Survey of Kentucky Residents on State Health Policy
Kentucky has received national attention as the only Southern state to fully embrace the Affordable Care Act (ACA) by creating its own state-based health insurance marketplace and by choosing to expand Medicaid to cover more low-income adults. Roughly 425,000 state residents have gained Medicaid coverage since the expansion, and among all states, Kentucky had the second-highest drop in its uninsured rate. On November 3, Republican Matt Bevin was elected as the state’s next governor after promising during his campaign to roll back the Medicaid expansion, end the state marketplace (known as Kynect), and switch Kentucky to the federal marketplace. In light of this, the Kaiser Family Foundation conducted a survey of Kentucky residents to gauge their views on health care policy in the state, including their preferences for the future of the Medicaid expansion and Kynect. This is the Foundation’s second poll of Kentucky residents, following a survey of four Southern states – including Kentucky – conducted in partnership with The New York Times in April 2014.
The poll finds that Kentuckians are divided, leaning negative in their views of the ACA in general (41 percent favorable, 49 percent unfavorable), but they feel more positively about the two biggest ways the law has played out in their state. Over six in ten (63 percent) have a favorable view of the Medicaid expansion, and more have a favorable than an unfavorable view of Kynect (42 percent versus 28 percent, with 29 percent saying they don’t know enough to say). Asked about next steps, more than seven in ten residents (72 percent) say they would prefer to keep the state’s Medicaid program as it is today rather than change it to cover fewer people. One in five (20 percent) would prefer to scale back the program so that fewer people are covered. When it comes to the health insurance marketplace, about half (52 percent) want the new governor to keep Kynect, while roughly a quarter (26 percent) would prefer to switch to the federal marketplace and 18 percent aren’t sure. As in the nation as a whole, Kentuckians’ views on the ACA and its provisions divide sharply along party lines. However, when it comes to Medicaid, even 54 percent of Republicans and 43 percent of those who say they voted for Governor Bevin would prefer to keep Medicaid as it is today rather than scale it back to cover fewer people.
Underlying these preferences is a belief among most residents that Medicaid is important and working well. Personal connections may also play a role, as a majority of residents say they know someone who has gotten coverage either through Kynect or from Medicaid. Still, despite this support for keeping Kynect and the Medicaid expansion in place, residents are somewhat divided as to the impacts these changes have had on the state so far. Six in ten (61 percent) recognize that the number of uninsured in the state has declined, but residents are more divided on whether Kynect and the Medicaid expansion have made it easier or harder for Kentucky residents to get, keep, and afford insurance, and most don’t feel there has been an impact on them personally. While campaigning, Governor Bevin made the argument that Kentucky can’t afford the recent health care expansion, and this argument resonates with many residents. Nearly four in ten (37 percent) say the impact of Kynect and the Medicaid expansion on the state budget has been negative, compared with 18 percent who say it’s been positive (the remainder either say there hasn’t been much impact or they aren’t sure). However there is much confusion over who pays for the Medicaid expansion; only 16 percent of residents know that the federal government pays for most of the cost of the expansion, while about a quarter (24 percent) think the state picks up the majority of the tab and four in ten (39 percent) think the costs are shared equally.
Health Care as a Priority for State Residents
Discussions of health care were prominent in the campaign for Kentucky governor, and that focus is reflected in the list of issues residents want state lawmakers to address going forward. About a quarter (24 percent) of residents name a health care-related issue as one of the top two issues they would like state policymakers to focus on in 2016, ranking above other issues such as jobs (14 percent), education (11 percent), and crime (7 percent).
Health care tops the priority list for Kentucky residents across parties, but is mentioned by a somewhat higher share of Democrats (30 percent) compared with Republicans (21 percent), along with 23 percent of independents. Among those who say they voted in the gubernatorial election, health care is named as a top priority by 42 percent of those who report voting for Attorney General Jack Conway, the Democratic candidate, and a smaller share (28 percent) of those who say they voted for Governor Bevin.
The 24 percent of state residents who name health care as a top priority express a variety of specific concerns when asked to expand in their own words on what they want lawmakers to focus on. Almost three in ten (28 percent) of this group mention health care costs and affordability, and a similar share (26 percent) mention maintaining the ACA coverage expansions in Kentucky. Fifteen percent of those who name health care as a priority give the opposite response, saying they want lawmakers to eliminate or scale back the coverage expansions.
