With continued attention from policymakers on prescription drug costs, a 2019 KFF Health Tracking Poll took a deep dive into the views of Americans on a variety of topics related to prescription drugs with special attention paid to the experiences and attitudes of older adults, defined here as people ages 65 and older. Older adults’ experiences with prescription medications can vary significantly based on their health status, how many prescription drugs they are currently taking, and other demographic variables like household income. This data note explores the varied experiences of older adults across such different demographic groups. With most older adults (83%) reporting that they currently have insurance that helps them pay for prescription drugs¹ , this data note also explores how older adults chose their prescription drug plans and what they prioritize in their coverage. In addition, it explores older adults’ views on several prescription drug policy options currently being discussed by policymakers.

Prescription Drug Use and Affordability Issues

Nearly nine in ten (89%) adults 65 and older report they are currently taking any prescription medicine. This compares to three-fourths of 50-64 year olds who report taking prescription drugs, half (51%) of 30-49 year olds, and four in ten (38%) 18-29 year olds. Older adults are also more likely than their younger counterparts to be taking multiple prescription medications. More than half of adults 65 and older (54%) report taking four or more prescription drugs compared to one-third of adults 50-64 years old (32%) and about one in ten adults 30-49 (13%) or 18-29 (7%).

Most seniors have prescription drug coverage through Medicare Part D, but majorities across party lines say drug costs are unreasonable. This @KFF data note examines this group’s experiences across a variety of demographics.

While a majority of older adults have prescription drug coverage through Medicare Part D, which is Medicare’s voluntary prescription drug benefit, most older adults (76%) think the cost of prescription drugs is unreasonable. This viewpoint is consistent across party identification, with majorities of Democrats (81%), independents (74%), and Republicans (70%) saying the cost of prescription drugs is unreasonable.

Nearly 1 in 4 older adults say it’s difficult to afford their prescription drugs. Who has the most trouble? Those in fair or poor health and those with low incomes. Read more @KFF

In addition, one-fourth of older adults (23%) who take prescription drugs say it is difficult to afford their prescription drugs, including about one in ten (8%) saying it is “very difficult.” As is true among the public as a whole, there are certain groups of older adults who are much more likely to report difficulty affording medications, including those who report being in either “only fair” or “poor” health (45%), whose household income is less than $30,000 annually (34%), and who take four or more prescriptions (28%). These factors are inter-related, as those who are in relatively poor health are also more likely to be taking four or more prescriptions and spending at least $25 a month on their medications.

About one in five older adults (21%) say they did not take their medicines as prescribed at some point in the past year because of the cost. This includes those who report that, due to costs, they haven’t filled a prescription (12% of total older adults), took an over-the counter drug instead (11% of total), or cut pills in half or skipped a dose (8% of total).

Notably, among those who report not taking their medicines as prescribed, slightly more than half (53%) say they didn’t tell their doctor or health care provider (11% of the total) and one-fifth (22%) of this group say their condition got worse as a result of not taking their prescription as recommended (5% of total).

Less Than Half Of older adults report discussing the cost of Their prescriptions with their doctor or pharmacist

The KFF polling finds that older adults are more likely to report discussing safety concerns than cost issues with their doctors and pharmacists when getting a new prescription. Seven in ten older adults (72%) say they usually talk to their doctor about the safety and potential side effects of the drug when their doctor writes a prescription for a drug they haven’t taken before. In contrast, around four in ten older adults (43%) say they usually talk to their doctor about whether there is a less expensive alternative, and just over one-third (36%) talk about the cost they will have to pay for the new medication.

Similarly, while half of older adults say they usually talk to their pharmacist about the safety and potential side effects of a new prescription drug, fewer (32%) say they talk to their pharmacist about whether there is a less expensive alternative available. About four in ten (43%) say they talk their doctor about the same thing.

Older adults who report difficulty affording their prescriptions are no more likely to report talking to their doctor or their pharmacist about drug costs than those who report no difficulty affording their medications.

Experiences with Prescription Drug Coverage

People with prescription drug coverage under Medicare Part D are encouraged to compare plans each year to find coverage that best meets their individual needs, based on the specific drugs they take. For 2019, Medicare beneficiaries could choose from among 27 stand-alone Medicare Part D prescription drug plans, and 21 Medicare Advantage prescription drug plans, on average.

