Introduction

While global trends show maternal morbidity and mortality improving, the U.S. stands out as one of the only countries where maternal morbidity and mortality have actually worsened over the last few decades. The U.S. has lagged behind other high-income countries, often attributed to poor access to prenatal care, high rates of chronic disease, and the highest rate of skipping necessary health care due to cost barriers. Poorer obstetrical outcomes are particularly pronounced among Black women and American Indian/Alaska Native women, as well as women living in rural areas. Ten million women in the U.S. live in rural counties where obstetricians are scarce and pregnant people often must travel significant distances to access care due to hospital closures. A recent study found that rural residents have a 9% greater likelihood of severe maternal morbidity/mortality than their urban counterparts because of factors including workforce shortages, transportation barriers, the opioid epidemic and limited access to specialty care.

Telemedicine, or telehealth, is one proposed method to address these disparities, defined broadly as the provision of health care services by health care professionals, using technology to exchange information in the diagnosis, treatment and prevention of disease. In fact, the American College of Obstetricians and Gynecologists (ACOG) has endorsed telemedicine to improve maternal morbidity and mortality, encourages OBGYNs to adopt these technologies. ACOG writes that telehealth opportunities “enhance, not replace, the current standard of care.” This brief outlines how telemedicine is currently used in obstetrical care, how these services are financed and regulated, and reviews federal efforts to expand the use of telemedicine, particularly to address maternal health disparities.

Telemedicine in Obstetrical Care

A broad range of pregnancy-related services can be offered via telemedicine. Telemedicine has been used for innovative approaches to prenatal/postpartum care, at-home monitoring for conditions like diabetes and hypertension, and for phone/video consultation with specialists (i.e. high-risk obstetricians, lactation consultants, mental healthcare providers) (Figure 1).

Utilization for pregnancy-related care is very low. Using a sample of outpatient medical claims of reproductive age women enrolled in large employer plans, KFF analyzed telemedicine utilization within the following domains of pregnancy-related care: supervision of normal and high-risk pregnancies, mental health disorders associated with pregnancy and lactation services.¹  Of all de-duplicated claims analyzed within pregnancy-related care, just 0.1% were delivered via telemedicine. The majority of telehealth encounters took place over the phone, while a minority took place online. Examples of the claims delivered via telemedicine included visits for lactation complications, postpartum mood disturbances, postpartum follow up and routine prenatal care. These data do not include uninsured patients or patients with public insurance, and also may not capture services delivered using bundled payment plans for pregnancy care.

Prenatal Care: Reducing the Need to Travel

Traditional prenatal care models recommend upwards of 14 in-person visits²  throughout pregnancy. This requires significant travel time and time away from work or family responsibilities. But only some prenatal visits truly require in-person care, like those for ultrasounds, lab testing and vaccinations. Many visits are to provide patient education, answer questions and monitor maternal and fetal vitals, measurements that could be taken at home if given the supplies. Research suggests that fewer prenatal visits are safe for low-risk pregnancies. In response, some medical centers have started to use telemedicine “virtual visits” via videoconference or phone to replace some in-person visits. Patients are given instructions and supplies to monitor blood pressure, weight, fetal heart rate and fundal height at home. These programs allow for patients to maintain continuity of care with their OB providers, while partaking in parts of their care from home or a convenient location. This can be especially helpful for patients who need to travel long distances to care, or have barriers to taking time off from work or family responsibilities. Figure 2 provides an example of how a virtual prenatal care schedule may compare to traditional care.

Currently, the vast majority of prenatal care in the U.S. happens in-person, but there are some medical centers who have begun to implement telemedicine in their prenatal care (Table 1). Research shows comparable pregnancy outcomes between telemedicine and traditional care groups, with the caveat that in one program, patients using virtual visits had a higher incidence of preeclampsia than in traditional care. Telemedicine was also saved patients time and potentially lowered visit-related costs to the patient.

