Key Findings:

• Congress is back in session and the public sees many health care issues as a “top priority” for Congress to work on including lowering prescription drug costs (70%), making sure the Affordable Care Act’s (ACA) protections for people with pre-existing conditions continue (69%), lowering the amount people pay for health care (64%), and protecting people from surprise medical bills (56%).
• One of the health care issues that Congress may take on this fall is legislation aimed at dealing with “surprise medical bills.” This month’s KFF Health Tracking Poll finds nearly eight in ten (78%), including majorities of partisans, support legislation protecting patients from paying the cost of care not covered by their insurance when they receive care from a provider or hospital who is not in their network. A majority of the public (57%) continue to support this legislation even after hearing an opposing argument that this legislation would lead to doctors and hospitals being paid less.
• Overall favorability of the ACA is slightly up this month (53%) with more than eight in ten Democrats viewing the ACA favorably (84%) – that is the largest share of Democrats with favorable views of the 2010 health reform law measured in the nine years of KFF Health Tracking Polls. The share of Democrats who hold favorable views of the ACA has increased 11 percentage points over President Trump’s term, up from 73% in February 2017.

  55% of Democrats and Democratic-leaning independents prefer a presidential candidate who wants to build on the ACA, compared to 40% who prefer a candidate who would replace it with #MedicareForAll, via @KFF poll

• With ACA favorability among Democrats at an all-time high, this month’s tracking poll also finds that leading up to the 2020 presidential election, most Democrats and Democratic-leaning independents would prefer to vote for a candidate who wants to build on the existing ACA in order to expand coverage and lower costs (55%) than replace the ACA with a national Medicare-for-all plan (40%). Among those who would prefer to vote for a candidate who wants to replace the ACA with a national health plan, few (14% of all Democrats and Democratic-leaning independents) say they would only vote for a candidate who wants to replace the ACA with Medicare-for-all.
• Nearly seven in ten (69%) of the public favor a so-called “public option” (a government-administered health plan that would compete with private health insurance plans and be available to all Americans), while about half (53%) favor “Medicare-for-all” (a national health plan in which all Americans would get their insurance from a single government plan). These remain relatively unchanged since the July KFF Health Tracking Poll.
• A week before the third round of Democratic presidential primary debates, about half (51%) of Democrats and Democratic-leaning independents say they want to know more about the Democratic candidates’ positions on health care. The health care topics they want to hear more about range from specific details about the candidates’ health plans (15%), how a national Medicare-for-all plan would work (13%), how the candidates will implement their plans (11%), how the candidates will pay for their health care plans (8%), and how the candidates plan to bring down health care costs (8%).

Health Care Priorities For Congress

The latest KFF Health Tracking Poll finds most Americans say many health care policy items included in the survey should be at the top of a busy Congressional agenda this fall. Majorities of the public say lowering prescription drug costs (70%), making sure the Affordable Care Act’s protections for people with pre-existing conditions continue (69%), lowering the amount people pay for health care (64%), and protecting people from surprise medical bills (56%) are all “top priorities” for Congress to work on in the coming year. Fewer (32%) say expanding government financial help to those who buy their own insurance coverage on the ACA marketplaces to include more people is a “top priority,” which is similar to the share who rank the other, more partisan health care actions as top priorities. Three in ten say implementing a national Medicare-for-all plan or repealing and replacing the ACA should be top priorities for Congress.

Drug prices, pre-existing conditions and out-of-pocket cost top the public’s list of health care priorities in this September @KFF poll. Majorities across political parties cite each as “top” priorities for Congress to address.

