Abstract
Using Pew Research Center's Voter Attitudes Survey from 2012, we assess the impact race has on the relationship between religious faith and worship attendance with support for the Affordable Care Act (ACA). We find that White Evangelicals, independent of partisan affiliation and social-demographic characteristics, are more likely than White Non-Evangelicals to reject the ACA. In addition, among Whites, support for the ACA weakens with increasing religious attendance, suggesting that responses to this law are shaped by experiences within religious settings. However, we find little evidence for religious faith or worship attendance associating with Black and Hispanic health-care policy attitudes.
Introduction
The Patient Protection and Affordable Care Act (ACA), passed in 2010 and upheld by the Supreme Court in 2012, has drawn both strong support and contestation, particularly along partisan lines (Harrington 2010; Rigby et al. 2014). The most well-known piece of this legislation is the individual mandate, which required Americans to purchase health insurance or face a tax penalty (Hymson and Ornelas 2016). The individual mandate was framed as a “shared responsibility” payment to increase accountability among Americans and reduce the burden of uncompensated care, but the mandate was repealed in late 2017 as part of a tax reform bill (Voigt 2013; Gasteier 2018). The ACA created new insurance exchanges to provide affordable health care plans and implemented new requirements for contraceptive coverage to be included as an essential health benefit. Partly because of concerns about religious freedom, the Supreme Court ultimately exempted closely held religious companies from paying for contraceptives (Charo 2014). The ACA also provided support for states to expand Medicaid, thereby increasing health care access for Americans falling up to 138% above the poverty level. Beyond health insurance, the ACA provided additional funding for community health centers and disease prevention (Han et al. 2017).
Although the number of uninsured nonelderly Americans decreased from “over 44 million in 2013 (the year before the major ACA coverage provisions went into effect) to roughly 28 million in 2017,” Americans are largely divided over whether they believe the ACA is good policy (Kaiser Family Foundation 2018a, b). In 2018, however, 53% of Americans approved of the ACA (Kaiser Family Foundation 2018a, b), up from 40% when the ACA was implemented in 2012, demonstrating growing support. Early studies on ACA implementation show that the ACA not only has increased the number of insured Americans but also has reduced coverage disparities between White Americans and both Hispanics and African Americans (Artiga et al. 2019). Although the largest absolute coverage gains were among Whites, relative to population the largest gains in insurance coverage were among Hispanics and African Americans. To date, however, we know little about how support varies across different racial/ethnic groups and whether religious affiliation shapes views toward the ACA. As such, we are interested in the degree to which religion and race are associated with support for this policy.
There is reason to believe that both religion and race should associate with perceptions of the ACA. Major religious councils, representing Mainline, Catholic, and Black Protestant churches, have spoken out publicly about health care reform. For example, the National Council of Churches, an ecumenical body of Mainline Protestant churches, specifically endorses “the development of a national health system which will assure quality health care as a right to all persons” (1999, 2017). In addition to public support, leaders from these traditions have coordinated efforts to assist congregants and community members in enrolling for Medicaid or health plans on the ACA's insurance exchanges (Banks 2014).
The African Methodist Episcopal (AME) Church, one of the country's oldest Black Protestant Denominations, has worked to enroll and renew people in ACA insurance plans through their social action commission (AME Social Action Commission 2016). In 2013 alone, the AME Church sponsored more than 5000 enrollment-related events. The Catholic Church, which is the religious home to more than half of Hispanic Americans, has also spoken publicly about health care reform. In his January 18, 2017, letter to Congress, the Most Reverend Frank J. Dewane, chairman of the United States Conference of Catholic Bishop's Committee on Domestic Justice and Human Development, argued that the ACA represented the nation's commitment to protecting the God-given dignity of all humans, particularly those on its margins. He went on to state that health care is not a luxury but “a necessary building block to help individuals and families thrive and contribute to the good of the community and the nation” (2017).
Evangelical Protestants, more than three-quarters of whom are White, have taken a modified stance on health care reform. The National Association of Evangelicals shares a commitment to increase health care access, including for marginalized populations (1994, 2009), but advocates for collaboration among “governmental institutions, social agencies, insurance companies, and churches to establish health care provisions that will maximize the creativity of the private sector while minimizing governmental control” (National Association of Evangelicals 2009). This variation in support for the ACA among religious traditions in the United States suggests that religious beliefs and worship settings may relate to health care attitudes. To date, however, no systematic investigation has considered the role that religious attendance and race play in shaping support or opposition to the ACA at the time of its implementation. In this study, we examine the extent to which race and cultural frames cultivated within religious groups are operative in assessments of this policy.