At-Home Monitoring

High risk pregnancies can also benefit from telemedicine, particularly through use of at-home monitoring for high blood pressure and diabetes, which is then transmitted to their providers. Studies show patients value at-home monitoring, as it allows for active participation in their care and promotes self-efficacy. For patients with diabetes, at-home monitoring of blood sugar may allow for fewer visits to diabetes specialists, and improved health-related quality of life. A review of 7 studies found the use of telemedicine for blood sugar monitoring was as effective as standard care in achieving glucose control in pregnancy. Multiple studies of women with gestational diabetes showed similar pregnancy outcomes between telemedicine and traditional care.

Hypertension management normally requires frequent in-person checks.³  With telemedicine, patients may monitor their blood pressure at home, with results sent to their providers who can decide if they need in-person evaluation. Two studies of women with hypertension in pregnancy (both prenatal and postpartum) found at-home blood pressure measurement was feasible in detecting spikes in blood pressure and acceptable to most patients. More research is warranted to compare blood pressure control and pregnancy outcomes between telemedicine and traditional in-person models.

Consultation with Specialists

Many rural areas lack access to specialists, in particular maternal-fetal medicine doctors (MFMs) (high risk obstetricians). In fact, in 2010, there were only 1,355 MFMs across the entire U.S., with nearly all in urban centers. With telemedicine, patients and their local prenatal care providers can videoconference with a MFM or other specialist rather than traveling to see them in-person. Specialists can not only evaluate patients remotely and recommend management plans using this technology, but can even review ultrasound imaging as a remote technician conducts the exam. Telemedicine can also connect patients to genetic counselors, fetal cardiologists, and diabetes educators (Table 2).

Evaluations of these programs show that remote consults are generally feasible, acceptable to patients, and can save patients time and money on travel. Telemedicine may also increase access to specialty care for patients who may otherwise forgo this care due to lack of availability in their communities. Having specialists accessible via telemedicine may also encourage local providers to maintain care of their high-risk patients and safely facilitate more deliveries in nearby hospitals.

Communication with Providers

Telemedicine can also facilitate direct communication with providers, via online platforms or web-based apps. For example, participants in the Mayo Clinic telemedicine program can message nurses and peers through an online platform. Similarly, on Due Date Plus, a free mobile app created by Wyoming Medicaid patients can directly access nursing support. This app also includes pregnancy education, appointment reminders and information about Medicaid benefits and providers. A study of 85 app users compared to over 5000 non-users found app use was associated with a lower risk of delivering a low birth weight infant and a higher likelihood of completing prenatal care appointments.

Postpartum Visits

Postpartum care is key to addressing not only the physical well-being of the patient after delivery, but also their emotional and social well-being, breastfeeding concerns, contraceptive needs, birth spacing and any ongoing chronic disease management. However, the postpartum period, is often overlooked. Traditionally, patients wait 6 weeks before their postpartum visit, even though problems may arise before then. ACOG now recommends contact with the patient within 3 weeks of delivery, but up to 40% of women do not attend any postpartum visit. Use of telemedicine in postpartum care could help address this, through use of app-based support, enhanced phone or text communication with providers, and at-home blood pressure monitoring.

Most programs using telemedicine for prenatal care have a postpartum telemedicine visit built into the program. For example, patients enrolled in MultiCare’s program see a nurse practitioner via a virtual visit at 1 week postpartum, and their doctor in person at 6 weeks postpartum. Patients in the Mayo Clinic program have a phone call with a nurse at 1 week postpartum, before seeing their doctor in clinic at 6-8 weeks. Patients in these telemedicine programs already have monitoring equipment at home, which means they can monitor their blood pressure postpartum, important in delayed preeclampsia.

Lactation Support

Several telemedicine platforms allow individuals with breastfeeding difficulties to access lactation consultants from their home or a nearby telemedicine “hub” (Table 3). These “telelactation” services allow clients to message consultants (typically International Board Certified Lactation Consultants), and participate in virtual visits by phone or videoconference. This model can offer benefits over in-person care, including increased convenience, eliminating travel costs and allowing for more timely delivery of services, often within minutes or hours of when the need arises. Virtual visits can be challenging, however, especially for those with inadequate internet access and limited computer literacy.