Less than four in ten older adults report comparing plan premiums (36%) or co-pays for prescription drugs they were currently taking (36%), and about three in ten (28%) say they compared which prescription drugs were covered by each of the different drug plans. Overall, about half (47%) of older adults who have prescription drug coverage say they did some comparison shopping when choosing their current prescription drug plan.

Some older adults report various problems accessing prescription drugs through their plan

Overall, nearly half (45%) of older adults with prescription drug coverage say they have experienced various problems accessing prescription drugs through their drug plan in the past 12 months. Nearly three in ten older adults (28%) report that their plan did not cover a drug prescribed by their doctor. Nearly one-fourth (23%) report that their plan required them to try a less expensive drug before they could get a more expensive drug initially prescribed by their doctor—a utilization management tool known as step therapy—and one in five (21%) report having to wait more than two days to get a prescription filled due to prior authorization requirements by their drug plan.

Certain groups of older adults were more likely than others to report experiencing difficulty with their prescription drug coverage in the past 12 months, including more than half of those with a household income of less than $30,000 a year and just over half of those taking four or more prescription drugs.

Few older adults report using patient assistance programs or other types of discounts

One-fifth of older adults say they have received a discount on a prescription drug in the past year, either through a coupon, a co-pay card, drug company patient assistance program, or some other type of discount. Those who report difficulty affording their medications are no more likely than those who do not report difficulty affording their medications to say they have received a discount on a prescription drug in the past year (25% compared to 20%, respectively).

When older adults with prescription drug coverage were asked what feature of their coverage is more important to them, a larger share say having a lower co-pay at the pharmacy is more important to them than paying a lower premium each month (51% versus 35%). This finding may reflect the greater frequency of payment for prescription drug co-pays versus monthly premiums. In addition, monthly Part D premiums have been relatively stable in recent years, which may help to lessen concerns about premium levels among older adults.

Majorities of Older Adults Support Various Actions Aimed at Keeping Costs Down

Unlike many other health policies that divide partisans, majorities of older adults across party identification favor many of the policy proposals included in the KFF poll, including recent Trump administration proposals like international reference pricing, Democratic proposals to allow the federal government to negotiate drug prices, and bipartisan proposals to add a cap on out-of-pocket spending to Part D. Each of these policy proposals is supported by large majorities of Democrats, independents, and Republicans.

Fewer older adults favor allowing Medicare to restrict access to certain prescription medications such as allowing Medicare drug plans to put more restrictions on the use of certain drugs (45%) or allowing these plans to exclude more drugs (24%).

This KFF Health Tracking Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted February 14^th–24^th 2019, among a nationally representative random digit dial telephone sample of 1,440 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 more than nine months ago. This month’s poll also includes an analysis of older Americans age 65 or older (n=606). To obtain a large enough sample, the sampling frame included an oversample of older adults using cell phones (n=26) and landlines (n=75) as well as callbacks to adults who fit the age criterion using the SSRS Omnibus poll (n=136). 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=11). Both the random digit dial landline and cell phone samples were provided by Marketing Systems Group (MSG).

Computer-assisted telephone interviews conducted by landline (464) and cell phone (976, including 662 who had no landline telephone) were carried out in English and Spanish by SSRS of Glen Mills, PA. 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 with additional funding for the over-sample provided by the John Hopkins’ Bloomberg School of Public Health.

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 January-June 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. To ensure accurate representation of the older population, the data were weighted separately for those younger than 65 and those 65 or older. 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. Another analysis conducted by the Kaiser Family Foundation of Medicare Part D enrollment data finds about three-fourths of older adults are Part D enrollees (72%), but some older adults may have other sources of drug coverage, such as retiree health benefits or coverage through the Veterans Administration. ↩︎

Medicare-for-All proposals have sparked discussion about the role of private health insurance in the U.S. health care system. Some of the current Medicare-for-All proposals would essentially eliminate private insurance. Others would allow private insurers to administer benefits under the new public program, similar to the role of Medicare Advantage plans today, which serve as a private-plan alternative to traditional Medicare. Another set of proposals would create a new Medicare-like public plan option, but preserve a role for private health insurance, including employer-sponsored coverage and policies sold to individuals and families in the Affordable Care Act (ACA) Marketplaces.

As context for these discussions, this brief examines and compares the financial performance of insurers in the Medicare Advantage, individual, and fully-insured group markets, using data reported by insurance companies to the National Association of Insurance Commissioners and compiled by Mark Farrah Associates. We analyze how insurers’ gross margins vary across the three markets, over time, and among insurers. Gross margins are the difference between premiums collected and medical expenses and do not account for administrative expenses. The brief also examines medical expenses as a percentage of premiums collected (simple loss ratios) across these three markets. See the Methods section for more information on calculations.