Religious Socialization and Views on Social Change
Emerson and Christian Smith's (2000) argument that religious communities use cultural tool kits to help individuals evaluate social problems and interventions provides a useful framework for understanding potential religious differences in support for the ACA. Cultural tool kits are collections of values or habits that aid in the interpretation of social arrangements or policies (Swidler 1986). Emerson and Smith (2000) made the case that Evangelicals’ individualistic interpretation of sin and free will informs their political ideals. The free will individualistic argument is as follows: Because individuals have free will, they can choose to accept Christ as their personal Savior, the essential intervention to sin. Constitutional freedoms that allow for freedom of religion, speech, assembly, and press make Americans particularly well positioned to act on their free will. These freedoms also allow Americans, if so inclined, to spread the “good news” to nonbelievers in an effort to defeat sin, one convert at a time. For Evangelicals, the root of man's inhumanity to man is sinfulness, defined as separation from Christ. The solution to sin, therefore, does not rest in government programs, which cannot, after all, alter man's heart. Rather, the solution rests in one's dedication to Christ. If individuals accept Christ as their savior and treat one another as Christ instructed, so goes the theology, there is no need for government programs to address social problems, such as inadequate access to quality health care.
Social psychological research on religion and political attitudes suggests that individualistic cultural frames may also associate with concerted attempts to maintain group position and control of valued resources (Kluegel and Smith 1986). In religious communities more specifically, scholars have demonstrated the relationship between racial prejudice and religious identification, particularly among individuals who embrace fundamentalism and are motivated by extrinsic factors such as social status (Abanes 1996; Hunsberger and Jackson 2005). In these studies, religious identification offers a clear demarcation, particularly among Whites, between one's own group and an out-group (Hall et al. 2019). The cultivation of these specific cultural tools, however, is a recent configuration owing at least partially to the rise of the Religious Right, as opposed to a longer history of Evangelical social action (Wilcox and Robison 2009; Steensland and Wright 2014; Balmer 2016). The social location of White Evangelicals within communities that emphasize individual effort is also vital to understanding their political attitudes. Among Evangelicals more specifically, Tranby and Hartmann (2008) and other critical race theorists have built upon existing theories of racism to explain why the sociocultural tool kit is more salient among White Evangelicals. They have argued that antistructuralist and relational values serve as a covert mechanism to maintain White privilege (Tranby and Hartmann 2008). This type of individualism, according to Lawrence Bobo and colleagues, is related to “persistent negative stereotyping of African-Americans, a tendency to blame Blacks themselves for the Black-White gap in socioeconomic standing, and resistance to meaningful policy efforts to ameliorate U.S. racist social conditions and institutions” (Bobo et al. 1997, p. 16).
The point is that religious and cultural frames that favor individualism and legitimate racial discrimination may strongly associate with political attitudes, independent of either political affiliation or theological beliefs. Despite arguments suggesting that Christian ethical values conflict with individualism in many ways (Lloyd and Prevot 2018), the cultural tool kit is a strong predictor of political attitudes among White Evangelicals. Adherence to this cultural tool kit is fairly apparent among Evangelical clergy, as they are less likely than Mainline Protestant and Catholic clergy to preach about and identify their congregations as being committed to social justice (Smidt et al. 2010). Relative to their peers, White Evangelical clergy are also less likely to agree with liberation theology, which supports the church's role in challenging individuals and institutions, such as governments and corporations, to stand in solidarity with and politically advocate with the poor, powerless, and marginalized (Smidt et al. 2010).
Individualism and Beliefs about Inequality
Evangelicals’ individualistic cultural tool kit also aligns with a strong belief in an American exceptionalism that identifies the United States as a providential nation. American providence affords the United States economic opportunities and democratic freedoms, thereby setting it apart as the moral beacon that God has chosen for all other nations to follow (Amstutz 2014). Evangelical Protestants believe in this ideal more strongly than do other Americans, as Evangelicals are more likely than other Americans to believe that God has granted the United States a special role in human history (PRRI 2015). Individuals who have a stronger belief that Americans possess unique opportunities also tend to believe that the extent to which social inequalities, such as disparities in health care access, persist is less a consequence of blocked opportunities than a weak work ethic (Jackson et al. 2004).