Majorities of Democrats, independents, and Republicans say lowering health care costs and maintaining the ACA’s protections for people with pre-existing conditions should be top priorities for Congress. At least seven in ten Democrats say maintaining the ACA’s pre-existing condition protections (87%), lowering prescription drug costs (81%), and lowering the amount people pay for health care (72%) are a “top priority” for Congress, as do two-thirds of independents (68%, 66%, and 65%, respectively). Fewer – but still at least half of Republicans also rank all of these a “top priority” (51%, 62%, and 51%, respectively). Republicans and Democrats disagree on the more partisan health care priorities with large shares of Democrats saying expanding financial help to those who buy their own coverage on the ACA marketplaces (49%) and implementing a national Medicare-for-all plan (44%) are top priorities for Congress, while a large share of Republicans (46%) say repealing and replacing the ACA is a top priority.

When forced to choose which is more important for Congress to work on: making sure all Americans have health insurance coverage or lowering the amount people pay for their health care premium, deductibles, and prescription drugs; the public leans slightly towards lowering costs. Half of the public say it is more important for Congress to work on lowering the amount people pay for health care while 44% say it is more important for Congress to work on expanding coverage to all Americans.

There are distinct partisan differences with majorities of Republicans (76%) saying it is more important for Congress to work on bringing down health care costs while two-thirds of Democrats (68%) choose making sure all Americans have health insurance coverage as the more important of the two health care objectives. Independents are more divided with a slightly larger share saying it is more important for Congress to work on bringing down health care costs (53%) than expanding health care coverage (42%).

Congressional Action on Surprise Medical Bills

One of the health care issues that Congress may take on this fall is legislation aimed at dealing with “surprise medical bills.” The term “surprise medical bills,” describes charges from when an insured individual inadvertently receives care from an out-of-network provider either during an emergency or routine care.¹  Previous KFF polling has found that majorities of the public say the federal government should take action to protect patients from having to pay these surprise medical bills. This month’s KFF Health Tracking Poll finds nearly eight in ten (78%) support legislation protecting patients from paying the cost of care not covered by their insurance when they receive care from a provider or hospital who is not in their network. This includes a majority of Democrats (84%), independents (78%), and Republicans (71%) who support this legislation.

A majority of the public (57%) continue to support this legislation even after hearing opponents’ argument that this legislation would lead to doctors and hospitals being paid less. About one-fifth (17%) now oppose the legislation after hearing this counter-argument bringing total opposition to this legislation up to 37%.   

Proposals Aimed At Expanding Coverage

This month’s KFF Health Tracking Poll continues to track public opinion on two proposals that would expand the role of public programs in health care: a national Medicare-for-all plan and a government-administered health plan known commonly as a “public option.”

While Democratic presidential candidates are debating the merits of their various health care proposals, fewer than half of the public overall – and fewer than half of Democrats – think there are differences between a national Medicare-for-all plan that would have all Americans get their health care coverage from a single government plan and a government-administered health plan public option. About half of the public (47%) say the two proposals are either “very similar” or “somewhat similar,” while a nearly equal share (44%) say the two proposals are either “very different” or “somewhat different.” There are no partisan differences in the perceptions of the similarities of the two proposals.

Half (51%) of the public say they have heard at least some about a national Medicare-for-all plan, fewer have heard about the public option. Nearly two-thirds (64%) of the public say they have heard either “a little” or “nothing at all” about a government-administered health plan, sometimes called a public option.

Overall, favorability of both a national Medicare-for-all plan and a government-administered health plan holds steady since July 2019. Nearly seven in ten (69%) favor having a government-administered health plan that would compete with private health insurance plans and be available to all Americans, while about half (53%) favor a national health plan in which all Americans would get their insurance from a single government plan.

Majorities of Democrats and independents continue to favor both of these proposals aimed at expanding coverage, while majorities of Republicans oppose – with significant shares of Republicans saying they “strongly oppose.” Seven in ten Republicans (69%) “strongly oppose” a national Medicare-for-all plan while four in ten (39%) “strongly oppose” a government-administered public option.

Are Democrats Rallying Around The Affordable Care Act?

Since President Trump took office in January 2017, public opinion towards the Affordable Care Act (ACA) has slowly increased in popularity with 53% of the public now holding favorable opinions in the most recent KFF Health Tracking Poll.