A recent review of 23 articles from 2000 to 2018 evaluated lactation support delivered via phone calls, videoconference, text messaging, mobile apps and interactive websites. While evidence in the field is limited due to small sample sizes, researchers found telelactation services were feasible and associated with user satisfaction. In a study of 10 mom-baby pairs who videoconferenced weekly with a lactation consultant, 100% of women were comfortable talking about breastfeeding via videoconference and found the service helpful. Sound quality and connectivity issues were cited as barriers. Further, in a study of 724 women, those who received weekly telephone support from lactation consultants were significantly more likely to continue breastfeeding at 1 and 2 months postpartum as compared to those with standard care.

Obstetrics & Mental Health

Many individuals require mental health services while pregnant or postpartum. This could include help for mood disorders, including postpartum depression and anxiety, postpartum psychosis, trauma, and substance use disorders. Some medical centers have started to offer telemedicine mental health services alongside pregnancy care. The Medical University of South Carolina (MUSC) offers behavioral health telemedicine visits for pregnant/postpartum patients living outside the Charleston area, and accepts most insurance plans. The University of Arkansas Medical Sciences will expand their Women’s Mental Health Program in the upcoming year, to include telemedicine services for pregnant patients. Yale University received a large federal grant to study the use of telemedicine for substance use disorders in pregnancy.

Patients can also access mental health clinicians through Amwell, an online platform offering video visits to diagnosis and treat postpartum depression. This service is accessed completely online, rather than in conjunction with an in-person health system. An initial psychiatry visit costs $199. Follow up visits cost $95; Amwell accepts many private insurance plans but does not accept public insurance at this time.

Research to support use of telemedicine for prenatal/postpartum mental health is limited. A systematic review (10 studies) showed cognitive behavioral therapy via telemedicine (phone, email, app/websites) overall resulted in improvements in maternal depression, although the quality of evidence varied. Preliminary data from another systematic review (4 studies) on telemedicine for postpartum mood disorders suggested improvement in symptoms at 3-12 months post-intervention. The crossover between reproductive health and psychiatry constitutes a growth opportunity in telemedicine, especially given that outside of pregnancy, tele-mental health is reimbursed more often than other specialties.

Cost Considerations

It remains unclear how many of the aforementioned telemedicine services in obstetrics are financed and how cost compares to in-person care. For medical centers experimenting with video visits for prenatal care, these virtual visits may be able to be included as part of a bundled care model, as is the case for the Mayo Clinic OB program. For practices using fee for service models, it is less clear how the cost of using telemedicine would compare to an in-person prenatal care visit. An important consideration when using telemedicine to consult with specialists is for referring providers to ensure consulting providers are in-network for their patients.

For at-home monitoring in pregnancy, purchasing of the monitoring devices poses a challenge to implementing this care model. While some medical practices provide devices free of charge to patients for home monitoring, others require the patients purchase equipment out of pocket, which is prohibitive for low-income patients. This may involve purchasing a scale, blood pressure cuff, fetal doppler monitor and glucometer, not to mention having access to a smartphone or computer with reliable internet.

Coverage Regulations

While the Affordable Care Act (ACA) requires private insurance plans⁴  and Medicaid expansion programs⁵  to cover maternity care without cost sharing to the patient, including prenatal screenings and lactation consultations, there is no federal requirement to reimburse for telemedicine, or telemedicine in pregnancy. Each state regulates and reimburses for telemedicine differently, and regulations differ between public and private insurance plans. In a recent committee opinion, ACOG encouraged insurance companies to provide clear guidelines regarding telehealth coverage and reimbursement, as variation in payment models poses a barrier to telehealth implementation.