The idea that God has blessed Americans with adequate resources may help further explain why Evangelical Protestants tend to embrace a “just-world” belief that life is generally fair and that people get what they deserve (Hunt 2000). This idea is made evident in a number of studies. For example, White Evangelical Protestants are more likely than others to believe that children from all income groups have adequate opportunities to be successful (PRRI 2013). White Evangelicals are more likely than secular Whites to believe that Blacks are more likely than Whites to be poor because they lack a strong work ethic (Hinojosa and Park 2004). Similarly, White Evangelical Protestants are more likely than other Whites to believe that Blacks should work their way up, like White European immigrants had in the past (Jackson et al. 2004). Given that White Conservative Protestants tend to embrace antistructuralist explanations for social inequality, it follows that they also tend to oppose policy solutions to social inequalities (Taylor and Merino 2011). For example, White Evangelicals are more likely than other Whites to support spending cuts to antipoverty programs, to oppose programs that target African Americans, and to oppose Affirmative Action (Brown et al. 2014, 2016; Taylor and Merino 2011).
There is some evidence that, even when controlling for religious denomination, antistructuralist orientations are reinforced within the worship services that Whites attend. Frequent worship-going Whites are more likely to believe that America is a land of opportunity for those who are willing to work hard, children from all income groups have adequate opportunities to be successful, Blacks should work their way up like White European immigrants, and welfare spending should be cut (Jackson et al. 2004; PRRI 2013).
In contrast to Whites, religious faith and worship attendance are largely unrelated to the structural orientation of African Americans or Hispanics (Brown 2009; Putnam 2012). It is plausible that experiencing racial discrimination, being disproportionately poor, being uninsured or underinsured, and having family members and friends with these experiences call into question the individualistic assumptions that life challenges are linked to a lack of effort. So, although theological conservatism and religious faith are associated with political conservativism and partisanship among Whites, no such correlation exists among Blacks or Hispanics (Putnam 2012). For this reason, the religious cultural tool kit as a means of shaping political ideology may be more apparent in explaining denominational and worship attendance differences among Whites than among Black Americans or Hispanics.
Religion and Support for the ACA
Given the studies just discussed, one might also expect religious differences in support for the ACA. Early polls suggested that Evangelicals were significantly opposed to all aspects of health care reform compared with other religious groups and the general American population (Grant 2012). Evangelicals’ heightened opposition to the ACA may partially reflect that their clergy were unlikely to support government-sponsored health care, to discuss the issue over the pulpit, and to host discussion groups about the issue at their place of worship (Smidt 2009).
Evangelicals’ greater opposition to the ACA may also reflect Evangelicals’ interpretation of the ACA as a social safety net for the undeserving poor (Franz 2018). Franz's qualitative study on Evangelical views of the ACA found that although the interviewees agreed abstractly with the spirit of helping the poor and providing health care access, they preferred solutions on a personal level, such as having churches play a role in providing health care services for which individuals could be held personally accountable before receiving assistance (Franz et al. 2016). Drawing on the cultural tool kit of Evangelicalism, Franz et al. (2016) concluded that personal relationships and antistructuralism were cultivated in a particular way in the context of health care reform. These findings suggest that the Evangelical cultural tool kit may distinguish this group from other religious Americans in interpretations of the ACA. As mentioned earlier, independent of religious faith, the worship services that Whites attend may also cultivate an individualistic cultural tool kit that associates with their public policy attitudes. A 2013 PRRI poll found that the more often Whites attended worship services, the more likely they were to oppose the government providing health care to children whose families were unable to afford health insurance.
Among Blacks and Hispanics, however, there is no clear relationship between denominational affiliation and worship attendance with exposure to sermons about health care policy and/or congregations sponsoring health-related programs (Smidt 2009). Along these lines, McDaniel (2003) found that among historically Black Protestant clergy, the more theologically conservative Church of God in Christ clergy and liberal AME clergy were equally likely to support universal government-provided health care. We now turn to our hypotheses.
Hypotheses
In this study, we use data from a Pew Research Center poll to examine the extent to which religious faith and worship attendance associate with White, Black, and Hispanic views of the ACA. Based on previous findings, we hypothesize the following:
Among Whites, frequent worship attendees and Evangelical Protestants will hold more critical views of the ACA than their counterparts. We expect no such relationship among Black and Hispanic Protestants.
