Kaiser Health Tracking Poll: ACA, Replacement Plans, Women’s Health

KEY FINDINGS:

• The latest Kaiser Health Tracking Poll examines the public’s early attitudes towards the House Republican plan to replace the Affordable Care Act and finds that more expect the new plan will make things worse rather than better when it comes to the number of people with coverage and costs for those buying insurance on their own. Republicans are more optimistic, with nearly half expecting the plan to decrease costs and one-third saying it will increase the number of people covered.
• More expect the law to increase rather than decrease costs in the individual insurance market for various groups, including younger and older people, those living in urban and rural areas, and those with lower incomes. The public is more divided on whether costs will increase or decrease for higher-income people who buy their own insurance.
• Three-quarters of the public support continuing current federal Medicaid funding to Planned Parenthood to pay for non-abortion services received by people on Medicaid, while 22 percent support cutting off all federal funding to the group. Majorities of both Republican women and Republican men support continuing current funding.
• At the same time, only one-third of the public is aware that there is currently a ban on federal Medicaid funds being used to pay for abortions, while almost half say there is not a ban and one in five say they don’t know.
• After shifting in a positive direction in February, the public’s overall views of the ACA hold steady this month, with 49 percent holding a favorable view of the 2010 law and 44 percent holding an unfavorable view. The public is split on the question of repeal, with 51 percent saying Congress should not vote to repeal the law and 45 percent saying they should. As previous Kaiser surveys have found, more say lawmakers should wait to vote on repeal until the details of a replacement plan are worked out (24 percent) than say they should repeal the law immediately and work out the details of a replacement plan later (19 percent).

Public Opinion on ACA Replacement Plan

On March 6, 2017, House Republicans announced their plan to replace the Affordable Care Act (ACA) – the American Health Care Act (AHCA). While Americans are still learning about the details of this plan, the latest Kaiser Health Tracking Poll (which was in the field before the Congressional Budget Office released its analysis of the plan) examines the public’s first impressions of its likely effects on the number of uninsured, those who buy insurance on their own, and those with pre-existing conditions.

About half (48 percent) the public thinks the Republican replacement plan will decrease the number of people who have health insurance, while one in five (18 percent) say the number of insured people will increase and three in ten say it will stay about the same. Notably, the public is confused about the effect the current health care law has had on coverage rates in the U.S.; while four in ten (41 percent) know that the share of people who are uninsured has decreased since the ACA was passed, nearly as many (31 percent) believe it has increased and 26 percent think it has remained about the same.

When it comes to costs, about half (48 percent) expect the new plan to increase costs for people who buy insurance on their own, while about a quarter each say costs for these people will decrease (23 percent) or stay about the same (25 percent). Similarly, four in ten (41 percent) expect the replacement plan to provide health insurance with higher deductibles, while a quarter each think deductibles will decrease (25 percent) or stay the same (23 percent). When it comes to protections for people with pre-existing conditions, nearly half the public (45 percent) expects the replacement plan would provide similar protections to the current law, but about twice as many say the plan would offer fewer protections as say it would offer more (32 percent versus 15 percent).

Not surprisingly, partisans hold very different views of how the replacement plan would impact coverage and costs. While majorities of Democrats believe the plan will decrease the number of people with insurance and increase costs, Republicans’ views are more mixed. Nearly half of Republicans (46 percent) think the plan will decrease costs for people who buy their own insurance, four in ten (41 percent) think it will provide insurance with lower deductibles, and one-third (34 percent) think it will increase the number of people with health insurance.

Table 1: Partisan Views on Likely Effects of Republican ACA Replacement Plan
Percent who say in general, compared to the current health care law, the replacement plan will…	Total Public	Democrats	Independents	Republicans
…decrease the number of people with health insurance	48%	68%	49%	22%
…increase the number of pople with health insurance	18	13	15	34
…not change the number of people with insurance	30	17	32	38
…increase costs for people who buy their own insurance	48	71	47	19
…decrease costs for people who buy their own insurance	23	6	25	46
…not change costs for people who buy their own insurance	25	20	26	28
…provide insurance with higher deductibles	41	60	41	16
…provide insurance with lower deductibles	25	13	26	41
…provide insurance with about the same deductibles	23	17	23	29
…provide fewer protections for people with pre-existing conditions	32	49	30	9
…provide more protections for people with pre-existing conditions	15	12	15	20
…provide about the same protections for people with pre-existing conditions	45	32	47	63

Expected Changes in Costs for Different Groups Under Replacement Plan

A Kaiser Family Foundation analysis has shown that the tax credit structure under the replacement plan would generally increase costs for certain groups of people buying insurance in the non-group market and decrease costs for others. For example, compared with current law, lower-income individuals, older adults, and those living in rural areas would pay more for insurance on average under the replacement plan, while younger adults, those with higher incomes, and those living in urban areas would pay less.¹

However, the public does not see a distinction in how the replacement plan would impact costs for these different groups of individuals, except when it comes to income. About four in ten Americans expect costs to increase for younger, older, urban-dwelling, and rural-dwelling people buying insurance on the individual market, while between about two in ten and one quarter expect them to decrease. Similarly, almost half (46 percent) think costs would increase for lower-income people buying their own insurance, while one quarter think they would decrease. Views are more divided on how higher-income people buying their own insurance would be affected, with over four in ten (45 percent) saying their costs would be about the same, and about a quarter each saying they would increase (25 percent) or decrease (27 percent).