Medicaid

In 2018, Medicaid financed 42% of all births in the U.S., including 65% of births for Black women, 59% of births for Hispanic women, and 77% of births for women under 20 years old. Under federal law, Medicaid must cover pregnancy-related services and provide 60 days of postpartum coverage for women with incomes up to 133% of the federal poverty line (FDL), while many state Medicaid programs extend eligibility beyond this income level. While maternity care services may be covered in-person, few states require coverage if delivered via telemedicine.

Only a handful of state Medicaid programs specifically address obstetrical care in their telemedicine reimbursement laws; some choose to explicitly cover services like video visits with an OBGYN or behavioral health provider in pregnancy, real-time OB ultrasounds via telemedicine, and at home monitoring during pregnancy for certain conditions (Table 4). Meanwhile, North Dakota’s Medicaid program specifically excludes coverage of live video services for use in case management for high-risk pregnancies. Only 19 state Medicaid programs reimburse for telemedicine services delivered to the patient in their home, therefore limiting the reimbursement of tele-lactation services and at-home monitoring in pregnancy. Most states do not specifically mention pregnancy-related care in their Medicaid reimbursement laws and policies, meaning these technologies may be out of reach for low-income women.

Private Insurance

No states specifically require private insurance plans to cover pregnancy services in their telemedicine reimbursement laws. However, in approximately half of states, if telemedicine services are shown to be medically necessary and meet the same standards of care as in-person services, private insurance plans must cover telemedicine services if they would normally cover the service in-person, called “service parity.” Fewer states require “payment parity,” meaning telemedicine services are reimbursed at the same rate as equivalent in-person services. Before utilizing telemedicine services during pregnancy, patients would need to check with their insurance carrier for coverage information, as these services are not explicitly required to be covered. KFF’s brief on telemedicine in sexual and reproductive health goes into further detail on how states regulate telemedicine more generally, including licensing/malpractice concerns, online prescribing laws, and reimbursement/coverage of services.

Access and Policy

The majority of pregnant individuals do not have access to telemedicine services at this time. Only a handful of medical centers have adopted telemedicine into their prenatal care schedules. While more have incorporated telemedicine services for specialist consults, including MFMs, lactation consultants and psychiatric care, utilization is minimal. Aside from insurance considerations, barriers to initiating a telemedicine program include significant planning time and start-up costs, reliable broadband connections both at the site of the provider and the patient, HIPPA compliance, and integration into the electronic health record. This can be particularly challenging in low-resource and rural settings; however, efforts are in place by the Federal Communications Commission (FCC) to increase internet access for use in telehealth for these populations. Clinicians must also ensure they are licensed to practice in other states (if applicable), and their malpractice insurance covers telemedicine.

A few states have included telemedicine interventions in their plans for addressing maternal health care disparities. For example, the Montana Obstetric and Maternal Support program launching in 2020 received $10 million from the federal government to address maternal health disparities; the program will focus in part on expanding telehealth interventions, including connecting rural patients and clinicians to OBGYN specialists in urban communities. Similarly, Maine is one of 10 states to receive a Centers for Medicare and Medicaid funded grant to tackle opioid use disorder in pregnancy; part of their approach will include use of telehealth to increase provide capacity across the state. Other states have introduced legislation to expand telemedicine’s use. In 2019, New Jersey proposed bills to create telemedicine practice standards for midwives and genetic counselors. Texas proposed multiple telemedicine projects, including researching the costs/benefits of reimbursing prenatal and postpartum care, establishing a program to treat mood disorders in pregnancy and requiring hospitals to have obstetricians available by telemedicine or in-person at all times, but these efforts all failed to pass. At a federal level, several bills addressing maternal morbidity and mortality have included telemedicine interventions, all of which are currently referred to or in committee (Table 5).