Key findings include:

• Annual gross margins in the Medicare Advantage market averaged $1,608 per covered person between 2016 and 2018, about double the margins in the individual and group markets (E.S. Figure). Between 2016 and 2018, the individual market experienced substantial volatility, and the three-year average gross margins are not representative of any single year.  In 2016, individual market insurers saw significant losses, and in 2018, margins were unusually high and plans were overpriced due to policy uncertainty.
• When aggregated across all plans in this analysis, annual gross margins sum to $23.9 billion, $10.6 billion, and $26.5 billion for the Medicare Advantage, individual, and group markets, respectively, for 2016-2018.
• Total medical expenses as a share of premiums collected (simple loss ratios) were similar for across the three markets between 2016 and 2018 (about 84-86%; E.S. Figure).

Each of these three health insurance markets now appear to generate high gross margins per person, particularly for insurers of Medicare Advantage plans.

Background on Private Insurance Markets

The Medicare Advantage, individual (also known as non-group), and fully-insured group (employer) health insurance markets are three distinctly different markets. Each of these private insurance markets has unique features that affect the profitability for insurers, and which in turn affect coverage for eligible people. These markets are dominated by many of the same health insurers, with most of the country’s largest health insurers offering plans in all three markets.

Medicare Advantage. The Medicare Advantage market provides Medicare-covered benefits through private plans to 22 million Medicare beneficiaries in 2019, with enrollment steadily increasing over the past decade. The federal government makes risk-adjusted payments (higher payments for sicker enrollees and lower payments for healthier enrollees) to plans (averaging $11,545 per enrollee in 2019) to cover the preponderance of the cost of Medicare benefits for plan enrollees, with some plans charging enrollees an additional premium. In addition, the Medicare program pays plans more if they submit bids below the “benchmarks” set in statute or qualify for quality-related bonus payments; all of these payments are included as premiums in this analysis. In 2019, the federal payments to Medicare Advantage plans are about the same as what it would cost to cover the same people under traditional Medicare. When health risk coding differences are fully taken into account, payments to plans are 1-2% higher than traditional Medicare. Selection bias has been estimated to result in annual spending that is $1,253 lower for each Medicare Advantage enrollee compared to similar people who remain in traditional Medicare, suggesting that pegging payments to the costs of people in traditional Medicare overpays plans.

Individual Market. The individual market, which accounted for about 14 million people in 2018, includes coverage purchased by individuals and families through the Affordable Care Act’s exchanges (Marketplaces) as well as coverage purchased directly off-exchange, which includes both plans complying with the ACA’s rules and non-compliant coverage. (e.g., grandfathered policies purchased before the ACA went into effect and some short-term plans). The federal government provides subsidies for low-income people in the Marketplace and includes measures, such as risk adjustment, to help limit the financial liability of insurers. Insurers in the individual market receive premium payments from enrollees, plus any federal subsidies for people in the Marketplaces. Individual market premiums and plan availability have been considerably less stable than the Medicare Advantage and group markets.

Group Market. The fully-insured group market, the largest of the three markets (over 30 million people in 2018, excluding plans regulated by California’s Department of Managed Health Care), serves employers and their employees that are enrolled in fully-insured health plans. This market includes both small and large group plans, but excludes employer-sponsored insurance plans that are completely or partially self-funded, which account for 61% of all workers with employer-sponsored insurance.¹  Plans typically receive premium payments from both employers and their employees. While both average claims and average premiums for enrollees in the group market have increased, the market has been relatively stable for insurers over the past decade.

Average Gross Margins

Average gross margins, or the average amount by which premium income exceeds claims costs per enrollee in a given year, are a key measure of insurer financial performance.

Average Gross Margins. Gross margins for Medicare Advantage plans averaged $1,608 per covered person per year between 2016 and 2018 – about double the average annual gross margins for plans in the individual and group markets ($779 and $855 per member per year, respectively; Figure 1).

Average gross margins were calculated as the difference between total premiums collected and total medical expenses incurred, and were averaged across the past three years (2016 to 2018) to even out year-to-year fluctuations, particularly those in the individual market. As discussed more below, there has been significant volatility in individual market margins, due in part to underpricing in the early years of ACA implementation and more recent overcorrections amid uncertainty about ACA repeal, enforcement of the individual mandate, and in response to the Trump Administration’s decisions to cease cost-sharing subsidy payments and reduce funding for outreach. The three-year average gross margins shown in Figure 1 include a year when individual market insurers generally saw significant losses as well as a year when profits were unusually high.

