By Richard Feldman

The Republican-controlled Congress failed in multiple efforts to dismantle the Affordable Care Act because of Republican divisiveness and a slim Senate majority. The repeal of the individual mandate in the tax reform bill, and President Trump’s termination of cost-sharing subsidies and allowance of low-cost stripped-down health insurance policies, appealing to the young and healthy, will only serve to further destabilize ACA health insurance exchanges and increase premiums.

The prevailing Republican agenda remains: contract Medicaid funding and coverage, end the Medicaid expansion, terminate employer mandates, reduce or eliminate premium assistance for low-income individuals and families, deregulate insurers and allow states more autonomy to create health-system polices that will likely further contraction of insurance coverage.

The Republicans have had difficulty mustering public support for their proposals, and with attempts to push them through, Obamacare appears to have actually gained public support. Now some polls indicate that the majority of Americans favor retaining the ACA and to fix its shortcomings.

A basic concept in government is that “public opinion drives public policy.” This isn’t occurring in the case of the persistent Republican holy war to fulfill its promise to end Obamacare. Current Congressional voting is more about party affiliation and ideology than the views of the public.

The New England Journal of Medicine recently published a special report on public opinion regarding healthcare reform. The report analyzed 27 national opinion polls by 12 survey organizations giving valuable insight into public opinion concerning Obamacare, the proposed Republican healthcare policy changes, and public values concerning health-care coverage.

Here are some of the combined survey results:

  • The public remains split in its support of the ACA, with more people approving than disapproving (49 percent vs 44 percent, approval increasing 5 percent in the past 5 years).
  • Fifty-eight percent think that Obamacare has not directly affected them, suggesting that public opinion is not largely based on experience but beliefs and values regarding the role of government in extending coverage. More people report that the ACA has benefited them rather than hurt them (24 percent to 16 percent).
  • Sixty-percent of respondents believe that the federal government should be responsible for ensuring health coverage for all Americans. Fifty-seven percent believe that the federal government should play a major role in health-care system improvement.
  • Sixty-three percent prefer that lawmakers make legislative changes which would enable more people to obtain health insurance even if it costs the government more money. Twenty-seven percent think that spending should be reduced.
  • Fifty-one percent believe that Obamacare should be retained and improved. Forty percent favor either repeal and replacement or no replacement at all.
  • Fifty-seven percent think that financial assistance provided to purchase health insurance should be maintained at present levels, whereas 34 percent prefer to provide assistance to fewer people. Seventy-two percent support keeping the number of people covered by Medicaid the same number as is now (interestingly, 50 percent of Republicans).
  • Thirty-five percent had a favorable opinion of the individual mandate in 2016. Now, 50 percent of those polled are opposed to ending the mandate.
  • Only 24 percent support permitting charging more for those with preexisting conditions.
  • Fifty-six percent disapprove of the Republican Congressional proposals put forward thus far (24 percent approved, Republican support was 50 percent).

As expected, there are differences in opinion on virtually all issues between Democrats and Republicans based on ideology. Compounded by the divisiveness among Republican lawmakers, it will be very difficult to come to any consensus on healthcare reform. Even more difficult will be to enact legislation based on public opinion.

Richard Feldman, M.D., is an Indianapolis family physician and the former Indiana State Health commissioner. Send comments to