Affordable, quality health care. For everyone.

The Affordable Care Act’s Missing Consensus

The Issue

Ten years after the Affordable Care Act (ACA) became law, the most sweeping health reform legislation in decades has yet to garner the support of more than a slim majority of Americans. During this presidential campaign season, there are now calls to transform U.S. health care, potentially upending the system upon which the ACA was built. Drawing on findings from a national public opinion survey, researchers from Harvard University and the Commonwealth Fund examined values, attitudes, and experiences associated with competing preferences regarding the direction of health reform in the United States.

What the Study Found

  • One-third of Americans say that keeping and improving the ACA is their most-preferred direction for health system reform.
  • The remaining two-thirds are equally divided between wanting to replace the ACA with a “Medicare for All” type of reform and giving individual states the authority and funding to chart their own path to reform.
  • Those who favor the Medicare for All approach are more likely than those who favor keeping or improving the ACA to rate the health care system as fair or poor (75% vs. 66%, p = .01) and more likely to have an unfavorable opinion of employer-based insurance (41% vs. 27%, p < .001). In both cases, these opinions are informed by personal experience with the health care system.
  • People who favor a state-based option over the ACA are more likely to rate the health care system as good or excellent (48% vs. 33%, p < .001) and less likely to have unfavorable views of employer-based insurance (14% vs. 27%, p < .001).

Respondents who favor Medicare for All share many common values and attitudes with respondents who want to build on the ACA . . . but tend to be more dissatisfied with their own experiences with the current health care system.


The Big Picture

Those who prefer the ACA as a foundation for future health reforms are generally more content with the status quo compared to those who favor Medicare for All. Although a majority of ACA supporters believe it’s the government’s responsibility to make sure all Americans have health insurance and would be willing to pay more in taxes to ensure everyone has coverage, these beliefs are more pronounced among people who prefer Medicare for All.

Meanwhile, the roughly one-third of Americans who favor leaving health care policy to the states are “much more staunchly opposed to growing governmental power and paying taxes to support universal coverage,” the researchers say.

The Bottom Line

Despite their differences over which policy to pursue, people in favor of improving the ACA and people who prefer Medicare for All both agree that the U.S. needs to get to universal coverage.

Publication Details

Publication Date: July 2, 2020
Contact: Bethanne Fox, Vice President, Outreach and Strategy, The Commonwealth Fund
Summary Writer: Christopher Hollander

Adrianna McIntyre et al., “The Affordable Care Act’s Missing Consensus: Values, Attitudes, and Experiences Associated with Competing Health Reform Preferences,” Journal of Health Politics, Policy and Law, published online June 19, 2020.


Adrianna McIntyre
Teaching Fellow and Ph.D. Candidate in Health Policy, Harvard T.H. Chan School of Public Health
Robert J. Blendon
Richard L. Menschel Professor of Public Health and Professor of Health Policy and Political Analysis, Emeritus
Acting Director, Division of Policy Translation and Leadership Development, Harvard T.H. Chan School of Public Health
John M. Benson
Managing Director, Harvard Opinion Research Program, Harvard University
Mary G. Findling
Research Associate, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health
Eric C. Schneider, M.D.
Senior Vice President for Policy and Research, The Commonwealth Fund