Gross margins do not necessarily translate into profitability since they do not account for administrative expenses. Nonetheless, gross margins are an indicator of financial performance and signal how much insurers retain, including profits, after paying for enrollees’ covered medical expenses.

Variation in Gross Margins Over Time. In every year since 2006, average gross margins for Medicare Advantage plans have exceeded those of plans in the individual and group markets (Figure 2).  Average gross margins for Medicare Advantage plans climbed between 2006 and 2009, somewhat flattened after 2009, as federal overpayments to Medicare Advantage plans took on a more prominent role in policy discussions. Average margins then dipped somewhat after 2012 as federal payments to plans were reduced as a result of the ACA. Since 2015, average gross margins for Medicare Advantage plans have been on the rise, with the average gross margin for 2018 ($1,683 per member) nearly reached its peak 2009 value of $1,692 per member. The increase in average gross margins in the past few years has primarily been due to a sharp increase in the size and number of plans receiving bonus payments for high quality ratings, with total bonus payments more than doubling between 2015 and 2018.

Figure 2: Since 2006, Medicare Advantage plans’ average gross margins have exceeded those for plans in the individual or group markets

Gross margins in the individual market have been more volatile. Gross margins fell from about $446 per member per year in 2013 to -$122 in 2015 as the ACA’s market rules and consumer protections went into effect in 2014. At the time, insurers had very little information to work with in setting their premiums and many underpriced, experiencing significant losses. By 2017, the individual market generally had begun to stabilize. However, going into 2018, insurers raised benchmark premiums by an average of 34% in response to policy changes such as the Trump Administration’s decision to cease cost-sharing subsidy payments and uncertainty over whether the ACA as a whole would remain law or whether the individual mandate would be enforced. These premium hikes, along with slow claims growth, made 2018 the most profitable year for individual market insurers since the ACA went into effect. These high 2018 individual market profits will be offset somewhat by record high Medical Loss Ratio rebates insurers are required to issue in 2019 to 2018 enrollees due to overpricing. Premiums fell slightly on average for 2019, as it became clear that some insurers had raised 2018 rates more than was necessary, and margins will likely be lower for 2019.

Average gross margins for plans in the fully-insured group market have slowly, but steadily, increased since 2006, rising 71% from $525 per member in 2006 to $897 per member in 2018.

Simple Loss Ratios

Simple loss ratios, or the percentage of premium income that insurers pay out in claims, provide further context about the financial status of each of these markets. Despite differences in gross margins, medical expenses comprised a similar share of total premiums collected (simple loss ratios) across plans in the Medicare Advantage, individual, and fully-insured group markets (Figure 3). Between 2016 and 2018, the medical expenses of Medicare Advantage enrollees averaged about 86% of the total premiums collected by Medicare Advantage plans (primarily federal payments for Medicare-covered benefits), which is similar to the individual market (84%) and fully-insured group market (84%) three-year averages.

Medical expenses as a percentage of total premiums collected have been relatively constant since 2006, the first year for which data are available, for the plans in the Medicare Advantage and group markets. There has been quite a bit more year-to-year variation in the individual market since 2014, as the major provisions of the ACA went into effect and created uncertainty for insurers (see Appendix Table 1).

As with the gross margins, the simple loss ratios do not account for administrative expenses, and medical loss ratios as defined by the ACA are generally higher because the ACA calculation makes adjustments for taxes, fees, and quality improvement expenses. As with the analysis of gross margins, medical expenses as a percentage of premiums collected were averaged across three years (2016 to 2018) to even out year-to-year fluctuations in the individual market.

Reconciling Gross Margins and Simple Loss Ratios. Although loss ratios are similar across the three markets, gross margins are much higher for Medicare Advantage plans because both medical expenses and premiums are substantially higher for Medicare Advantage enrollees. In other words, a 5% margin, for example, in the Medicare Advantage market is a larger amount than a 5% margin in the individual or group market. People on Medicare tend to use more health care and incur higher medical expenses than people in the individual and group markets, and the federal payments (premiums) to Medicare Advantage plans are tied to the medical expenses of people in traditional Medicare. For instance, in 2018, Medicare Advantage enrollees spent an average of 1,856 days in a hospital per 1,000 enrollees, compared with averages of 304 and 294 hospital days for people in the individual and group markets, respectively (Appendix Table 2).

