Information, Partisanship, and Public Support for Health Insurance Requirements in the United States

The passage of the Patient Protection and Affordable Care Act in 2010 (ACA) was marked by substantial controversy around the extent to which government can and should place requirements (i.e., “mandates”) on citizens to obtain health insurance. Democratic leaders, including President Barack Obama, argued that the federal “individual mandate” included in the bill was a justified exercise of federal authority that would provide access to health coverage for an estimated 45 million uninsured Americans. Citing the 10th Amendment to the U.S. Constitution, Republicans countered that “Obamacare” would constitute an illegitimate intrusion by the federal government into state-level matters. In fact, a resolution passed by the mostly Republican South Carolina General Assembly (Resolution 424, 118th Session, 2009-2010) argued that the state had a historical and constitutional precedent for regulating health care and that the federal government was depriving states of their rights to regulation, thereby limiting state citizens’ free choice regarding medical coverage. Similar language appeared in state bills across the country, becoming a rallying cry for Republicans to oppose the federal health care mandate. In the end, the ACA passed Congress without a single Republican vote and was signed into law by President Obama.


Introduction
The passage of the Patient Protection and Affordable Care Act in 2010 (ACA) was marked by substantial controversy around the extent to which government can and should place requirements (i.e., "mandates") on citizens to obtain health insurance. Democratic leaders, including President Barack Obama, argued that the federal "individual mandate" included in the bill was a justified exercise of federal authority that would provide access to health coverage for an estimated 45 million uninsured Americans. Citing the 10 th Amendment to the U.S. Constitution, Republicans countered that "Obamacare" would constitute an illegitimate intrusion by the federal government into state-level matters. In fact, a resolution passed by the mostly Republican South Carolina General Assembly (Resolution 424, 118 th Session, 2009-2010) argued that the state had a historical and constitutional precedent for regulating health care and that the federal government was depriving states of their rights to regulation, thereby limiting state citizens' free choice regarding medical coverage. Similar language appeared in state bills across the country, becoming a rallying cry for Republicans to oppose the federal health care mandate. In the end, the ACA passed Congress without a single Republican vote and was signed into law by President Obama.
The debate over government-mandated health insurance continued the 2012 presidential campaign. The contest for the Republican nomination featured a front-runner-and eventual winner-who had signed a state law including a health insurance mandate: former Massachusetts Governor Mitt Romney. During the nomination campaign, Romney's rivals argued that he was the wrong candidate to face the incumbent, President Obama, given his previous support for "Romneycare." For example, in a December 11, 2001 debate between the Republican candidates, Texas Governor Ricky Perry said that Romney wanted his state policy to be "the model for the country," telling him, "you were for individual mandates, my friend." Romney countered these arguments by emphasizing the distinction between state and federal mandates and his opposition to a one-size-fits-all [states] approach. As Romney was securing the Republican nomination, the U. S. Supreme Court issued a June 28, 2012 ruling that upheld the core of the ACA. The decision did not settle the debate over health insurance mandates, however; indeed, Romney and Obama traded arguments over the issue throughout the course of the general election campaign that ultimately resulted in the latter's reelection.
During all of this, the issue of health insurance mandates received extensive attention in news media coverage. Figure 1 depicts trends in coverage of Obama and Romney in conjunction with health insurance mandates or requirements, along with coverage specifically mentioning "Obamacare" or "Romneycare." 1 As the graph illustrates, these topics drew a high volume of coverage during the height of the Republican nomination campaign and on into the summer, peaking in March 2012 (when the U.S. Supreme Court held its hearings on the case) and again in June 2012 (when the same court made its ruling). Thus, it seems likely that many members of the public were exposed to the polarized partisan messages about government health insurance requirements. Less clear, however, is how the members of the general public and specific partisan audiences actually responded to the distinction between federal and state requirements or how they responded to such requirements when associated with their principle political architects, Obama and Romney.
To address these questions, we draw on public opinion data from a question-wording experiment embedded within a nationally representative sample survey of U.S. adults.

Abstract
We ask whether including information about the level of government and policy actor involved affects public opinion on health insurance requirements. To answer this question, we examine data from a question wording experiment embedded in a nationally representative telephone survey (n=906) that randomized whether a health insurance requirement was presented as a federal or state requirement and as being signed by a specific leader (President Barack Obama for the federal requirement or former Massachusetts Governor Mitt Romney for the state requirement). For the sample as a whole we found no statistically significant differences in support across the different versions, suggesting that the state/federal distinction may be unimportant to citizens. We also found that associating Obama with the federal requirement moved opinion among Democrats whereas associating Romney with the state requirement failed to move opinion among Republicans (but did sway independents).

Information, partisanship, and public opinion
A sizable body of research demonstrates that exposure to political information-including cues from partisan elites [1] and frames that emphasize particular considerations [2] can influence issue opinions at the individual level. In the context at hand, one recent study indicates that information about elite support for health care reformspecifically, Obama's stance-shaped public opinion about the issue in conjunction with racial attitudes. To be sure, this does not mean that exposure to information will inevitably shape opinion. The emergence of information effects can depend on a range of factors, including the credibility of the information's source and the extent to which that information resonates with audience member's prior values and beliefs [3]. For example, previous studies have shown that the receiver's party identification can moderate the impact of elite cues and frames [4] on issue opinions. With this in mind, we examine how varying the level of government (federal or state) and the actor associated with the policy (Obama or Romney) influences support for health insurance requirements not among only the general public but also among three partisan subgroups: Democrats, independents, and Republicans [5,6].