Attitudes towards President Obama’s health reform law have largely been driven by party identification with most Democrats viewing the ACA favorably (84%) while most Republicans hold unfavorable views towards the law (79%). The increase in favorability over the past several years is also largely driven by an increasing share of Democrats viewing the law favorably. The share of Democrats who hold favorable views of the ACA has increased 11 percentage points over President Trump’s term, up from 73% in February 2017. Republican views towards the ACA have stayed relatively stable over the same time period.

Leading up to the 2020 presidential election, most Democrats and Democratic-leaning independents say they would prefer to vote for a candidate who wants to build on the existing ACA in order to expand coverage and lower costs (55%) than replace the ACA with a national Medicare-for-all plan (40%). Even among those who would prefer to vote for a candidate who wants to replace the ACA with a national health plan, most (56%) say they would still vote for a candidate who wants to build on the ACA (22% of all Democrats and Democratic-leaning independents). Fewer (14% of all Democrats and Democratic-leaning independents) say they would only vote for a candidate who wants to replace the ACA with Medicare-for-all. 

The Democratic Presidential Primary Debates

Over the past few months, KFF Health Tracking Polls have found health care leading the list of possible topics Democrats and Democratic-leaning independents want to hear the 2020 Democratic presidential candidates talk about during their upcoming primary debates. This month’s tracking poll, conducted a week prior to the third round of Democratic presidential debates, finds a majority of Democrats and Democratic-leaning independents say they know at least “some” about the Democratic candidates’ positions on most national issues including immigration (69%), gun policy (67%), health care (66%), and climate change (65%). Fewer – but still more than half – say they know at least some about the candidates’ positions on the economy and jobs (59%), and taxes (54%). Not quite half say they know at least some about the candidates’ position on foreign policy or national security (49%) or international trade and tariffs (43%).

About half (51%) of Democrats and Democratic-leaning independents say they want to know more about the Democratic candidates’ positions on health care. The topics they want to hear more about range from specific details about the candidates’ health plans (15%), how a national Medicare-for-all plan would work (13%), how they candidates will implement their plans (11%), how the candidates will pay for their health care plans (8%), and how the candidates plan to bring down health care costs (8%).

This KFF Health Tracking Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted September 3^rd – 8^th 2019, among a nationally representative random digit dial telephone sample of 1,205 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 (305) and cell phone (900, including 634 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=6). 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 2017 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.

1. K. Pollitz (2016). Surprise Medical Bills. Kaiser Family Foundation. Available at https://modern.kff.org/private-insurance/issue-brief/surprise-medical-bills/. ↩︎

More than one year out from the general election, there are many factors that could influence voters’ decisions to either vote for President Trump or the Democratic nominee or even stay home on November 3, 2020. These factors include the characteristics of the eventual Democratic nominee, views of President Trump, and how motivated voters are feeling about the election. The latest analysis from the Kaiser Family Foundation, in collaboration with the Cook Political Report, finds that while a large share of voters are already firm about how they plan to vote in the 2020 presidential election (63%), there is a still a substantial share (30%) who say they have not made their minds up. With three in ten votes still up for grabs, this data note examines the demographics of swing voters: those who either report that they are undecided about their vote in 2020 or are leaning towards a candidate but haven’t made up their minds yet. It also explores the policy issues that could swing these voters to vote for either President Trump or the Democratic nominee.