Variation in Performance Among Insurers Over Time

Annual gross margins varied substantially among insurers in the individual market and Medicare Advantage market, with relatively less variation among insurers in the fully-insured group market (Figure 4). In 2018, most of the Medicare Advantage market had gross margins between $1,014 (25^th percentile) and $2,342 (75^th percentile), and gross margins in most of the individual market varied substantially between $358 and $2,027 (25^th and 75^th percentiles, respectively). In contrast, gross margins in the fully-insured group market varied much less (from $501 at the 25^th percentile to $1,215 at the 75^th percentile in 2018).

Figure 4: Gross margins varied less across group market insurers than insurers in the individual or Medicare Advantage markets

In 2018, gross margins among insurers in the bottom quartile of the Medicare Advantage market (those with margins below $1,014) were similar to, or higher than, the average gross margin in the group market ($897). Conversely, many insurers in the top quartile of gross margins in the group market (those with margins above $1,215) had margins lower than the average in the Medicare Advantage market ($1,683) in 2018. The group market may have less variation in gross margins in part because of less uncertainty and because it has not been as subject to changes in policy. In all markets, 5-10% of insurers had negative gross margins, with medical expenses exceeding premiums, indicating that some insurers are losing money in the same markets where other insurers are making profits.

Total Gross Margins

After aggregating gross margins across all plans and enrollees in this analysis, total gross margins were highest for the fully-insured group market for all years between 2006 and 2017 (Figure 5). However, as of 2018, the Medicare Advantage market has caught up to the group market, with both markets reaching $27 billion in total gross margins in 2018. The rise in total gross margins for the Medicare Advantage market is primarily due to a steady increase in people enrolling in Medicare Advantage plans over the past decade. Total gross margins in the individual market remain significantly lower than the fully-insured group or Medicare Advantage markets, reaching $18 billion in 2018, in part because fewer people are covered in the individual market.

Figure 5: Total gross margins for Medicare Advantage plans have been rapidly nearing those for the group market

For 2016 to 2018, total gross margins averaged $23.9 billion, $10.6 billion, and $26.5 billion per year for the Medicare Advantage, individual, and group markets, respectively.²  Since this analysis excludes some plans in these markets (see Methods for more details), these aggregated margins would be larger if all plans were included.

Discussion

This analysis suggests insurers are profitable in each of the three markets. There is a particular focus in policy debates right now on Medicare Advantage plans. Several Medicare-for-All and other health reform proposals would allow private insurers to administer benefits under a new Medicare-like public option, which could be lucrative and attractive for health insurers, depending on how payments to plans are set. Based on the history of Medicare Advantage plans, setting payments to private plans at the appropriate rate remains a challenge, given competing goals of broadening plan choice and fiscal accountability. With a new public program or option, policymakers are likely to face similar challenges, depending on their goals and priorities.

We analyzed insurer-reported financial data from Health Coverage Portal TM, a market database maintained by Mark Farrah Associates, which includes information from the National Association of Insurance Commissioners (NAIC). The dataset analyzed in this report does not include NAIC plans licensed as life insurance or California HMOs regulated by California’s Department of Managed Health Care. We excluded plans that filed negative enrollment, premiums, or claims and corrected for plans that did not file “member months” in the annual statement but did file current year membership. The group market in this analysis only includes fully insured plans.³   Premiums to Medicare Advantage plans do not include payments for Medicare Part D benefits.

Gross margins were calculated by subtracting the sum of total incurred claims from the sum of unadjusted health premiums earned and dividing by the total number of members in each market. Premiums for Medicare Advantage plans primarily consist of federal payments made to plans for Medicare-covered benefits, and also include any additional amounts plans may choose to charge their enrollees.  Premiums for the individual market were not adjusted to account for rebates required to be remitted to enrollees.  To calculate medical expenses as a percentage of premiums (or simple medical loss ratios), we divided the market-wide sum of total incurred claims by the sum of all unadjusted health premiums earned. Medical loss ratios in this analysis are simple loss ratios and do not adjust for quality improvement expenses, taxes, or risk program payments.