Public Opinion on the ACA

These views of the replacement plan are set against a backdrop of a public that continues to be divided in its view of the ACA. After shifting in a more favorable direction last month, public opinion on the current health care law mostly holds steady this month, with 49 percent having a favorable view and 44 percent unfavorable. Partisanship continues to underlie these views, with 77 percent of Republicans expressing an unfavorable view, 73 percent of Democrats expressing a favorable one, and independents evenly divided (46 percent favorable, 47 percent unfavorable).

The public also remains divided in their views of repeal, with half (51 percent) saying lawmakers should not vote to repeal the law and 45 percent saying they should vote to repeal it. Of those who want to see Congress vote to repeal the law, more say they want lawmakers to wait to vote to repeal the law until the details of a replacement plan have been worked out (24 percent) than say Congress should vote to repeal the law immediately and work out the details of a replacement plan later (19 percent).

Again, these views are largely driven by party identification, with the vast majority of Republicans (81 percent) saying Congress should vote to repeal the law and a similar share of Democrats (78 percent) saying they do not want the law repealed. Republicans are about evenly divided between those who want Congress to wait to vote on repeal until the details of a replacement plan have been worked out (41 percent) and those who say they should vote to repeal the ACA immediately and work out the details of a replacement plan later (36 percent).

Table 2: Next Steps for the ACA
Percent who would like to see lawmakers do each of the following with the 2010 health care law:	Total	Democrats	Independents	Republicans
Should not vote to repeal	51%	78%	50%	14%
Should vote to repeal (NET)	45	19	46	81
Wait to vote to repeal the law until the details of a replacement plan have been announced	24	9	29	41
Vote to repeal the law immediately and work out the details of a replacement plan later	19	10	15	36

Views on Planned Parenthood Funding

The House replacement bill includes a provision that would block Planned Parenthood for one year from receiving federal funds to provide services to low-income people on Medicaid, including non-abortion services like contraception, testing and treatment for sexually transmitted infections, and cancer screenings. Seventy-five percent of the public thinks Medicaid should continue to pay Planned Parenthood for non-abortion services, while 22 percent think all federal payments to the organization should be stopped.

While there are partisan and gender differences on this question, majorities across groups, including just over half of Republican men (55 percent) and Republican women (57 percent) say that the federal government should continue to pay Planned Parenthood for non-abortion services received by people on Medicaid.

Americans’ attitudes towards federal payments to Planned Parenthood through the Medicaid program are largely stable, with few being persuaded from their opinions after hearing arguments for and against continued funding. Among those who think all federal Medicaid payments to Planned Parenthood should be stopped, about one-third (7 percent of the public overall) change their mind after hearing that this would make it difficult for many lower-income women to access certain health services, including treatment for sexually transmitted infections, cancer screenings, and birth control. On the other hand, a small share of those who initially support continuing current federal Medicaid payments to Planned Parenthood (10 percent overall) shift their opinion to oppose these payments after hearing that even though no federal funding goes directly to abortion services, Planned Parenthood does provide and refer women for abortions.

When asked about services currently provided by Planned Parenthood, most are aware of the variety of health care services provided by the organization including contraception (87 percent), treatment and testing for sexually transmitted infections (80 percent), cancer screenings (68 percent), and abortions (68 percent). Similar shares of women and men are aware that Planned Parenthood provides each of these services.

Awareness is lower when it comes to the question of whether federal funds can be used to pay for abortion services. While the Hyde Amendment currently prohibits federal Medicaid funds from being used to pay for abortions, just one-third (33 percent) of the public is aware of this ban, while almost half (45 percent) say there is not a ban and one in five (21 percent) say they don’t know.

Republicans are less likely than Democrats to be aware that there is a ban on federal funds being used to pay for abortions. One-quarter of Republican women (25 percent) and Republican men (26 percent) are aware of the ban, compared with about four in ten women and about a third of men who identify as Democrats and independents.

Government Role in Women’s Health

Beyond the question of federal funding for Planned Parenthood, more generally, a majority of the public says it is important that the federal government provides funding for reproductive health services including family planning and birth control for lower-income women. While a large majority of Democrats (84 percent) and over half of independents (56 percent) say this is “very” important, the share is much smaller among Republicans (36 percent).