General Views on the ACA, Kynect, and Medicaid Expansion
When it comes to the ACA, the views of Kentucky residents lean negative on the law as a whole, but are more positive towards the programs the law has created in the state. About half (49 percent) say they have an unfavorable view of the health care law while about four in ten (41 percent) have a favorable view. When told that Kentucky expanded its Medicaid program under the health care law and asked their view of that expansion, more than six in ten (63 percent) say they have a favorable view and about a quarter (24 percent) are unfavorable. Residents are also more likely to have a favorable rather than an unfavorable view of the state health insurance marketplace, Kynect (42 percent versus 28 percent), though about three in ten (29 percent) say they don’t know enough to say. Among those who say they know “a lot” or “some” about the state marketplace, 58 percent have a favorable view and 34 percent are unfavorable.
Views on the Future of Medicaid Expansion in Kentucky
When asked about next steps for the Medicaid expansion in the state, over seven in ten Kentuckians (72 percent) say they think Governor Bevin should keep Medicaid as it is today rather than changing the program to cover fewer people. One in five (20 percent) would prefer to scale back Medicaid so that fewer people are covered. Large majorities of both Democrats (89 percent) and independents (75 percent) favor keeping Medicaid as is over changes that would reduce the number of people covered, as do a slim majority (54 percent) of Republicans. The contrast is sharper among those who report voting in the recent gubernatorial election; 92 percent of those who report voting for Attorney General Jack Conway want to keep Medicaid as is, while those who say they voted for Governor Bevin are more divided (50 percent want to scale back Medicaid to cover fewer people and 43 percent want to keep it as it is today).
When those who say they prefer keeping Medicaid as it is today are read arguments about the cost of the expansion, some change their mind, but a majority continues to support keeping the program as is rather than scaling it back to cover fewer people. For example, after being told that Governor Bevin has said the current Medicaid program is unsustainable and unaffordable, 59 percent say they still want Medicaid kept as it is today, while 8 percent switch their position, for a total of 28 percent who want to scale back the program so fewer people are covered. When read the argument that “keeping Medicaid as it is today will require Kentucky to spend more money on Medicaid in the future, even though the federal government would be picking up most of the cost,” 61 percent continue to support keeping Medicaid as it is today, while 6 percent switch their position, for a total of 26 percent who support scaling back the program to cover fewer people after hearing this argument.
On the other side, few of those who want to scale back Medicaid to cover fewer people change their minds when read arguments in favor of keeping the program as it is today. Support for keeping Medicaid as is inches up from 72 percent to 75 percent when initial opponents are told that scaling back Medicaid to cover fewer people would mean “Kentucky would be giving up additional federal dollars for covering uninsured residents,” and also up to 75 percent with the argument that “some people would lose the coverage they have now, and many low-income people would be left without insurance.”
Views of the Future of Kynect
In terms of next steps for the state health insurance marketplace, just over half (52 percent) of state residents want the new governor to keep Kynect, about one quarter (26 percent) want him to switch to the federal marketplace healthcare.gov, and almost one in five (19 percent) say they don’t know enough to say. Among those who say they know “a lot” or “some” about Kynect, support for keeping the state-based marketplace is somewhat higher (59 percent). A majority of Democrats (70 percent) and about half of independents (52 percent) prefer to keep Kynect, while Republicans are more evenly divided (38 percent want Kentucky to switch to the federal marketplace and 35 percent prefer to keep Kynect). Among those who report voting for Governor Bevin, more than twice as many want to switch to the federal marketplace as want to keep the state-run marketplace (53 percent versus 24 percent).
Arguments for and against keeping the state-based marketplace have the potential to move the needle on residents’ views. When those who support keeping Kynect are told that Governor Bevin has said Kentucky could save money by switching to the federal marketplace, some people change their position so that support for keeping Kynect drops below a majority, to 39 percent, while the share wanting to switch to the federal marketplace increases to 33 percent.
On the other side, when those who support switching to the federal marketplace are read the argument that “dismantling the state health insurance marketplace would cost Kentucky 23 million dollars and waste the financial investment that has already been made,” support for keeping Kynect increases from 52 percent to 59 percent, while 15 percent continue to prefer switching to the federal marketplace.