1. As of 2016, states must define small group as 1-100 employees (and large groups as having 101 or more employees). Prior to 2016, however, states were allowed to continue to define small groups as having a maximum of 50 employees. ↩︎
2. These figures are extrapolated based on enrollment in the plans included in this analysis, which do not represent the full enrollment of the private insurance market. Enrollment figures do not include plans that do not file data with the NAIC, plans licensed as life insurance, California HMOs regulated by Californiau2019s Department of Managed Health Care, plans that recorded negative premiums, claims, or enrollment numbers, or plans domiciled outside of the U.S. ↩︎
3. 61% of workers with employer-sponsored insurance are enrolled in a plan that is completely or partially self-funded. This analysis only includes fully-insured group plans. ↩︎

Key Findings:

• Health care is playing a prominent role at the start of the 2020 presidential primary season with Democratic candidates offering competing proposals aimed at expanding coverage to more Americans. The latest KFF Health Tracking Poll finds a larger share of Democrats and Democratic-leaning independents preferring approaches that expand coverage building on the Affordable Care Act (55%) rather than replacing the ACA with a national Medicare-for-all plan (39%).
• The poll also finds a slight dip in overall favorability of the idea of a national Medicare-for-all plan. About half (51%) of the public now say they favor such a proposal compared to 56% in April 2019. On the other hand, nearly two-thirds of the public (65%) favor a public option, which would compete with private health insurance plans and be available to all Americans. But as with polling on Medicare-for-all, attitudes toward this change to the current health care system can be swayed by common arguments. For example, net favorability towards such a plan ranges as high as +53 and as low as -18 after hearing arguments either in favor of or against a public option.
• The survey finds that, while a majority of the public hold favorable views of Medicare (83%), the public also has largely favorable views of employer-sponsored insurance (76%) and Medicaid (75%). In addition, both those with Medicare coverage (95%) and employer coverage (86%) rate their own health insurance coverage positively.
• Health care, climate change, and issues affecting women are among the top issues that Democrats and Democratic-leaning independents want to hear the candidates discuss in the upcoming second Democratic presidential debate. Issues affecting women has consistently ranked among this group’s top issues for the candidates to speak about and when asked specifically what they want to hear about, at least three in ten overall offer topics related to reproductive rights (33%) and equal pay (30%).
• With the ACA and its various provisions under legal threat from an ongoing federal court case, this month’s KFF Health Tracking Poll probes the public on how important it is for different ACA provisions to remain in effect if the law is ruled unconstitutional. Most Americans say it is “very important” to them that each of the provisions included in this month’s survey are kept in place.

Public Opinion on the Competing Health Care Proposals Aimed At Expanding Coverage

Health care is playing a prominent role at the start of the 2020 presidential primary season with Democratic presidential candidates offering competing proposals aimed at expanding coverage to more Americans. This month’s KFF Health Tracking Poll examines public support for both a national Medicare-for-all plan and a government-administered public option.

Medicare-for-all

Support for a Medicare-for-all plan stands at 51% in July @KaiserFamFound poll, a slight dip from April’s 56%.

KFF has been tracking public polling on a national Medicare-for-all plan since the 2016 presidential campaign and this month’s tracking poll finds a slight dip in overall favorability towards Medicare-for-all. About half (51%) of the public say they favor such a proposal compared to 56% who said they were in favor earlier this year and a high of 59% more than a year ago in March 2018.

The gradual decline in favorability is driven by both Democrats and Republicans with somewhat smaller shares of both now saying they favor such a proposal. In addition, the share of Democrats who now say they “strongly favor” a national Medicare-for-all plan is down from 54% to 42% compared to last time it was asked in April 2019. A majority of Democrats (72%) still express favorable views towards this proposal.

Overall, a larger share of Democrats and Democratic-leaning independents would prefer lawmakers build on the existing ACA (55%) to expand health care coverage to more Americans rather than replace the ACA with a national Medicare-for-all plan (39%).

This is true across ideology (liberal v. moderate) as well as for self-identified Democrats. Similar shares of Democratic-leaning independents say they prefer replacing the ACA with a national Medicare-for-all plan (45%) as say they would prefer building on the ACA (50%).

Public Option

Another type of government health plan garnering recent attention is a public option. This type of plan would allow everyone to have access to a public health insurance option like Medicare. Earlier this month, Democratic presidential candidate Joe Biden announced his own health care proposal, which builds heavily on the ACA – legislation passed during his term as Vice President in the Obama administration – and one element of which includes a public option. Previous KFF polling conducted in 2009, prior to the passage of the ACA, found about half of the public (47%) said a government-administered public health insurance option that would compete with private plans was an important feature of health reform.