Sample
We pursue this inquiry with the Pew Research Center's June 2012 Voter Attitude Survey. We used 2012 data to assess the baseline response to the health care law as it was first being implemented. Between June 7 and 12, Princeton Survey Research Associates International administered an English and Spanish language telephone survey to a nationally representative sample of 2013 adults living in the United States. They interviewed 1127 respondents via landline, and the rest were contacted via cell phone. The average response rate across the sample was 14%. The margin of sampling error for the complete set of weighted data is 2.6% points.1
Measures
Dependent Variables: ACA Attitudes
We determined Americans’ views about the ACA with a question that assessed approval of this 2010 legislation and another that assessed their happiness with the 2012 Supreme Court ruling that left the ACA intact.
Independent Variables: Religion
The Affordable Care Act (ACA), religion, and race
This table reports the percentages for each racial group. The percentages of Blacks and Hispanics are compared with Whites
* < .05, ** < .01: confidence intervals are in brackets
Control Variables
Our analyses also account for mode of interview, language of survey, political partisanship, and the following social demographic variables: age, education, income, gender, and region.
Analytic Strategy
We use predicted probability estimates based on logit regression analyses that examine the association between worship attendance and religious faith with the health care policy attitudes of Blacks, Hispanics, and Whites.3 All of our analyses account for the aforementioned control variables. We also use treatment effect analyses to simulate an experimental design of the relationship between worship attendance and religious faith with health care policy attitudes. In doing so, these analyses calculate the probability that someone would support the ACA assuming that everyone has the same opportunity to attend worship services and to be a member of a given religious faith. They also calculate the probability of someone holding the same policy attitude assuming that everyone has the same chance to attend infrequently or not at all and to be a member of another religious faith. This approach allows us to address the empirical contention that frequently attending worship services may involve some level of bias, in that people with certain policy proclivities self-select places of worship and/or religious faiths that match their interests in and stance on political issues. Using a simulated treatment of the same level of potential exposure to worship settings and religious faiths, we attempt to address this problem. In every case in which we observed a relationship between religious faith and worship attendance with health care policy attitudes, the treatment effect was significant.4
Results
Probability of approval of Obamacare by race and worship attendance and religious faith: Controlling for mode, language of survey, partisanship and social demographics
* < .05, ** < .01: confidence intervals are in brackets
aThe interaction effect is significant: the Black and/or Hispanic main effect is significantly different from the White main effect
bIndividuals who attend worship services less than once a month are compared with individuals who attend at least once a month
cWe compare non-Evangelicals with Evangelicals
Probability of being “happy” with supreme court upholding Obamacare by race and religious faith: controlling for mode, language of survey, partisanship and social demographics
* < .05, ** < .01: confidence intervals are in brackets
aThe interaction effect is significant: The Black and/or Hispanic main effect is significantly different from the White main effect
bIndividuals who attend worship services less than once a month are compared with individuals who attend at least once a month
cWe compare non-Evangelicals with Evangelicals
Race, Religion, and Support for ACA
The White analyses of Table 2 indicate that the more often Whites attend worship services, the less likely they are to approve of the ACA (see White column). We find no such relationship for Blacks and Hispanics. In fact, our interaction analyses indicate that worship attendance maintains a statistically stronger relationship with Whites not supporting the ACA than it does for Blacks and Hispanics.
Table 2 also shows that White Evangelicals are less likely than White non-Evangelicals to approve of the ACA. In contrast, we find no such faith differences among Blacks and Hispanics. Our interaction analyses point to a significantly larger difference between the proportion of secular or non-Christian persons and Evangelicals supporting the ACA among Whites than we observe among Blacks and Hispanics.
Compared with Evangelicals, a significantly larger proportion of Mainline Protestants support the ACA among Whites than is the case among Hispanics. This religious faith difference almost has the opposite effect on White ACA attitudes than it does on Hispanics. As mentioned earlier, a greater proportion of White Mainliners support the ACA than do White Evangelicals (see White column). Although the difference is statistically nonsignificant, the converse is true for Hispanics (see Hispanic column).