Key Findings

Who are swing voters? They’re younger, more moderate, and less engaged on national politics. At least a quarter say they didn’t vote in ’16 or ’18. This @KFF / @CookPolitical analysis shows how the issues could affect their vote on #ElectionDay2020

• Three in ten voters are swing voters, meaning they haven’t made up their minds about who they plan to vote for in the 2020 presidential election. While swing voters look similar to their decided counterparts on many demographics, they tend to be younger, more moderate, and less engaged on national politics. Nearly one-fourth of swing voters say they didn’t vote in the 2018 election (22%) or in the 2016 presidential election (24%).
• It is important to note that not all “swing voters” could potentially change their vote to support the other party’s candidate. About half of swing voters (16% of all voters) are truly persuadable. These voters either say they are undecided about who they plan to vote for (8%) or say that while they are probably going to vote for either President Trump or the Democratic nominee, there is a chance they will vote for the other party’s candidate (8%). The other share of swing voters (14% of all voters) say that they are probably going to vote for either President Trump or the Democratic nominee and there is no chance they will vote for the other party’s candidate. While they say there is no chance they will vote for the other party’s candidate, they could choose to not vote at all. In other words, these folks may not change their minds to support another candidate, but if they don’t like what they see from the party they like, they could just stay home. 
• Many factors could influence voters’ decisions to either vote for President Trump or the Democratic nominee or even stay home on Election Day. This analysis finds issues like climate change, health care, immigration, or the economy could influence swing voters’ vote choice in 2020. Democrats may have the edge on three issues among swing voters: climate change (38 percentage point advantage), health care (18 percentage points), and immigration (10 percentage points) while President Trump, on the other hand, may have the edge on the economy (12 percentage points). As the 2020 presidential campaign continues, this data indicates that Democrats may benefit more when the focus is on climate change, health care, and immigration, while President Trump may have the advantage on the economy among this group of swing voters. Yet, it is important to note that if the economy slows down significantly, the edge that President Trump has on the economy may dissipate.
• The issue of health care means different things to voters on different sides of the aisle. Nearly half (44%) of swing voters who prefer the Democratic nominee on health care offer responses related to increasing access to health insurance coverage as the reason why they support the Democratic nominee on this issue. Swing voters who prefer President Trump on health care do not appear to be rallying behind a single health care issue but offer varying responses. Lowering the amount people pay for health care ranks high for both sets of swing voters (19% and 16%, respectively).

Who Are The 2020 Swing Voters?

Nearly two-thirds of voters say they have already made up their minds about which candidate they plan to vote for. About one-third of voters (34%) say they are “definitely” going to vote for the Democratic nominee while three in ten (29%) say they are “definitely” going to vote for President Trump. This leaves three in ten voters as the crucial voting block known commonly as “swing voters.” This group of voters either say they are “probably” going to vote for President Trump (9%), “probably” going to vote for the Democratic nominee (13%), or say they are undecided about how they will vote (8%).

It is important to note that not all “swing voters” could potentially change their vote to support the other party’s candidate. Among voters who say they are probably going to vote for either President Trump or the Democratic nominee, few say there is “a chance” they will vote for the other party’s candidate. Among all voters, 5% say they will probably vote for President Trump but there is “a chance” they will vote for the Democratic nominee, while 3% of all voters say they will probably vote for the Democratic candidate but there is “a chance” they will vote for President Trump.

A vast majority of Democratic voters (85%) and most Republican voters (70%) say they aren’t going to cast a vote for the other party’s candidate. Seven in ten voters who identify as Democrats or Democratic-leaning independents say they are “definitely” going to vote for the Democratic nominee and an additional 16% say they are “probably” going to vote for the Democratic nominee and there is “no chance” they will vote for President Trump. On the other side of the aisle, six in ten Republican and Republican-leaning voters say they will “definitely” vote for President Trump with an additional 9% saying they are “probably” going to vote for President Trump and there is “no chance” they will vote for the Democratic nominee.

Instead of voting for the other party’s candidate, some of the voters who are leaning towards a candidate but haven’t made up their minds yet may choose to not vote in the 2020 presidential election. Nearly one-fourth of swing voters say they didn’t vote in either the 2016 presidential election (24%) or in the 2018 election (22%). A slightly larger share of Democrat swing voters (33%) say they didn’t vote in the 2016 election than both independents (23%) or Republicans (21%).

