Today in Obamacare: a polling expert explains why the health law is looking more popular

The Friday Interview: Obamacare polling expert Robert Blendon

Editor’s note: Today in Obamacare is testing out a new regular feature, the Friday Interview. Each week, we plan to sit down with an expert in health policy to get a new perspective on the constantly shifting landscape. This will likely range from an enrollment counselor who can talk about what Obamacare looks like on the ground to a senator making decisions about the law’s future. First up, we have a Harvard professor who has spent decades studying public opinion on health care to make sense of the law’s sharply improving poll numbers.

Like this feature? Don’t like it? Have someone you want to suggest? Drop me (Sarah Kliff) a line at sarah@vox.com.

Obamacare’s polling numbers sure are looking up.

Two new polls today — one from Pew and another from the Kaiser Family Foundation — both show record-high approval ratings for the Affordable Care Act.

But it turns out if you’re a professional pollster, this isn’t really the important question to watch. What matters more is looking at Republicans specifically, and whether their views — who Republican legislators will care about — are shifting.

“I don’t think [the higher approval ratings] means opinions are changing,” says Robert Blendon, a professor of health policy and political analysis at the Harvard Kennedy School of Government. “I think what is changing is that people are becoming aware that saying ‘disapprove’ may mean dropping 21 million people from coverage.”

Blendon has spent decades surveying America on health policy. He argues, convincingly, that the change in approval numbers doesn’t actually matter that much to the legislative debate. Most of the people changing their minds to become more favorable about the law are Democrats and independents. That won’t worry congressional Republicans very much.

Instead, he thinks Republican pollsters are watching a different trend much more closely: Republicans shifting their views from supporting repeal to supporting repeal and replace.

Blendon and I spoke Thursday morning about why he thinks this is the most important question Republican pollsters are watching — and why he expects Medicaid expansion to become the most challenging issue for Republicans to address. What follows is a transcript of our conversation, lightly edited for clarity and length.

Sarah Kliff

Let’s start with the big, basic question: How do you think about the recent uptick in approval ratings for the Affordable Care Act? Is it big enough that you consider it significant?

Robert Blendon

The standard tracking question we’ve been asking for three years is do you approve or disapprove of the Affordable Care Act. I think what is changing is people are becoming aware that saying “disapprove” may mean dropping 21 million people from coverage.

I don’t think it means that opinions are necessarily changing. Before, you might have people thinking, “I don’t like the mandate; I think it’s too expensive.” These people who said “disapprove” might not be in love with the bill, but I think now they’re thinking more seriously about what their answer means.

The implications of what it means to say you disapprove have changed for some people. Generally, the polls show the biggest shift [to approve] is among Democrats and independents. The growth is not that great among Republicans.

Sarah Kliff

So let’s say you’re a Republican legislator or pollster. What are you thinking about this new polling? Is it worrisome — or, like you’re suggesting, it might not actually suggest a shift in opinions?

Robert Blendon

A general poll doesn’t reflect voters very much anymore. A general poll would have had Donald Trump losing substantially and the Democrats winning the House. About 45 percent of people in general polls don’t vote at all. What you saw in the election was that Republican voters came out at a very high rate. They got high turnout from non-minority people from small towns.

The minute the election is over, we switch back to general polls of everybody. For people in the House or Senate, they know a general poll doesn’t reflect who voted for them. So what’s important to me, if I’m in the House, is whether Republicans are changing their minds. That is really the key.

Sarah Kliff

So what are we seeing on that front? Are Republicans changing their minds about the Affordable Care Act?

Robert Blendon

I do think there is change, but it’s not identical [to the approve/disapprove change]. What we’ve seen among Republicans is a movement from those who support just repeal to those who support repeal and replace. We did some polling in the primaries, and we had about 65 percent of Republican voters picking repeal only. They were angry about the law, but they weren’t thinking about the implications. Now you’re seeing some shift toward supporting repeal and replace instead.

I am sure somebody who works for the party has more demographics on who this is, whether it’s small-town America that is shifting, for example, or somewhere else. But among Republicans, this is what you want to know. It’s what the House members should ask from their pollsters: Are Republicans changing their opinion?

I think Republicans are suddenly realizing this issue has real consequences. Their dream is some big change that keeps a lot of people covered, but I don’t think any of them have an idea of how to get there.

Meanwhile, the politics of Medicaid and pushback from Republican governors is getting to be the biggest issue. The people who lose Medicaid have the name of their state on their insurance card, so the governor gets held responsible. So Congress will be facing Republican governors who will criticize them. I think the Medicaid issue will get a lot more attention in the next month.

Sarah Kliff

How do you think the politics of repealing Medicaid expansion could play out for Republican governors? My understanding was lower-income people vote at lower rates, which makes programs that serve a lower-income population harder to protect.

Robert Blendon

Lower-income people do tend to vote at lower rates, especially in off-year elections. But Medicaid will be a visible issue because you’ll suddenly have huge bills at hospitals that are unpaid. If you hear the hospitals are in trouble, it sounds like something is wrong.

You’re going to have stories of people losing coverage. In general, the backlash from lower-income voters is less strong than backlash from seniors. That’s why Medicare battles are always so hard. But this will be visible, and various organized groups will blame the governor for letting this happen. ... The governors will be held responsible when community health centers report large deficits or rural hospitals say they have all these unpaid bills. A lot of local things will be attributed to the governor, just like the economy going badly.

Sarah Kliff

You mentioned earlier that we’ve seen a shift from Republicans supporting just repeal toward supporting repeal and replace. You also said we’ve seen an uptick in approval ratings for the health law, but that tends to be among Democrats and independents.

Would you ever expect, as this debate moves forward, to see a shift in Republicans who approve of the law? Or is the law just too polarizing to ever expect that type of effect?

Robert Blendon

I don’t think Republicans will ever say they like the bill. I think they’ll move to repeal and replace. And these are the questions that Republicans absolutely should and do worry about.

Programming note!

Saturday at 1:15 pm, I’ll be moderating a panel at the National Governors Association about the future of health policy along with former Govs. Haley Barbour of Mississippi and Ben Nelson of Nebraska. We’ll also talk about what the current debate in Congress means for the states. Will you be at NGA and want to chat health care? Drop me a line at sarah@vox.com.

Kliff’s Notes: Today’s top 3 health policy reads

“House markup of repeal bill in the air”: “Several lobbyists said Republicans on the committee sent some elements of a healthcare bill to the Congressional Budget Office (CBO), but did not receive the cost estimates that they had expected. Those same sources stressed that Republicans have not sent a final plan to the CBO for budget scoring, because they are still working through a variety of issues that need to be addressed in the legislative text.” —Peter Sullivan, the Hill

“GOP Congressman Says A Drop In The Number Of Insured People Could Be ‘A Good Thing’”: “Burgess was asked about concerns that repealing Obamacare will lead to a drop in the number of people with health insurance. He responded that it would be a good thing because it means fewer people are subject to the individual mandate. ‘First off, we’re not going to send an IRS agent out to chase you down and make you buy health insurance,’ said Burgess. ‘So if the numbers (of insured people) drop I would say that’s a good thing because we restored personal liberty in this country.’” —Paul McLeod, BuzzFeed

“Indiana’s Claims About Its Medicaid Program Don’t All Check Out”: “The key part of Indiana's experiment requires low-income participants to make monthly payments. Advocates say this promotes recipients' taking personal responsibility for their health care. But some health policy experts say the information provided by the state shows that the provision isn't working as well as it should.” —Paul Harper, NPR

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