Race, Religion, and Support for Supreme Court Ruling on ACA
As in Tables 2 and 3 the more often that Whites attend worship services, the less likely they are to approve of the Supreme Court upholding the constitutionality of the ACA (see White column). We find no such relationship for Blacks and Hispanics. Even further, our interaction test indicates that more frequently attending worship services has a statistically stronger relationship with Whites not supporting the ACA Supreme Court ruling than it does for Hispanics.
Table 3 also shows that White Evangelicals are less likely than White Catholics and non-Christians or secular persons to support the Supreme Court's ruling on the ACA. We do not observe these faith differences, however, among Blacks and Hispanics. Going further, our interaction analyses point to a significantly larger difference between the proportion of secular or non-Christian persons and Evangelicals supporting this Supreme Court ruling among Whites than is the case among Blacks and Hispanics.
Finally, when compared with Evangelicals, a significantly larger proportion of Catholics support the ACA ruling among Whites than is the case among Hispanics. Religious faith seems to associate with views of the ACA Supreme Court ruling among Whites very differently than it does for Hispanics. As stated earlier, White Catholics are more likely than White Evangelicals to support the ACA ruling (see White column). Although the difference is statistically nonsignificant, the opposite is true for Hispanics (see Hispanic column). In sum, our analyses suggest that, when controlling for political partisanship, social-demographic characteristics, and mode of survey, worship attendance and religious faith inform White ACA attitudes more meaningfully than they do for Blacks and Hispanics.
Discussion
The aim of this study was to understand how religion and race associate with interpretations of the ACA and the subsequent Supreme Court decision to uphold this health care law. Among Whites, we found that Evangelical Protestants and frequent worship-goers were less likely than other Whites to support the ACA. These findings may suggest that although past research has demonstrated the salience of social responsibility within Evangelicalism (Craig 2014), the emphasis on personal relationships, nonstructural social change, and individualism is operative in their interpretations of health care reform. That is, for White Evangelicals, the imperative to care for others is likely more strongly attenuated by individualism and antistructuralism. Relative to other Whites, White Evangelicals may interpret this responsibility as involving personal relationships and voluntarism rather than as a rationale for supporting government-based programs that provide aid or care to the poor.
The fact that worship attendance also associates with Whites of varying denominations and faiths opposing the ACA suggests that worship settings may subtly reinforce views about individualism, thereby discrediting social policies like the ACA. This is not to say that the worship settings that Whites attend discourage aiding the sick and chronically ill. The National Congregations Study indicates that roughly six in ten worship-going Whites attend congregations that host groups or events that provide support for people with terminal illness or chronic health problems (NCS 2004–2012). More than one-third of worship-going Whites attend congregations with a formal committee for hosting and/or sponsoring “health-focused programs such as blood pressure checks, health education classes, or disease prevention information” (NCS 2004–2012). Nonetheless, our findings do suggest that worship-going Whites tend to maintain an individualistic orientation to explain health and other socioeconomic disparities and the government's role in addressing such problems. It may also be the case that such attitudes are reinforced by other congregants and/or clergy within worship settings.
That many Americans attend racially segregated congregations may help explain the connection between worship attendance and opposition to the ACA (Yancey and Emerson 2003; Blanchard 2007). Connecting with individuals who differ in race and socioeconomic status is an important predictor of a more tolerant racial attitude (Emerson et al. 2002; Pettigrew and Tropp 2008). For this reason, contact with other groups might have particular importance for Evangelicals as they consider personal accountability and whether individual or structural interventions are necessary to improve health outcomes. Lack of interracial contact within congregations may increase reliance on cultural stereotypes to describe other racial groups (Yancey 1999), thereby shaping support for structural changes such as those found in the ACA. Within highly segregated White congregations, laissez-faire racism may be particularly apparent; the ACA may be interpreted as helping individuals and racial groups who are not morally deserving as opposed to removing institutional or structural barriers to good health. As described in the introduction, the reliance on individualism as an explanation for social mobility may be associated with covert, contemporary forms of racism that maintain privilege while overlooking structural causes of inequality.
Unlike Whites, worship attendance and religious affiliation are not strongly related to support for the ACA or the Supreme Court's ruling among Black Americans or Hispanics. This finding is consistent with prior studies that have shown worship attendance and religious affiliation to be unrelated to African American political attitudes and partisanship (Brown 2009). Scholars have argued that the social location of African Americans is important for understanding the role that religion plays in shaping political beliefs. In particular, there seems to be less variation in the political beliefs of African Americans, as compared with Whites, suggesting that the role of religion in altering political ideology may be diminished. Extending the contact hypothesis, scholars have suggested that this lack of variation may result from experiences of discrimination, or more frequent contact with individuals in poverty (Brown 2009).