Looking forward

Despite low utilization at this time, there are a myriad of ways telemedicine can be integrated into prenatal and postpartum care. These technologies could be particularly useful in addressing rural-urban health disparities in maternal care, by improving access to specialists like MFMs and mental health providers, enabling at-home monitoring of hypertension and diabetes, and reducing transportation barriers. While these interventions hold great promise in improving access and maternal/infant health disparities, major implementation challenges persist. Nearly half of births in the U.S. are financed by Medicaid, however state Medicaid programs rarely require coverage for telemedicine services in pregnancy, limiting utilization in a significant portion of the pregnant population. In addition, limited internet access among low-income and rural populations and high startup investments for health systems pose challenges to telemedicine’s implementation. Federal and state efforts to support use of telemedicine services for maternity care exist, but expansion of these services will likely depend on decisions regarding insurance coverage and reimbursement. Broadening the reach of telemedicine to more underserved communities may help improve maternal and infant health outcomes.

1. KFF analyzed a sample of medical claims obtained from the 2017 IBM Health Analytics MarketScan Commercial Claims and Encounters Database, which contains claims information provided by large employer plans. We only included claims for women ages 15-44 who were enrolled in a plan for more than half a year. Claims were de-duplicated, meaning they were limited to one claim per person per day. We defined outpatient telemedicine utilization to include any clinical interaction between a patient and health care provider (physician or non-physician), delivered via live-video, remote patient monitoring, store and forward technology or telephone. Telehealth claims were captured using procedure modifiers specific to telehealth, including GT and 95 for synchronous telecommunication and GQ for asynchronous telecommunication, and “place of service 2” to indicate delivery by telemedicine. We also analyzed the following procedure codes specific to telehealth: 99441-99444, 98966-98969, G2010, G2012, G9868-G9870, S9110, G0071. Inpatient and emergency department uses of telemedicine were excluded, as were provider-provider interactions. Codes used to capture pregnancy-related care are as follows: Z34, Z39.2, O09, O10-16, O20-29, O30-48, O85-92, 094-O9A, Z34, Z39.2, O09, O10-16, O24, F53, F53.0, F53.1, O99.34, O99.340, O99.341, O99.342, O99.343, O99.344, O99.345, O90.6, B37.89, L01.00, O91.02, O91.03, O91.13, O91.219, O91.22, O91.23, O92.03, O92.13, O92.20, O92.29, O92.3, O92.4, O92.5, O92.6, O92.70, O92.79, Q83.8, R20.3, Z39.1. CPT codes for ultrasound imaging in pregnancy were also analyzed: 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, 76818, 76819, 76825, 76826). ↩︎
2. Traditional prenatal care models typically recommend 1 visit per month in the 1st trimester, 2 visits per month in the 2nd trimester and 1 visit per week in the 3rd trimester. ACOG now recommends all patients are seem in the first 3 weeks postpartum, but traditionally patients were seen at 6 weeks postpartum. ↩︎
3. ACOG recommends at least weekly or biweekly blood pressure measurement for women with gestational or chronic high blood pressure. ↩︎
4. These requirements apply to most private plans – including individual, small group, large group, and self-insured plans in which employers contract administrative services to a third party. ↩︎
5. These requirements do not apply to traditional Medicaid programs. ↩︎

On December 31, 2019 in Wuhan, China the first cases of a new Coronavirus were reported. Over the span of two months, the virus – also known as COVID-19 to public health experts – has spread beyond Wuhan, across China, and around the world. On January 30, 2020, the World Health Organization (WHO) declared the Coronavirus outbreak a public health emergency of international concern, only the 6th declaration of its kind in WHO history. Subsequently, the U.S. Department of Health and Human Services declared it a public health emergency for the United States on January 31, 2020.

The February KFF Health Tracking Poll gauged the public’s knowledge of and concerns about the Coronavirus in addition to exploring public opinion on how the outbreak is being addressed by the U.S. government.

The public is hearing a lot about the Coronavirus

Our poll indicates that the Coronavirus outbreak is on the public’s radar, with an overwhelming majority saying they have heard or read at least “a little” about the outbreak, and over half (56%) saying they have heard or read “a lot.” In addition, nearly nine in ten (87%) are aware that there have been cases of Coronavirus diagnosed in the U.S. As of February 25, there have been 35 confirmed cases of Coronavirus in the United States, and no confirmed deaths. Track the virus’ spread on the KFF COVID-19 Coronavirus Tracker.

