Note: An analysis of first quarter 2019 data for the individual insurance market is available here.

The early years of the Affordable Care Act (ACA) exchanges and broader ACA-compliant individual market were marked by volatility. Markets in some parts of the country have remained fragile, with little competition, an insufficient number of healthy enrollees to balance those who are sick, and high premiums as a result. By 2017, however, the individual market generally had begun to stabilize. Absent any policy changes, it is likely insurers would have required only modest premium increases to regain or maintain profitability in 2018.

However, by mid-2017 when insurers were considering 2018 premiums and participation, it was unclear whether the individual mandate would be enforced, cost-sharing subsidies would be paid, or the ACA as a whole would remain law. In October 2017, the Trump Administration ceased payments for cost-sharing subsidies, which led some insurers to exit the market or request larger premium increases than they would have otherwise. The Administration also reduced funding for advertising and outreach. And, Congress ultimately repealed the individual mandate penalty, effective for 2019. Amid these policy changes and legislative uncertainty, insurers raised benchmark premiums by an average of 34% going into 2018.

In this analysis, we find individual market insurers saw better financial performance in 2018 than in all the earlier years of the ACA and returned to, or even exceeded, pre-ACA levels of profitability. Premiums fell slightly on average for 2019, as it became clear that some insurers had raised 2018 rates more than was necessary. It is likely premiums would have fallen even more if the individual mandate penalty were still in effect.

In this brief, we use financial data reported by insurance companies to the National Association of Insurance Commissioners and compiled by Mark Farrah Associates to look at the average premiums, claims, medical loss ratios, gross margins, and enrollee utilization from 2011 through 2018 in the individual insurance market, as well as the amount of medical loss ratio rebates insurers expect to issue to 2018 enrollees. These figures include coverage purchased through the ACA’s exchange marketplaces and ACA-compliant plans purchased directly from insurers outside the marketplaces (which are part of the same risk pool), as well as individual plans originally purchased before the ACA went into effect.

Our analysis also finds that insurers are expecting to pay a record total of about $800 million in rebates to individual market consumers for not meeting the ACA medical loss ratio threshold, which requires them to spend at least 80% of premium revenues on health care claims or quality improvement activities. This comes from initial estimates reported by insurers; actual rebates could end up being either higher or lower. In total, across the individual, small group, and large group markets, insurers expect to issue about $1.4 billion in rebates this year based on their 2018 performance. If insurer expectations hold true, these will be the largest consumer rebates issued since the MLR program began.

These new data from 2018 offer further evidence that insurers in the individual market are regaining profitability, though more recent policy and legislative changes taking effect in 2019 – the repeal of the individual mandate penalty as part of tax reform legislation and the proliferation of loosely-regulated short-term insurance plans – continue to cloud expectations somewhat for the future.

Medical Loss Ratios

As we found in our previous analysis, insurer financial performance as measured by loss ratios (the share of health premiums paid out as claims) worsened in the earliest years of the ACA Marketplaces, but began to improve more recently. This is to be expected, as the market had just undergone significant regulatory changes in 2014 and insurers had very little information to work with in setting their premiums.

The chart below shows simple loss ratios, which differ from the formula used in the ACA’s MLR provision.¹  Loss ratios began to decline in 2016, suggesting improved financial performance. In 2017, following relatively large premium increases, individual market insurers saw significant improvement in loss ratios, a sign that individual market insurers on average were beginning to better match premium revenues to claims costs. Loss ratios have continued to decline, averaging 70% in 2018. This suggests insurers were able to build in the loss of cost-sharing subsidy payments when setting premiums and some insurers likely over-corrected.

Margins

Another way to look at individual market financial performance is to examine average gross margins per member per month, or the average amount by which premium income exceeds claims costs per enrollee in a given month. Gross margins are an indicator of performance, but positive margins do not necessarily translate into profitability since they do not account for administrative expenses.

Gross margins show a similar pattern to loss ratios. Insurer financial performance improved dramatically through 2018 (increasing to $167 per enrollee, from a recent annual low of -$9 in 2015). These data suggest that insurers in this market are now financially healthy, on average.