Decided Voters v. Swing Voters

On most demographics, swing voters look very similar to their counterparts (voters who say they have already decided who they are going to vote for in the 2020 election), but they differ on three key variables: age, party identification, and ideology. To see a complete demographic profile of swing voters, see the appendices.

Age

When we look at the share of demographic groups who get classified as either “swing voters” or “decide voters,” we find that about three in ten – across all socioeconomic groups such as gender, education, and urbanicity – are classified as swing voters. This is not true among the different age groups. A larger share of voters between 18 and 29 years old are “swing voters” (44%) which is nearly identical to the share of this group who are “decided voters.”

Party identification and ideology

Perhaps as expected, the decided voters are the more partisan voters with strong ties to party identification and less likely to self-identify as political moderates. Half of political independents have not made up their mind about who to vote for in the 2020 presidential election compared to one-fourth (24%) of Democratic voters and 31% of Republican voters. In addition, four in ten self-identified moderates are classified as “swing voters” which is much larger than the share among those who call themselves liberal (79%) or conservative (70%).

Those with less polarized views of President Trump are also more likely to be classified as “swing voters.” Most of those who either “somewhat approve” (69%) or “somewhat disapprove” (60%) of President Trump are “swing voters,” while majorities of those who either “strongly approve” (85%) or “strongly disapprove” (72%) of President Trump have already made up their minds.

Overall, swing voters tend to be younger: one-fourth are between 18 and 29 years old (27%), compared to 14% of voters who have already decided on their 2020 vote choice. More than half of swing voters (56%) say they have a moderate political ideology, compared to 29% of decided voters; and smaller shares identify as Democrats or Democratic-leaning independents (37% compared to 52%).

Despite the relative similarities between swing voters and decided voters, they behave very differently towards politics and elections. Swing voters are much less likely to say they pay “a lot of attention” to what is going on in national government and politics and much less likely to say the outcome of the presidential election matters a lot than decided voters. On the other hand, voters who have decided they either are going to definitely vote for President Trump or the Democratic nominee are quite similar in how much attention they are currently paying and how important they view the outcome of the presidential election.

About four in ten (39%) of swing voters say they normally pay “a lot” of attention to what is going on in national government and politics compared to a majority of decided voters (68%).

There are no partisan differences among the decided voters with a majority of those who have decided they either are going to definitely vote for President Trump (70%) or the Democratic nominee (66%) saying they normally pay “a lot” of attention to national government and politics.

Similarly, swing voters are seemingly less concerned about the outcome of the presidential election. While a majority of swing voters (66%) say it “really matters who wins the 2020 presidential election,” more than one-third of swing voters say that it either “somewhat matters” (27%) or “doesn’t really matter” (7%) who wins the 2020 presidential election. The vast majority of decided voters (92%) say it “really matters who wins the 2020 presidential election.”

Once again, there are no partisan differences among those voters who have decided their 2020 vote choice. Vast majorities of voters who have decided they either are going to definitely vote for President Trump (92%) or the Democratic nominee (93%) say it “really matters who wins” the 2020 presidential election.

Which Issues Could Swing The Election?

Many factors could influence voters’ decisions to either vote for President Trump or the Democratic nominee or even stay home on Election Day. These include the characteristics of the eventual Democratic nominee, views of President Trump, and how motivated voters are feeling about the election. When swing voters were asked whether a series of different issues could persuade them to vote for President Trump or the Democratic nominee, the latest analysis finds issues like climate change, health care, immigration, or the economy could influence swing voters’ vote choice in 2020.

Democrats have the edge on three issues among swing voters: climate change, health care, and immigration. The Democratic candidate has a 38 percentage point advantage on the issue of climate change with six in ten swing voters (59%) saying the issue of climate change makes them “more likely to vote for the Democratic candidate” compared to 22% who say climate change would make them more likely to vote for President Trump. Similarly, half of swing voters say the issue of health care makes them more likely to vote for the Democratic candidate compared to 32% who say health care would make them more likely to vote for President Trump; giving the Democratic nominee an 18 percentage point advantage on this issue. The Democratic candidate also as a 10 percentage point advantage on immigration (49% v. 40%). This data suggests that during the 2020 presidential race, Democrats may benefit more when the focus is on climate change, health care, and immigration – the three issues that swing voters say could influence them to vote for the Democratic presidential candidate.