There is also a long history documenting disparities in health outcomes and health care access in Black communities, dating back to Du Bois's (1899) description of life in Philadelphia and the health problems that resulted from systematic disadvantage. In his pioneering study documenting African American health, he wrote, One thing we must of course expect to find, and that is a much higher death rate at present among Negroes than among Whites: this is one measure of the difference in their social advancement. They have in the past lived under vastly different conditions and they still live under different conditions: to assume that, in discussing the inhabitants of Philadelphia, one is discussing people living under the same conditions of life, is to assume what is not true. (148)
Disparities in health outcomes persist in the United States, with Black Americans more likely than Whites to experience discrimination and other chronic stressors. The result is comparatively poorer health based on a variety of indicators (Hicken et al. 2014). Recent studies have documented the role that residential segregation, perpetuated by discriminatory housing practices, plays in hypertension (Kershaw et al. 2017). Other race-based health disparities include an infant mortality rate two to three times higher among Blacks than Whites, increased exposure to environmental contaminants, and decreased life expectancy (Williams and Sternthal 2010; Speights et al. 2017; Mikati et al. 2018). Racial/ethnic health disparities have continued in the United States for a long time, which may contribute to a greater awareness of structural disadvantage and more progressive attitudes toward health care policy change among Black Americans. As with other policies addressing socioeconomic stratification or racial discrimination, an understanding of institutional practices that perpetuate disadvantage may help explain the limited role that religion plays in shaping policy preferences among Black Americans.
This is not to suggest that religious organizations play an unimportant role in emphasizing healthy behaviors and support for policies that promote health and well-being among the poor. Indeed, African American congregations are more likely than White congregations to host health workshops within their religious congregations (Brown 2008). Rather, because of the disproportionate poverty that persists within Black communities, it is likely that religious messages that encourage congregants to improve the well-being of others overlap existing social policy beliefs among African Americans in and outside of religious settings. Religious affiliation and attendance do not seriously alter support for policies aimed at increasing access to health care among Blacks, which suggests that disparate racial experiences impact the role that religion plays in potentially reinforcing health policy attitudes (Feagin 1975; Hunt 2002; Brown 2009).
Among Hispanic Americans, we also do not see a strong relationship between religious affiliation and health care reform attitudes. There may be less variation between Hispanics of different religious traditions for several reasons. Like African Americans, Hispanic Americans were disproportionately uninsured before the ACA went into effect (Buchmueller et al. 2016). Among all racial/ethnic groups, uninsurance was highest among Hispanics prior to ACA implementation (Artiga et al. 2019). Since ACA implementation, coverage disparities between Hispanics and White Americans have declined (Artiga et al. 2019). Hispanic Americans, regardless of religious orientation, may support the ACA because this policy represented an important opportunity to redress existing disparities in health care access as compared with dominant racial/ethnic groups in the United States.
Other factors besides religious affiliation might help explain the health care policy attitudes of Hispanic Americans. Despite their lower social position relative to Whites, Hispanics have relatively favorable health outcomes compared with other racial/ethnic groups, including Whites. Epidemiologists have coined this phenomenon the “Hispanic health paradox,” because it contradicts the usual pattern of lower health status among socially disadvantaged groups (Padilla et al. 2009). Scholars cite strong social support networks, which provide pathways by which Hispanics can gain social mobility to explain better-than-expected health outcomes (Teruya and Bazargan-Hejazi 2013). Most important, the relative health advantage among Hispanics is highest among first-generation immigrants and declines with increasing assimilation. These results suggest that as Hispanics adopt an American diet and other health behaviors, health status declines (Medina-Inojosa et al. 2014). Therefore, unlike traditional theories of assimilation based on the experiences of European immigrants, Hispanic Americans may benefit from retaining social ties to immigrant communities, where they can use social capital and protect themselves from discrimination (Portes and Rumbaut 2001). As a result, the adoption of individualism in attitudes toward social policies may be less salient among Hispanic Americans, regardless of religious affiliation (McKenzie and Rouse 2012).