Underlying Trends

Driving recent improvements in individual market insurer financial performance are the premium increases in 2018 combined with more modest growth in claims for medical expenses. On average, premiums per enrollee grew 26% from 2017 to 2018, while per person claims grew only 7%. This growth in premiums is in part due to the loss of cost-sharing subsidy payments; insurers are required by law to provide cost-sharing subsidies to eligible enrollees, but are no longer being reimbursed by the federal government. Rate hikes to offset the termination of federal cost-sharing subsidy payments were a major factor in 2018 premium increases.

One concern about rising premiums in the individual market was whether healthy enrollees would drop out of the market in large numbers rather than pay higher rates. While the vast majority of exchange enrollees are subsidized and sheltered from paying premium increases, those enrolling off-exchange would have to pay the full increase. Despite this dynamic, the average number of days individual market enrollees spent in a hospital in 2018 was slightly lower than inpatient days in the previous three years.² 

Taken together, these data on claims and utilization suggest that the individual market risk pool is relatively stable, though sicker on average than the pre-ACA market, which is to be expected since people with pre-existing conditions have guaranteed access to coverage under the ACA. Despite concerns that healthier enrollees may be dropping out of the market in recent years, somewhat lower average inpatient days indicate that the individual market did not get sicker, on average, during 2018.

Expected Rebates

The medical loss ratio (“MLR”) provision of the ACA requires most insurance companies that cover individuals to spend at least 80% of their premium income on health care claims and quality improvement, leaving the remaining 20% for administration, marketing, and profit. Beginning in 2012, insurers failing to meet the applicable MLR standard for the prior year (2011) were required to issue rebates to consumers and employers. Thus far, the 2011 rebates had remained the largest ever issued – totaling $399 million in the individual market alone (and $1.071 billion across the individual, small group, and large group markets).

Insurers’ preliminary estimates indicate they expect to issue about $800 million in rebates to 2018 individual market enrollees, which would be the highest total for the individual market by far since the program began. While this represents initial insurer estimates, and the actual rebate amount issued could be lower or higher³ , these high expected rebates provide further evidence that some insurers over-corrected in raising individual market premiums for 2018.

Insurers estimate more than 3 million 2018 individual market enrollees, or 26%, are eligible to receive rebates. Insurers owing rebates expect to issue about $260 per member, on average. All rebates must be issued by September 30 of the year following the applicable MLR reporting period (i.e., September 2019 for the 2018 reporting period).

Across all commercial markets – individual, small group, and large group – rebates are expected to total approximately $1.4 billion. If insurer estimates hold true, these will be the largest rebates issued since the MLR program began. These higher rebates are mostly driven by the individual market. Rebates in the small and large group markets are expected to be larger than average, but not significantly so.

Discussion

Annual results from 2018 suggest that despite significant challenges and recent enrollment declines, insurers in the individual insurance market are now generally profitable. Insurer financial results from 2018 – after the Administration’s decision to cease cost-sharing subsidy payments, but before the repeal of the individual mandate penalty in the tax overhaul went into effect – reveal the most favorable year in the ACA-compliant market’s history.

Premium and claims data support the notion that 2017 premium increases were necessary as a one-time market correction to adjust for a sicker-than-expected risk pool, and premium increases in 2018 were in large part compensating for policy uncertainty and the termination of cost-sharing subsidy payments, though some insurers appear to have over-compensated. Without these policy changes, it is likely that insurers would generally have required only modest premium increases in 2018. Low loss ratios and higher margins indicate that some insurers raised premiums more than was necessary to cover claims and administrative costs and earn a reasonable profit in 2018.

Across the individual market, insurers expect to pay record-high rebates to consumers for failing to meet the medical loss ratio requirement, providing further evidence that insurers over-corrected when setting 2018 premiums. Before the ACA’s MLR provision went into effect, insurers in such a situation would have experienced windfall profits. The MLR rule requires insurers to repay consumers in the form of a cash rebate or premium credit when the prior year’s premiums are determined to have been too high relative to claims costs.