Large majorities of the public also say it is important (either “very” or “somewhat”) for several of the ACA’s requirements affecting women and children to be kept in place in any replacement plan. Roughly eight in ten say that if lawmakers decide to repeal and replace the 2010 health care law, it is “very” important that insurance companies cannot deny coverage to pregnant women (85 percent), that all private health plans must cover the full cost of preventive care with no cost-sharing for women (81 percent) and children (80 percent), and that insurance companies cannot charge women more than men for the same policy (79 percent). Fewer – 54 percent –  say it is very important to keep in place the requirement for health plans to provide birth control with no cost-sharing, but three-quarters (78 percent) say this is at least “somewhat” important.

Large majorities of women, regardless of political party, say keeping most of these requirements in place is very important. One exception is the requirement that private health plans cover the cost of birth control with no cost-sharing, which majorities of women who are Democrats and independents view as very important compared with a smaller share of Republican women (38 percent). Men’s views are more divided by partisanship, with substantially higher shares of men who identify as Democrats saying each requirement is very important compared with Republican men. Three in ten Republican men (31 percent) say it is very important that the requirement for private health plans to cover the full cost of birth control is kept in place if the ACA is repealed.

Table 3: Strong Support for Keeping in Place ACA Provisions Aimed at Women’s Health Services
	Male			Female
	Dems	Inds	Reps	Dems	Inds	Reps
Percent who say it is very important to them that each of the following requirements be kept in place if lawmakers decide to repeal the 2010 health care law:
Private health insurance companies cannot deny coverage to pregnant women	92%	78%	72%	97%	85%	80%
Private health plans must cover mammograms and cervical cancer screenings with no out-of-pocket costs	91	73	54	94	84	77
Private health plans must cover preventive care for children, including vaccinations, with no out-of-pocket costs	90	74	57	94	84	73
Private health insurance companies cannot charge women more than men for the same policy	83	73	59	92	83	81
Private health plans must cover the cost of birth control with no out-of-pocket costs	62	39	31	79	57	38

A large majority of the public (89 percent) also supports the ACA’s requirement that all private health plans must include coverage for maternity care,  including 86 percent of Republicans and 94 percent of Democrats.

Views on this requirement are somewhat malleable. When those who initially support the requirement are read the argument that it means some people have to pay for benefits they do not use, about a quarter (22 percent of the public overall) change their mind so that 31 percent overall oppose the requirement. Still, a solid majority of 65 percent continues to support the requirement for all private health plans to include coverage for maternity care after this argument is read.

Buying Insurance Across State Lines

President Trump and Republican leaders in Congress have supported the idea of allowing insurers to sell their plans across state lines as a way to drive down insurance costs, though this provision is not included in the current House repeal and replace legislation.² Overall, nearly two-thirds of Americans (64 percent) generally favor this proposal while three in ten (28 percent) oppose it. These attitudes are fairly malleable with both those who favor and oppose this policy being persuaded after hearing counter-messages.

Among the 28 percent who originally oppose this policy, four in ten (12 percent of the public overall) change their opinion after hearing that allowing the sale of insurance across state lines could encourage competition and decrease costs for consumers, increasing the total share who favor the policy to 76 percent.

On the other side, among the 64 percent who originally said they favor the policy, about half (30 percent of the public overall) change their opinion after hearing the argument that allowing the sale of insurance across state lines could encourage insurers to operate from states with fewer consumer protections and make it harder for people to get help if they have a problem with their plans, increasing the total share who oppose selling insurance across state lines to 57 percent.

Awareness of Key ACA Provisions

As the focus of debate moves away from the ACA itself and on to potential replacement plans, the public’s awareness of what the 2010 health care law actually does is somewhat uneven. While large majorities are aware of many of the ACA’s key provisions, others are less well-known. A large majority of the public is aware that the ACA allows young adults to stay on their parents’ insurance until age 26 (83 percent) and that it requires nearly all Americans to have health insurance or pay a fine (82 percent). Between six and seven in ten are aware the law requires insurance plans purchased by individuals to include a minimum package of benefits (71 percent), that it provides financial help to low-and moderate-income Americans who do not get coverage through an employer (69 percent), that it gives states the option of expanding Medicaid (65 percent), that it prohibits insurers from denying coverage to those with pre-existing conditions (60 percent), and that it requires health insurance plans to cover the cost of children’s preventive services, including immunizations, with no cost-sharing (59 percent).

Smaller shares – about half the public – know that the law eliminates out-of-pocket costs for preventive health care services (53 percent) and birth control (47 percent). Fewer still – 42 percent – are aware that the law prohibits insurance companies from charging women more than men.

At the same time, misconceptions about the law remain. Half (50 percent) incorrectly believe the ACA allows undocumented immigrants to receive financial help from the government to buy health insurance, and four in ten (40 percent) mistakenly think it cuts benefits for people in the traditional Medicare program.