Nearly two-thirds of the public (65%) favor having a government-administered health plan that would compete with private health insurance plans and be available to all Americans while 31% oppose. Views are largely driven by partisanship with majorities of Democrats (85%) and independents (68%) favoring a public option while a majority of Republicans oppose such a proposal (62%).

Similar to previous polling on other proposed changes to the current health care system such as Medicare-for-all, attitudes towards a public option can swing significantly, depending on what arguments the public hears.

Nearly two-thirds of the public support a government-run “public option” to compete with private health plans, – but views shift significantly after hearing arguments for and against the idea. More in this @KaiserFamFound poll

Net favorability towards a public health insurance option (measured as the share in favor minus the share opposed) starts at +34 percentage points and ranges as high as +53 percentage points when people hear the argument that this would help drive down costs because private insurers would be competing with the public plan. Net favorability is also high (+51 percentage points) when the public hears that this would provide more choice to people getting insurance through the ACA marketplaces. On the other side of the debate, net favorability drops to -18 percentage points when people hear the argument that it would lead to too much government involvement in health care. Net favorability also drops, but remains net positive (+12 percentage points) after people hear the argument that it would cause doctors and hospitals to be paid less.

Public’s Views towards Health Insurance Coverage

In the first set of Democratic presidential primary debates held last month, Medicare-for-all took a leading role with candidates debating the future of the current health care system. The July KFF Health Tracking Poll asks the public their overall impressions of both public and private health insurance programs as well as assesses how people covered by Medicare rate their coverage compared to those who have employer-sponsored coverage. The survey finds that while a majority of the public hold favorable views of Medicare, the public also has largely favorable views of employer-sponsored insurance and Medicaid, the government health insurance program for certain low-income adults and children.

Overall, 83% of the public hold a favorable opinion of Medicare, the government health insurance program for seniors and for younger adults with long-term disabilities, including 51% who view it “very favorably.” Somewhat similar shares hold favorable views of employer-sponsored insurance (76%) and Medicaid (75%). The public is more likely to hold a favorable view of Medicare, employer coverage, and Medicaid than private health insurance plans that people purchase on their own (59%).

Medicare is also very popular across partisanship. More than eight in ten Democrats (84%), independents (84%), and Republicans (83%) say they have a favorable opinion of Medicare.

Views towards the other ways that Americans get their health insurance coverage vary across party identification. Republicans hold more favorable views of both employer-sponsored insurance (91%) and private health insurance coverage purchased by individuals (80%) than Democrats (68% and 47%) and independents (77% and 58%). On the other hand, Democrats hold more favorable opinions of Medicaid (85%) compared to both independents (76%) and Republicans (65%).

When asked to rate their own health insurance coverage, nearly half of older adults with Medicare coverage (65 and older) give their coverage an “excellent” rating (48%) and an additional 47% rate it as “good.” Five percent of older adults give their coverage a rating of either “not so good” (4%) or “poor” (1%). Fewer adults 18-64 with employer coverage give their own coverage an “excellent” (36%) rating, but half give their coverage a “good” rating. About one in seven give their coverage a rating of either “not so good” (10%) or “poor” (4%).

Preview of 2^nd Democratic Debates

Last month’s KFF Health Tracking Poll 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 debates. This month’s tracking poll, conducted a week prior to the second round of Democratic presidential debates, finds health care once again among the top issues along with climate change. Eight in ten Democrats and Democratic-leaning independents say it is “very important” for candidates to talk about health care (83%) and three-fourths (76%) say the same about climate change. This is closely followed by seven in ten who say it is “very important” for the candidates to talk about issues affecting women (71%) and immigration (69%). Majorities also want to hear the candidates talk gun policy (64%), criminal justice reform (62%), the economy (60%), income inequality (58%), foreign policy or national security (56%), and taxes (53%). Less than half (42%) say it is “very important” for the candidates to discuss international trade and tariffs.

While there is a consensus among Democrats and Democratic-leaning independents that health care is the top issue they want to hear the 2020 presidential candidates discuss in the Democratic presidential debates, this group is more divided on whether they want to hear about how the candidates’ plans differ from each other or how they differ from President Trump’s approach to health care. About half of Democrats and Democratic-leaning independents (51%) say they want to hear how the Democratic plans differ from each other while four in ten (38%) say they want to hear how the plans differ from President Trump’s approach.