While markets in some parts of the country remain more fragile, the individual market on average is becoming more profitable. Some insurers have exited the market in recent years, but others have been successful and expanded their footprints, as would be expected in a competitive marketplace. Even though repeal of the individual mandate penalty and expansion of loosely-regulated insurance options had an upward effect on 2019 premiums, premiums actually decreased slightly because 2018 premiums were higher than necessary to cover claims costs. In 2019, new insurers have entered and some insurers are reentering markets they had previously exited. While signups through the marketplace during the 2019 open enrollment period declined somewhat compared to 2018, financial results suggest the market is still stable and sustainable.

Methods

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. 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; in total, the plans in this dataset represent at least 80% of the individual market. All figures in this issue brief are for the individual health insurance market as a whole, which includes major medical insurance plans and mini-med plans sold both on and off exchange. We excluded some 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.

To calculate the weighted average loss ratio across the individual market, 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. 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 member months (average monthly enrollment) in the individual insurance market. Using earned premiums adjusted for taxes and fees to calculate loss ratios and gross margins increases the MLR by 6 percentage points and decreases the gross margin per member by $42 in 2018. On average across all years, using earned premiums adjusted for taxes and fees increases the MLR by 3 percentage points and decreases the gross margin per member by $14.

Total rebates are based on preliminary estimates from insurers. Since 2014, the total rebate amount issued across the individual, small group and large group markets has varied by 3 to 5% from insurer estimates. At the market level, the difference between estimates and actual rebate totals have been more volatile. Since 2014, individual market estimates have varied by as much as $34 million, or over 20%, as compared to the final actual rebates reported in December of the year following the applicable MLR reporting period. In some years, final rebates are higher than expected and in other years, final rebates are lower.

1. The loss ratios shown in this issue brief differ from the definition of MLR in the ACA, which makes some adjustments for quality improvement and taxes, and do not account for reinsurance, risk corridors, or risk adjustment payments. Reinsurance payments, in particular, helped offset some losses insurers would have otherwise experienced. However, the ACA’s reinsurance program was temporary, ending in 2016, so loss ratio calculations excluding reinsurance payments are a good indicator of financial stability going forward. ↩︎
2. Hospital patient days for 2014 are not necessarily representative of the full year because open enrollment was longer that year and a number of exchange enrollees did not begin their coverage until mid-year 2014. ↩︎
3. See Methods for more discussion on how insurer estimates tend to vary from actual rebate totals. ↩︎

People on Medicare can choose coverage from either traditional Medicare or Medicare Advantage plans, typically trading off broad access to providers for potentially lower premiums and out-of-pocket costs. Beneficiaries who choose Medicare Advantage may differ from those in traditional Medicare in both measurable and unmeasurable ways, which may influence their use of services and spending. Yet, Medicare payments to Medicare Advantage plans per enrollee are based on average spending among beneficiaries in traditional Medicare.

This analysis looks at whether beneficiaries who choose to enroll in Medicare Advantage plans have lower spending, on average – before they enroll in Medicare Advantage plans – than similar people who remain in traditional Medicare. We compare average traditional Medicare spending and use of services in 2015 among beneficiaries who switched to Medicare Advantage plans in 2016 with those who remained in traditional Medicare that year, after adjusting for health risk. We adjust Medicare spending values for health conditions and other factors, with a model similar to the CMS HCC Risk Adjustment Model that is used to adjust payments to Medicare Advantage plans (see Methods).

Key Findings

• People who switched from traditional Medicare to Medicare Advantage in 2016 spent $1,253 less in 2015, on average, than beneficiaries who remained in traditional Medicare, after adjusting for health risk (ES Figure).

• Even among traditional Medicare beneficiaries with specific health conditions, those who shifted to Medicare Advantage in 2016 had lower average spending in 2015, including people with diabetes ($1,072), asthma ($1,410), and breast or prostate cancer ($1,517).

Even after risk adjustment, the results indicate that beneficiaries who choose Medicare Advantage have lower Medicare spending – before they enroll in Medicare Advantage plans – than similar beneficiaries who remain in traditional Medicare, suggesting that basing payments to plans on the spending of those in traditional Medicare may systematically overestimate expected costs of Medicare Advantage enrollees.