Underlying Views and Personal Connections to Medicaid and Kynect
Underlying residents’ general support for keeping the Medicaid expansion and Kynect in place is a sense that Medicaid is important and that it’s working well. A majority of Kentuckians (56 percent) say that Medicaid is either “very important” or “somewhat important” for them and their family. Among those who feel Medicaid is important, eight in ten, or 46 percent of all adults in Kentucky, say a reason they feel the program is important is because they or someone they know has received health care paid for by Medicaid.
Two-thirds (67 percent) of state residents also feel the Medicaid program is working well for most low-income people in Kentucky, a share that rises to 84 percent among those under age 65 who report that they are personally covered by Medicaid.
Most Kentucky residents also report some level of personal connection to Medicaid and/or Kynect. More than half (56 percent) say they know someone who got health insurance through Kynect, including 11 percent who say they personally got coverage through the marketplace. In total, 65 percent say they know an adult with Medicaid coverage, either from Kynect or otherwise. Overall, 15 percent of adults in the state report that Medicaid is their own main source of health insurance coverage, including 17 percent of those under age 65.
Views on the Effects of Kynect and Medicaid Expansion in Kentucky
Despite their general support for keeping the Medicaid expansion and Kynect intact, Kentucky residents are somewhat divided as to the impacts these changes have had for people in the state. Reflecting the fact that Kentucky has seen a large decline in the uninsured rate, about six in ten residents (61 percent) believe that Kynect and the expansion of Medicaid have reduced the number of uninsured in Kentucky. This share is up slightly from 52 percent who thought that the health care law had reduced the number of uninsured in a Kaiser Family Foundation/New York Times poll of Kentucky residents in April 2014. However, some residents hold the opposite view, with about almost four in ten (37 percent) believing that Kynect and the Medicaid expansion have caused many people in Kentucky to lose their health insurance.
Kentuckians’ views are also somewhat divided when it comes to how Kynect and Medicaid expansion have affected health insurance affordability and access. More than a third (36 percent) say the programs have made insurance more affordable for people in Kentucky, about the same share (32 percent) say they’ve made it less affordable and one in five (21 percent) say there hasn’t been much difference. Views are also divided, but tilting more positive, on access to insurance. About four in ten (41 percent) say Kynect and the Medicaid expansion have made it easier for people in the state to get and keep health insurance, while somewhat fewer (29 percent) say they’ve made it harder and 19 percent don’t see much difference.
Most residents say Kynect and the Medicaid expansion haven’t had much impact on their own ability to get and keep insurance (59 percent), and about half say they haven’t personally felt an impact in insurance affordability (49 percent). While at least four in ten across income categories say they haven’t seen a personal change in these areas, those with incomes below $20,000 a year are more likely to say recent changes in the state have made insurance more affordable and easier for them to access, while those with higher incomes are more likely to feel their own situations have been negatively affected in these areas.
One area where residents are more likely to see a negative rather than a positive impact of Kynect and the Medicaid expansion is on the state budget. About twice as many say the programs’ impact on the state budget has been negative (37 percent) as say it has been positive (18 percent), while one quarter (25 percent) say there hasn’t been much impact, and a fifth (20 percent) say they’re not sure. The share believing the impact on the state budget has been negative rises to 57 percent among Republicans, and to 66 percent among those who report voting for Governor Bevin.
While health care is a salient issue for many adults in Kentucky, not all are familiar with some of the basic facts about Kynect and Medicaid. One area where there is a large amount of confusion is the issue of who pays for the cost of expanding Medicaid under the health care law. When asked about the source of funding, only 16 percent of state residents correctly answer that the federal government pays for nearly all the costs of expanding Medicaid to cover more low-income adults, while about a quarter (24 percent) think the state government picks up most of the tab and 39 percent think the federal and state governments share costs equally.
Awareness gaps exist in other areas as well. About a third of residents say they know “a lot” (12 percent) or “some” (22 percent) about the state insurance marketplace, while about two-thirds say they know “only a little” (31 percent) or “nothing at all” (34 percent). Just over half (56 percent) are aware that Kynect was created as a result of the ACA, while 15 percent say the creation of the marketplace was unrelated to the health care law and 29 percent say they don’t know enough to say. Similarly, about half (51 percent) are aware that Kentucky expanded its Medicaid program under the ACA, while the other half either think the state did not expand Medicaid (15 percent) or say they don’t know (34 percent).