Data and Measures
Our data come from a telephone survey of a representative sample of 906 adults living in the continental United States. The survey was administered by Princeton Survey Research associates International (PSRAI) from May X X to June YY, 2012 2 using a dual sampling frame that included both landline (n=551) and cell phone (n=355) respondents. The response rate, calculated using the American Association for Public Opinion Research's (AAPOR) RR4, was 12.5 percent and reflects refusals as well as non-contacts. The contact and cooperation rates were 19 and 67 percent, respectively. The data are weighted to correct known demographic discrepancies related to sex, age, race-ethnicity, region, education, count population density, and household size and phone lines. The sampling error for the full sample is ± 3.9 percentage points. Support for health insurance mandates was gauged by asking respondents for their opinions on "requirements" that "all" have health insurance. To assess the effects of the level of government and the leader associated with the requirements, we randomly assigned respondents to one of five different question wordings. 3 The baseline version simply asked whether respondents favored or opposed "a requirement that all people have health insurance." A second version framed policy at the federal level and asked "Do you favor or oppose a federal requirement that all Americans have health insurance?" A third version framed policy at the state level and asked "Do you favor or oppose a state requirement that all state residents have health insurance?" A fourth version framed policy at the federal level and added a reference to Obama asking "Do you favor or oppose the federal requirement, signed by President Barack Obama, that all Americans have health insurance?" and a fifth version had a state frame and included a reference to Romney, asking "Do you favor or oppose the state requirement, signed by former Massachusetts Governor Mitt Romney, that all state residents have health insurance?" To allow for analysis across partisan subgroups, the survey also included a standard three-category (Democrat, independent, or Republican) self-report measure of party identification.

Results
Our survey results reveal that respondents exhibited evenly divided opinions on health insurance requirements. Slightly more than a majority (51%) favored health insurance requirements, while just under a majority (49%) opposed them. Support varied significantly by party ID (χ 2 (df=2)=136.9, p<.01) with Democrats (78%) expressing the highest levels of support, followed by independents (46%), and Republicans (27%). These partisan differences are not surprising given the polarized nature of the public debate about the health insurance. In our opinion, the real question is whether or not explicit political communication regarding the level of government and or chief policy Note: Searchterms included "Obama" AND ("Health insurance Requirement" OR Health insurance Mandate") or "Obamacare"/"Romney" AND ("Health insurance Requirement" OR Health insurance Mandate") or "Romney care". maker might influence these opinions. Figure 2 provides results from our question wording experiment. Among the sample as a whole we find that opinion about health insurance requirements do not vary significantly across the five different question wordings (χ 2 (df=4)=3.63, n.s.). Support in the baseline condition (49%) did not differ discernibly from support in either the federal (50%) or state (49%) conditions; nor did it differ discernibly from support in either the Obama-federal (55%) or Romney-state (55%) conditions. At first glance, these null findings may seem surprising. A closer look at effects among partisan subgroups, however, reveals that some of the treatments mattered for some respondents. Table 1 presents a series of logistic regressions predicting support for health insurance requirements within each partisan subgroup (Democrats, independents, and Republicans) in which a series of dichotomous variables captured each of the question wording treatments (with the baseline condition serving as the reference category). In addition, Figure 3 depicts support in each condition by partisanship. The results here indicate that among Democrats, support for a health insurance requirement was significantly-and sizably-greater in the Obama-federal condition (92%) than in either the baseline condition (78%) or the Romney-state condition (69%). In contrast, none of the question wording treatments significantly influenced support among Republicans. The Romney-state version, however, did increase support among independents relative to the baseline (57% versus 36%).

Conclusion
We set out to examine the extent to which public opinion on health insurance requirements depends on the level of government and political leader, if any, associated with them. Although Mitt Romney frequently argued that his state-level requirement was more in line with Republican and conservative values than a federal-level requirement, we find no evidence that this distinction mattered to the public in general or Republicans in particular. Nor did attaching Romney's name to a state-level requirement sway either the general public or Republicans. Romney's association with a state requirement did, however, boost support for such a requirement among independents. We can only speculate about what lies beneath this effect, but one possibility is that independents were swayed by the expectations-defying nature of the information they received; a Republican supporting health insurance requirements suggests comprise or a willingness put policy ahead of politics.
Meanwhile, Obama's association with the federal requirement mattered to one audience: Democrats. Support for health insurance requirements was high across the board among members of the president's party, but such support was almost universal among this subgroup when the question specifically attached his name to the federal requirement. Interestingly, Obama himself embraced the term "Obamacare" in the first presidential debate on October 3, 2012. In discussing how he would reduce federal spending, Romney said, "Obamacare is on my list. I apologize, Mr. President; I use that term with all respect." "I like it," was Obama's reply. Our results suggest that Obama's endorsement likely mattered to his "base," whereas Romney's own base was moved by neither the substance of his argument nor his own political association with a state mandate.