Overview

Medicare payments to Medicare HMOs and PPOs, known as Medicare Advantage plans, have always been based on Medicare spending by similar people in traditional Medicare, partly because Medicare has never had accurate, complete data on the use of services or health care spending for beneficiaries in Medicare Advantage plans.¹  The assumption has been that adjusting payments to plans for health status and other factors accounts for differences between beneficiaries in traditional Medicare and those in Medicare Advantage plans. Profits are assumed to be due to plans reducing spending by either managing fees (e.g., by having lower-cost hospitals in their network) or changing patterns of care (e.g., reducing hospital readmissions), rather than to favorable selection. Nonetheless, selection bias has been an ongoing concern and the subject of many studies over the years, with mixed evidence of favorable selection.^{2 ,3 ,4 ,5 ,6}  This question is important because it affects the accuracy of Medicare payments to plans on behalf of 20 million Medicare beneficiaries, and rising.

This is the first known analysis to examine whether beneficiaries who choose to enroll in Medicare Advantage plans have lower spending and use fewer services – before enrolling in Medicare Advantage – than similar people in traditional Medicare. If Medicare Advantage enrollees use fewer services and have lower Medicare spending before they enroll in Medicare Advantage plans, compared to similar beneficiaries in traditional Medicare, then basing payments to Medicare Advantage plans on the Medicare spending for similar beneficiaries in traditional Medicare would overestimate the expected costs of Medicare Advantage enrollees and overpay plans by billions of dollars over the next decade. Studies that have looked at differences in the use of services and Medicare spending for Medicare Advantage enrollees compared to beneficiaries in traditional Medicare that did not account for actual prior differences may have overestimated the extent to which plans are reducing enrollees’ spending or use of services.

To address this question, we examine Medicare Part A and B spending and service use for traditional Medicare beneficiaries in 2015. We compare average Medicare spending and use of services for traditional Medicare beneficiaries who enrolled in Medicare Advantage plans versus those who remained in traditional Medicare in 2016, after adjusting spending values for health conditions and other relevant factors (Figure 1). We examine how the results differ across demographics, chronic conditions, and counties, and also examine how the results change when Part D spending is included. The analysis is based on a five percent sample of Medicare claims data and excludes beneficiaries who may not have been active choosers in 2016; more details about the analysis are included in the Methods.

Differences in Medicare Spending

Among beneficiaries in traditional Medicare in 2015, those who enrolled in Medicare Advantage in 2016 had spending (for Part A and Part B) that was $1,253 lower (13% difference), on average, than beneficiaries who remained in traditional Medicare in 2016, after adjusting for health risk factors (Figure 2; Tables 1 and 2).⁷ 

When Part D spending is included, the results changed only slightly. Traditional Medicare beneficiaries in 2015 who switched to Medicare Advantage in 2016 had total Medicare spending (including Part D) that was 15 percent lower than spending for beneficiaries who remained in traditional Medicare in 2016.

Comparison to Other Payments Received by Medicare Advantage Plans. To put the difference in Medicare spending in context, the $1,253 average difference in spending is nearly four-times larger than the average per capita quality-based bonus payment ($336) paid to Medicare Advantage prescription drugs plans that qualified for bonuses in 2015 (Figure 3). The average difference in spending is also more than twice as large as the average annual premium paid by Medicare Advantage enrollees in 2015, including enrollees in plans with no premium.

Differences in Medicare Spending, by Demographics

Traditional Medicare spending in 2015 was lower for beneficiaries who enrolled in Medicare Advantage plans in 2016 than for similar beneficiaries who remained in traditional Medicare that year, by age and gender, and among beneficiaries dually eligible for Medicare and Medicaid, after adjusting for health risk and other factors (Table 1).