On this question, there is a difference between those who identify as Democrats and those who call themselves independents but lean towards the Democratic party. Nearly six in ten Democratic-leaning independents (58%) say they want to hear about how the Democratic plans differ from each other while fewer (29%) say they want to hear about how the plans differ from President Trump’s approach. Democrats are more divided, with similar shares saying they want to hear how the Democratic plans differ from each other (47%) and saying they want to hear about how the plans differ from President Trump’s approach (42%).

Issues Affecting Women

Over the past two months, women’s issues has ranked high on the list of possible topics that Democrats and Democratic-leaning independents want to hear the 2020 Democratic presidential candidates discuss in debates. When those who say issues affecting women is at least somewhat important for the candidates to discuss (which is 96% of all Democrats and Democratic-leaning independents) are asked to offer in their own words what specifically they want to hear about, a significant share of them offer reproductive issues. One-third of Democrats and Democratic-leaning independents overall say they want to hear the Democratic presidential candidates talk about reproductive issues such as abortion, reproductive rights, or women’s control over their own bodies. Similarly, three in ten Democrats and Democratic-leaning independents offer issues such as equal pay or the wage gap (30%). Slightly fewer offer equal treatment or equal rights (17%), women’s health care issues other than reproductive health (12%), workplace issues (7%), or violence against women and sexual assault (7%).

Democratic and Democratic-leaning women and men offer similar responses to what they mean when they issues affecting women is important for the candidates to discuss, with one exception. A larger share of Democratic women (38%) overall offer reproductive issues such as abortion, reproductive rights, or women’s control over their own bodies compared to the total share of Democratic men (27%).

The Affordable Care Act

About half of the public (48%) say they have a favorable opinion of the 2010 Affordable Care Act (ACA) while four in ten (41%) view the law unfavorably. Opinions have remained relatively unchanged for the past two years since the Republican efforts to repeal the law with a slightly larger share expressing positive views. Attitudes are also largely partisan with eight in ten Democrats having a favorable view of the ACA compared to nearly half of independents (49%), and a much smaller share of Republicans (14%).

Earlier this month, the U.S. Court of Appeals for the 5^th Circuit heard oral arguments in Texas v. U.S., the court case challenging the future of the ACA in which a federal judge sided with Republican state attorneys general and ruled the entire ACA is invalid. ¹  The future of this case is uncertain and it may be headed to the U.S. Supreme Court. About three-fourths (76%) of the public say they have heard at least “a little” about the ongoing legal battle over whether the ACA is unconstitutional.

If the judge’s decision takes effect, a host of ACA provisions would be eliminated. This month’s KFF Health Tracking Poll probes the public on how important it is for various parts of the ACA to remain in effect if the Supreme Court upholds the federal judge’s decision.

Across the provisions included in this month’s survey, most Americans say it is “very important” to them that each of the parts of the law are kept in place.

Majorities across partisans say it is “very important” that the ACA’s protections for people with pre-existing conditions remain in place. Nearly nine in ten Democrats (88%), 73% of independents, and 62% of Republicans say it is “very important” that the part of the law that prohibits private health insurance companies from denying coverage because of a pre-existing medical condition remains in place. Similarly, 76% of Democrats, 64% of independents, and 55% of Republicans say it is “very important” the part of the law that prohibits private health insurance companies from charging sick people higher premiums than healthy people remains in place.

Yet, as anything related to the ACA, there are partisan differences. Majorities of Democrats and independents and nearly half of Republicans say it is “very important” the parts of the law prohibiting health insurance companies from denying coverage to pregnant women (89% of Democrats, 73% of independents, and 49% of Republicans), requiring health insurance companies to cover the cost of most preventive services (80% of Democrats, 58% of independents, and 49% of Republicans), and prohibiting health insurance companies from imposing lifetime limits (72% of Democrats, 65% of independents, and 48% of Republicans) remain in place. Across the other provisions asked about, fewer than half of Republicans say it is “very important” for these parts of the law to be kept in place including less than four in ten who say it is “very important” that Medicaid expansion (36%) and subsidies for people who buy their own health insurance (31%) to stay in place.

This KFF Health Tracking Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted July 18^th – July 23^rd 2019, among a nationally representative random digit dial telephone sample of 1,196 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 289 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 (296) and cell phone (900, including 623 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=7). 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. For more information on this court case, see https://modern.kff.org/health-reform/issue-brief/explaining-texas-v-u-s-a-guide-to-the-5th-circuit-appeal-in-the-case-challenging-the-aca/. ↩︎