Across demographic groups, substantial shares report having heard “a lot” about the Coronavirus, including large shares across gender, education levels, and health status. Adults ages 50 and older are somewhat more likely than younger adults to have heard or read “a lot” about the outbreak compared to other age groups, with about half of adults under age 50 saying they have heard or read “a lot,” and this share rising to nearly two-thirds among adults ages 50 and older. In addition, roughly half of adults with less than a 4-year college degree say they’ve heard “a lot”, and this share rises to 66% among those with a college degree or higher. These patterns by age and education mirror findings from previous surveys showing that older adults and those with higher levels of education tend to pay closer attention to health news. See Appendix 1 for more information on demographic differences.

The Public IS concerned about the health and economic effects of Coronavirus

Large shares of the public report feeling concerned about various possible effects of the Coronavirus. At the time the survey was fielded (February 13-18, prior to the U.S. stock market decline on February 24), a majority (57%) said they were very or somewhat concerned that the Coronavirus would have a negative impact on the U.S. economy. A similar share (55%) expressed concern that there will be a widespread outbreak of the Coronavirus in the U.S.

On a personal level, a smaller, yet sizeable share (43%) is concerned that they or someone in their family will get sick from the Coronavirus. Those in fair or poor health are more likely to say they are very or somewhat concerned that they or a family member will contract the Coronavirus compared to those who report having an excellent, very good, or good health status (60% vs. 39% respectively). Furthermore, women, people with lower levels of education as well as adults ages 65+ are more likely to be concerned about this possibility than their counterparts (See Appendix 1).

Majorities across partisans say the U.s. government is doing enough in their Coronavirus response, and one in five Report Taking Personal Actions

When it comes to the government’s response, seven in ten (69%) say they think U.S. government officials are “doing enough” to prevent the spread of Coronavirus, including large majorities across partisans. Republicans are most likely to say the U.S. government officials are doing enough (80%), followed by independents (70%) and Democrats (60%).

Despite concerns about the possible effects of Coronavirus on the nation as a whole and on individuals and their families, as of the time of this poll, few say that they have taken personal preventive actions due to the Coronavirus outbreak. Roughly one in ten say they have cancelled or changed their travel plans (13%), or have bought or worn a protective mask due to the Coronavirus outbreak (9%). About two in ten overall (19%) say that they have taken either one of these actions.

Key Findings:

• The U.S. Supreme Court will decide today whether to take up Texas v. United States, which challenges the constitutionality of the 2010 Affordable Care Act (ACA). The February KFF Health Tracking Poll finds attitudes towards the ACA has hit its highest favorability since KFF began tracking opinions nearly ten years ago. The latest KFF poll finds a clear majority of the public viewing the law favorably (55%), while slightly more than one-third (37%) of the public hold unfavorable views.
• The Affordable Care Act took center stage in the Nevada Democratic presidential debate with Vice President Biden attacking Mayor Bloomberg’s record on the ACA. Nearly nine in ten Democrats (85%) and Democratic voters (86%) view the ACA favorably and while most Republicans view the unfavorably, significantly fewer Republicans offer repealing the 2010 health reform law as their top health care issue. Voters, overall, and across party identification, prioritize other health care issues such as health care costs.
• Health care remains a top issue for Democratic voters, independent voters, and the crucial group of voters who haven’t made up their minds yet – swing voters. More than one-third of Democratic voters (36%) say health care is the “most important” issue in their 2020 vote choice as do three in ten independent voters and 28% of swing voters. Yet, when asked what is the one thing that will motivate them to vote in 2020, a larger share of voters offer responses related to defeating President Trump and electing a Democrat than any issue, including health care. When voters who have decided to vote for the Democratic nominee are asked what is most important when choosing a Democratic candidate, a larger share say “a candidate with the best chance to defeat President Trump” (59%) than one “who comes closest to your views on issues” (39%).
• Both a national Medicare-for-all plan and a government-administered public option continue to garner majority support in the KFF Health Tracking Polls, including large shares of Democrats who express positive attitudes towards both proposals. Yet, the public option holds the advantage over a national Medicare-for-all plan when supporters of both are forced to choose one. The public option garners more support among many key groups in the 2020 Democratic primary including swing voters (49% v. 25%).