President Trump, on the other hand, may have the edge on the economy. Half of swing voters say the economy makes them more likely to vote for President Trump (48%) compared to one-third of swing voters who say it makes them more likely for the Democratic nominee (35%). So if the focus of the 2020 presidential campaign is on the economy, President Trump may have the advantage among swing voters.

For the other issues included in the survey, it is less clear whether President Trump or the Democratic candidate has an advantage. The Democratic candidate has a seven percentage point edge on foreign policy while President Trump has a seven point edge on gun policy¹ ; however these slight advantages are not statistically significant. Similar shares of swing voters say they prefer President Trump or the Democratic nominee on international trade and tariffs and taxes.

Health Care as An Election Issue

When swing voters who say health care is an issue that would make them more likely to vote for Democratic candidate (50% of swing voters) are asked to say in their own words what it is about health care that could influence their vote choice, nearly half (44%) offer responses related to increasing access to health insurance coverage. This is followed by one-fifth (19%) who offer lowering the amount people pay for health care. Fewer offer responses such as: Democrats care more about health care (7%), general opposition to President Trump (7%), or support or protection of the Affordable Care Act (7%).

On the other side of the ballot, when swing voters are asked to say in their own words what it is about health care that would make them more likely to vote for President Trump (32% of swing voters), they offer a variety of health care issues that could influence their vote choice. About one in six of these swing voters say lowering the amount people pay for health care (16%), free market or less government involvement (14%), opposition to the ACA (13%), or opposition to a national health plan or Medicare-for-all plan (12%) make them more likely to vote for President Trump in 2020.

Lowering the amount people pay for health care is the only health care issue that was offered by substantial shares of both swing voters who say the issue of health care makes them more likely to support President Trump (16%) and those who say it makes them more likely to vote for the Democratic nominee (19%).

This KFF Health Tracking Poll- Swing Voters was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The data from this topline is from two KFF Health Tracking Polls conducted May 30-June 4, 2019 and July 18-23, 2019, among a nationally representative random digit dial telephone sample of 2,402 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). To see the methodology for each poll, please visit the following: June 2019 available at https://www.kff.org/health-reform/poll-finding/kff-health-tracking-poll-june-2019/ and July 2019 available at https://www.kff.org/health-reform/poll-finding/kff-health-tracking-poll-july-2019/.

The combined landline and cell phone sample for each month was weighted to balance the sample demographics to match estimates for the national population using data from the Census Bureau’s 2017 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 of registered voters 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.

1. The surveys used for this analysis were completed prior to the recent mass shootings in El Paso, TX on August 3rd, 2019 and Dayton, Ohio on August 4th, 2019. ↩︎

The Community Health Center Fund (CHCF), which was established by the Affordable Care Act (ACA) and now accounts for the majority of health center grant funding, is due to expire at the end of September unless Congress acts to extend it. Health centers have faced this situation before. In 2017, the CHCF lapsed for five months before Congress extended it for two years. Although funding was ultimately restored, health centers around the country reported that they faced difficult decisions to reduce care, close service sites, and lay off staff because of the delay. Health centers are considering similar actions to prepare for another potential loss of funding, which will have implications for the patients and communities they serve. This data note reports findings from the 2019 KFF/Geiger Gibson Community Health Center Survey on how health centers may respond to ongoing funding uncertainty.

With a key source of funding set to expire Sept. 30, community health centers across the U.S. are considering steps to trim staffing, close some locations & eliminate or reduce services as they cope with uncertainty about their financing.

