketplace evaluations and policy attitudes,” Trachtman said. 

He added, "This is a problem for democratic accountability and the notion of a healthy feedback loop in which citizens reward politicians and parties for well-performing policy, and vice versa for poorly performing policy."

Independents and ACA benefit recipients, however, were more likely to rate their local insurance marketplace as performing well, especially in counties where the number of insurers increased from 2016 to 2017.

Independents were also more likely than Democrats and Republicans to attribute marketplace satisfaction to their state legislatures, demonstrating that independents may have more room to shape opinions based on policy outcomes and market conditions, Trachtman said.

Furthermore, he added, overall favorability of the ACA may be improved by adding more patients to the rolls, given that patients in the program generally have more favorable views of the law.

“The problem is that, especially when it comes to ACA marketplaces, coverage has not grown nearly as much as the designers of the law expected and hoped,” Trachtman said. “Had the ACA more quickly taken over a greater share of employer-sponsored health insurance in the U.S., I think it would have been more popular and less vulnerable to near-repeal during the Trump administration.”

It’s possible that similar patterns may be found in other U.S. health- and welfare-related policies, but more work is needed to determine how the dynamics of information processing vary by policy area, Trachtman said. Those results, however, may not be readily applicable in countries with less polarization.

“While polarization is also high in some other places, the U.S. has one of the most polarized political systems among peer countries,” Trachtman said. “This would probably lead to a greater role for policy performance in driving attitudes in other places.”

The paper, “Where Policies and Politics Diverge: Awareness, Assessments, and Attribution in The ACA,” was published Jan. 29 in Public Opinion Quarterly. It was authored by Amy Lerman, a professor of public policy and political science at the University of California, Berkeley, and Samuel Trachtman, a doctoral candidate in the Charles and Louise Travers Department of Political Science at the University of California, Berkeley. Their research was funded by grants from the Russell Sage Foundation, a nonprofit dedicated to research on social inequity and social sciences, and the National Science Foundation.