Health Care Among Top Issues for Voters, But Trump Looms Large

More than eight months before the 2020 general presidential election, health care (26%) and the economy (23%) are the top issues that registered voters say will be most important in deciding their vote for president. This is followed by climate change (14%), foreign policy (13%), immigration (9%), taxes (7%), and international trade and tariffs (2%).

Health care and the economy are also the top issues for these 2020 swing voters, with similar shares saying each is the most important issue in determining their vote choice (28% and 23%, respectively). A previous KFF analysis of swing voters along with The Cook Political Report found that swing voters give Democrats the advantage on health care while President Trump has the advantage on the economy.

More than one-third (36%) of registered voters who identify as Democrats say health care is the most important issue in deciding who they will vote for in 2020 while 29% say climate change is the most important issue, which is consistent with how N.H. Democratic primary voters prioritized these issues. Health care (30%) and the economy (24%) rank as the top issues for independent voters, while the economy (34%) is the top issue for Republican voters.

While health care and the economy are the top issues, President Trump and partisanship are also weighing heavily on the minds of voters. When voters are asked to say in their own words “the one thing that will motivate you to vote in the presidential election in 2020,” a larger share mention President Trump than any single issue including the economy and health care. Swing voters are more divided in their top motivation for voting in 2020 with similar shares offering responses related to defeating President Trump (8%), health care (8%), and the economy (7%).

As expected, the role that President Trump is playing in voters’ minds is largely party-driven with four in ten Democratic voters (39%) and 16% of independent voters offering responses related to defeating President Trump and electing a Democrat as their top motivation, while 28% of Republican voters mention re-electing President Trump or defeating Democrats as their top motivation.

With less than two weeks until March 3^rd, when 11 states will hold their Democratic primary contests or caucuses, the latest KFF Health Tracking Poll finds that two groups that are key to the Democratic nominee winning in 2020 – Democratic voters and swing voters – have different preferences on what is most important when choosing a presidential nominee for the Democratic Party.

A larger share of voters who say they are either “definitely” going to vote for the Democratic nominee in 2020, say it is most important to choose a candidate with the best chance of defeating President Trump (59%) than one who comes closest to your view on issues (39%). Swing voters who are leaning Democrat or undecided, prioritize selecting a candidate who comes closest to their views on the issues (78%) over a candidate with the best chance of defeating President Trump (18%).

2010 Affordable Care Act

The most recent KFF Health Tracking Poll finds 55% of the public now favoring the 2010 Affordable Care Act (ACA) – marking the highest overall favorability recorded since KFF began tracking it in April 2010. This slight uptick is largely driven by a continued support among Democrats with 85% now expressing favorable views compared to 53% of independents and 18% of Republicans. A majority of Republicans (77%) continue to hold unfavorable views towards the law.

The role that the Affordable Care Act is playing during the 2020 presidential election is quite different than how it was in 2016, especially among Republican voters. While most Republican voters (84%) hold unfavorable views towards the ACA, few offer it when asked to say in their own words what about health care is important to their vote. Three percent of Republican voters offer opposition to or repealing the ACA as their top health care issue in the most recent KFF Tracking Poll. This is a considerable decrease from the 2016 presidential election, during which three in ten (29%) Republican voters offered it as their top health care issue. It is also a decline from the 2018 midterm elections in which 18% of Republican voters mentioned opposition to the ACA or repealing the ACA as their top health care issue.

Now when voters are asked to say in their own words what is it about health care that is important to their vote, Republican voters are more likely to mention health care costs (24%), opposition to single-payer or Medicare-for-all (19%), or increasing access to health care (15%).

