The Affordable Care Act (ACA) was a central issue dividing Republicans and Democrats for the decade following its 2010 enactment. Given that, it offers key lessons about policymaking and public opinion during a highly polarized political period. Here, I draw out some of those lessons from my 2023 book Stable Condition: Elites' Limited Influence on Health Care Attitudes, detailing how polarization shaped both the elite- and mass-level politics of the ACA. At the elite level, polarization and nationalization within the federal and state governments laid the groundwork for a highly complex law that was a patchwork of policies experienced very differently by different Americans. At the mass level, polarization and nationalization contributed to a remarkable level of stability in public opinion, so much so that even direct beneficiaries of the law did not typically become markedly more positive toward it. Elite efforts at opinion leadership, through policymaking and messaging, were largely unsuccessful.

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