Our study provides further evidence that individualism is uniquely operative in White Evangelical interpretations of social policies and shapes more recent views toward the ACA. These results suggest that religious affiliation is related to beliefs about the ACA, but only among racial/ethnic groups in which there is a strong relationship between beliefs about individualism and religious worldviews. Because Whites control many social and economic resources in the United States, religious worldviews seem to cement ideologies that protect racial/ethnic privilege through an emphasis on individual work ethic. Among other racial/ethnic groups, beliefs about individualism may not be tied as directly to religious worldviews or reproduced within religious environments. In other words, there may be strong cultural support for improving equality through structural means that is not limited to the religious sphere. Our findings suggest that religious spaces may strengthen the emphasis on individualism among White Americans, which shapes support for social policies such as the ACA.
Limitations
Our findings help explain the relationship between race, religious attendance, and support for the ACA but are limited in several ways. Our analyses rely on survey data that are self-reported by participants and are susceptible to response bias as a result of the political focus of the survey. Furthermore, because our data were from 2012, we are limited to understanding support for the ACA early on its implementation, when support was starkly divided among partisan lines. In recent years, support for the ACA has grown among Americans, and the National Association of Evangelicals in particular has spoken out in opposition to repeal efforts (Bread for the World 2017; Kaiser Health News 2018). For this reason, future studies might consider how discussions regarding the ACA have unfolded in religious communities in the years since its implementation. As many more Americans have gained access to health care since 2012, it is possible that individualist approaches to assessing health care policy among Evangelicals have been tempered by this early success or more general political shifts within Evangelicalism. At the same time, the fact that Evangelicals continue to strongly support the Trump administration (Pew 2017), tell us that more attention should be given to understanding the durability of cultural tools within Evangelicalism and how conflicting frames, such as social responsibility and individualism, are negotiated in assessments of social policies.
By considering how religion and race intersect in interpretations of health care reform, this study supports previous findings and suggests that cultural tools such as individualism are an enduring feature of the Evangelical cultural tool kit. Using data from 2012, we were able to explore the role of religious attendance and affiliation in interpreting this health law within 2 years of its passing and immediately following the Supreme Court's decision to uphold the law as constitutional. Our findings suggest that religious identification and race are important in understanding American views toward the most recent round of health care reform, mirroring earlier findings on religion, race, and policy support. At least among Whites, religious socialization seems to shape perspectives on structural versus community-level approaches to improving health care access.
Footnotes
Acknowledgements
None.
Funding
None to report.
Appendix
See the Table 4.
Full survey questions on the Affordable Care Act
Question
Response options
Do you approve or disapprove of the health care legislation passed by Barack Obama and congress in 2010?
0 = Disapprove
1 = Approve
As you may know, the supreme court is expected to rule on the health care law later this month. I would like to ask how you would feel about a few possible outcomes of the ruling. For example, the court could decide to uphold the entire law. Would you be happy or unhappy with this decision?
0 = Unhappy
1 = Happy
1
We understand that all public opinion polls, Pew included, suffered declining response rates over the past 50 years. Between 1997 and 2018, the average telephone response rate at the Pew Research Center decline from 36 to 6% (Kennedy and Hartig 2019). However, this does not necessarily mean that the univariate responses in this survey are susceptible to response bias. Respondents in a 2017 Pew Research Poll were as likely to identify as Democrat, Republican, and Independent as respondents in the American National Election Studies and General Social Survey, both of which have response rates in the 70% range (Keeter et al. 
). The Pew Study that we use attempts to correct for its lower response rates by weighting the sample based on the demographic statistics that are reported by the Census. We mention this because weighting data is an impactful means to reduce nonresponse bias (Dey 1997; Keeter et al. 2017).
2
See the appendix for full question wording of these measures.
3
We exclude “other races” (approximately 126 persons) from our analysis, as the data set does not contain further information about who is included in this group.
4
The following formula expresses the average treatment effect—a counterfactual causal effect—of the association between attending worship services and health care policy attitudes by estimating policy attitudes based on respondents being randomly assigned to attending worship services at least once a month and less than once a month. In the formula, E = average health care policy attitude of sample, D i = variable of frequency of worship attendance, Y i = policy attitude of respondent who attended worship services once a month or more, and Y 0i = policy attitude of respondent who attended worship services less than once a month. We replicated the same analyses with religious faith as the independent variable.
5
Because so few Blacks and Hispanics identify as secular or non-Christian, we combine these groups in the multivariate analyses of Tables 2 and .