Health care costs are also important to Democratic voters (24%) and independent voters (24%); however, a similar share of Democratic voters and independent voters offer responses related to increasing access (32% and 20%, respectively).

Health Care In The Democratic Primary: Medicare-for-all and Public Option

One of the major health policy stories of the 2020 Democratic presidential campaign has been the divide between the top candidates on proposals to expand the public health insurance program in this country. KFF has been tracking public opinion on both a national health plan, sometimes called Medicare-for-all, as well as more incremental changes such as an optional government-administered health plan, sometimes called a public option. About half (52%) of the public favor a Medicare-for-all plan in which all Americans would get their insurance from a single government plan, while two-thirds favor a public option that would compete with private health plans and be available to all Americans.

Four in ten Americans (43%) favor both a national Medicare-for-all plan and a government-administered public option including six in ten (62%) Democrats and four in ten (43%) independents. A smaller share (17 percent) of Republicans favor both Medicare-for-all and a public option, while half of Republicans oppose both plans.

Choosing One: Medicare-for-all or Public Option

With the 2020 Democratic primary candidates strongly debating the two proposals, this month’s KFF poll wanted to see what happens to attitudes when voters are forced to choose between a national Medicare-for-all plan and a government-administered public option. When voters who favor both a national Medicare-for-all plan and a government-administered public option (40% of all registered voters) are asked which proposal they prefer, the public option retains its edge. More than four in ten voters (44%) either only favor a public option (26%) or prefer it (18%) compared to one-fourth of voters (26%) who either only favor a national Medicare-for-all plan (7%) or prefer it over a public option (20%).

A government-administered public option has the edge over a national Medicare-for-all plan among Democratic voters, independent voters, and Republican voters; however, a significant share of Democratic voters (39%) either only favor or prefer a national Medicare-for-all plan.

A government-administered public option also holds the advantage over a national Medicare-for-all plan among Democratic voters (51% v. 39%), independent voters (45% v. 24%), and swing voters (49% v. 25%).

This KFF Health Tracking Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted February 13th -18th, 2020, among a nationally representative random digit dial telephone sample of 1,207 adults ages 18 and older, living in the United States, including Alaska and Hawaii (note: persons without a telephone could not be included in the random selection process). The sample included 290 respondents reached by calling back respondents that had previously completed an interview on the KFF Tracking poll at least nine months ago. Computer-assisted telephone interviews conducted by landline (302) and cell phone (905, including 629 who had no landline telephone) were carried out in English and Spanish by SSRS of Glen Mills, PA. To efficiently obtain a sample of lower-income and non-White respondents, the sample also included an oversample of prepaid (pay-as-you-go) telephone numbers (25% of the cell phone sample consisted of prepaid numbers) as well as a subsample of respondents who had previously completed Spanish language interviews on the SSRS Omnibus poll (n=10). Both the random digit dial landline and cell phone samples were provided by Marketing Systems Group (MSG). For the landline sample, respondents were selected by asking for the youngest adult male or female currently at home based on a random rotation. If no one of that gender was available, interviewers asked to speak with the youngest adult of the opposite gender. For the cell phone sample, interviews were conducted with the adult who answered the phone. KFF paid for all costs associated with the survey.

The combined landline and cell phone sample was weighted to balance the sample demographics to match estimates for the national population using data from the Census Bureau’s 2018 American Community Survey (ACS) on sex, age, education, race, Hispanic origin, and region along with data from the 2010 Census on population density. The sample was also weighted to match current patterns of telephone use using data from the July-December 2018 National Health Interview Survey. The weight takes into account the fact that respondents with both a landline and cell phone have a higher probability of selection in the combined sample and also adjusts for the household size for the landline sample, and design modifications, namely, the oversampling of prepaid cell phones and likelihood of non-response for the re-contacted sample. All statistical tests of significance account for the effect of weighting.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll. Kaiser Family Foundation public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.