The Community Health Center Fund

The Community Health Center Fund is a key source of revenue for health centers, accounting for 72% of all federal health center grant funds. Initially authorized in 2010 under the ACA for a five-year period, the CHCF has been extended twice, in 2015 and 2018, growing from $1 billion in FY 2011 to $4 billion in FY 2019. Funding from the CHCF allows health centers to serve patients without health insurance, expand capacity, and offer a broader range of health services, including oral health care for adults and mental health and substance use disorder services. From 2010 to 2017, the number of health center sites increased by 59% and total patients served by 43%, and the share of health centers offering mental health and substance abuse services grew by 22% and 75%, respectively. CHCF funding also enables health centers to furnish services that improve patients’ access to care, such as transportation and interpretation services, that are not typically covered by public or private health insurance.  

Federal grant funding represents nearly one-fifth of total health center revenue, more for health centers in states that have not expanded Medicaid. Federal grant funding, also known as Section 330 funding, totaled over $4.7 billion in calendar year 2017 and accounted for 18% of health centers’ total revenue that year (Figure 1). Health centers located in states that have not implemented the ACA Medicaid expansion are especially reliant on federal grants to support their operations. In these states, where uninsured rates are considerably higher, grant funding accounts for 26% of total health center revenue. In 2017, Section 330 funding accounted for 30% or more of total health center revenue in 12 states.

Health Centers’ Response to a Potential Funding Delay

Anticipating a delay in extending the CHCF, health centers have taken or are considering a number of actions that could affect patients’ access to care. To prepare for a possible reduction in funding, a small number of health centers have limited or reduced staffing costs, and many more are considering doing so. Nearly six in ten (59%) health centers have in place or are considering adopting a hiring freeze, and over four in ten (42%) say they are considering laying off staff or reducing staff hours (Figure 2). Some heath centers report considering steps that would even more directly affect their capacity to serve their patients, such as reducing operating hours (35%) or closing one or more health center sites (26%). Other actions health centers report taking or considering include tapping into reserves (52%) and canceling or delaying renovations or expansions (52%).

Although less common, health centers are considering cutting some services. With funding still in place, few health centers (1%-2%) have already taken steps to eliminate or reduce services, but more are weighing cutting services if funding is delayed. Nearly four in ten (39%) say they have or might scale back enabling services, such as case management, transportation, and education services, and a quarter had implemented or are considering reductions in dental services (Figure 3). In addition, one in five had or is considering eliminating or reducing mental health services and about one in six (17%) is targeting substance use disorder treatment services.

Health centers in non-expansion states were more likely to report having taken or considering actions. With their greater reliance on CHCF funding to support operations, health centers in states that have not expanded Medicaid appear more sensitive to a funding delay. Compared to those in Medicaid expansion states, health centers in non-expansion states were more likely to say they have or are considering reducing operating hours (44% vs. 31%) and have already closed or are weighing closing one or more health center sites (34% vs. 22%) (Figure 4). They were also more likely to report they have or are considering reducing or eliminating certain services, including dental, mental health, and substance use disorder services.

What’s Next?

Bills to extend the CHCF at current funding levels await votes in both chambers of Congress. In both the House and the Senate, bills that include provisions to extend the CHCF have advanced out of Committee but were not voted on prior to Congress adjourning for the August recess. The House bill (HR 2328) would extend the CHCF for four years, through the end of fiscal year 2023, at the current funding level of $4 billion per year. The Senate bill (S 1895) would extend the fund for five years, through the end of fiscal year 2024, also at current funding levels. Upon returning from the August recess, Congress will have just over three weeks to pass legislation before the CHCF expires.

A funding delay could limit access to care for millions of health center patients. Health centers are an important source of care for over 28 million patients in medically underserved rural and urban areas throughout the country and play a leading role in efforts to address public health crises, such as the recently announced Trump administration initiative to stop new HIV infections. In response to funding uncertainty, a small number of health centers are already taking steps to reduce or curtail services, and more are considering such actions, particularly those in states that have not expanded Medicaid.