• Age: The difference in average traditional Medicare spending in 2015 among beneficiaries who switched to Medicare Advantage in 2016, compared to those who remained in traditional Medicare, was evident for beneficiaries of all ages, and increased with age for beneficiaries over the age of 65, after risk adjustment. For example, among beneficiaries ages 65-69, average traditional Medicare spending in 2015 was $1,119 lower among beneficiaries who switched to a Medicare Advantage plan in 2016 than for similar beneficiaries who remained in traditional Medicare; among beneficiaries ages 85-89, the difference in spending was $1,314. This finding suggests that selection bias, and the associated potential overpayments, may increase with age.
• Gender: The average difference in spending between the two groups was similar among men and women ($1,271 and $1,247, respectively).
• Dual eligibility for Medicaid: Traditional Medicare spending in 2015 for Medicare beneficiaries with full Medicaid benefits (full dual eligible) who enrolled in Medicare Advantage in 2016 was $1,142 lower, on average, than spending for similar full dual eligibles who stayed in traditional Medicare in 2016, after adjusting for health and demographic factors. Similarly, partial dual eligibles who enrolled in Medicare Advantage in 2016 had traditional Medicare spending in 2015 that was $1,162 lower than spending for those who remained in traditional Medicare in 2016, after adjusting for risk factors. In other words, among dually eligible beneficiaries – a group of beneficiaries with relatively high Medicare spending – those who used more services and incurred higher Medicare spending in 2015 were more likely to remain in traditional Medicare in 2016 while dual eligibles with lower service use and spending were more likely to enroll in a Medicare Advantage plan in 2016.
• Institutional status: Among Medicare beneficiaries living in institutions, such as nursing homes, traditional Medicare spending in 2015 was $1,825 lower among those who enrolled in Medicare Advantage plans in 2016 than among similar institutional residents who stayed in traditional Medicare that year. If higher-cost nursing home residents are remaining in traditional Medicare while lower-cost residents are moving to Medicare Advantage plans, it could make it easier for Medicare Advantage plans serving the nursing home population to be profitable, which may explain the relatively recent increase in firms offering Special Needs Plans for this population (I-SNPs).⁸  

Differences in Medicare Spending, by Chronic Conditions

Even among beneficiaries with the same chronic conditions, those who enrolled in Medicare Advantage plans in 2016 consistently had lower Medicare spending in 2015 than similar beneficiaries who remained in traditional Medicare in 2016 (Table 1).

For example, among traditional Medicare beneficiaries with diabetes in 2015, those who enrolled in Medicare Advantage plans in 2016 had Medicare spending that was $1,072 lower in 2015, on average, than similar beneficiaries with diabetes who stayed in traditional Medicare in 2016, after adjusting for differences in health status (Figure 4). In other words, it would appear that lower-cost beneficiaries with diabetes are more inclined to enroll in Medicare Advantage than higher-cost diabetics. Likewise, traditional Medicare beneficiaries with asthma who enrolled in Medicare Advantage plans in 2016 had Medicare spending that was $1,410 lower in 2015, on average, than similar beneficiaries with asthma who remained in traditional Medicare in 2016, even after adjusting for health risk factors.

The difference in average, adjusted 2015 traditional Medicare spending between beneficiaries who subsequently enrolled in Medicare Advantage versus those who remained in traditional Medicare increases with the number of chronic conditions, rising from $226 among those with no chronic conditions to $1,629 or more among beneficiaries with 5 or more chronic conditions (Figure 5). This finding suggests that potential overpayments may be largest for the Medicare Advantage plans that are serving the sickest beneficiaries.

Differences in Medicare Spending, by County

In this section, we looked at whether the observed differences in spending and service use persist across markets, and the extent to which differences may vary from one market to another. We compared average spending in 2015 among beneficiaries who switched to Medicare Advantage in 2016 versus those who remained in traditional Medicare, without adjusting for other factors. We were not able to replicate the analysis by county with the adjustment for risk factors, such as health conditions and demographics, due to sample size constraints. For this analysis, we looked at 20 relatively large markets that vary geographically, and vary by Medicare Advantage penetration and payment quartiles.

Among large, urban counties, the differences in spending between Medicare Advantage enrollees and beneficiaries in traditional Medicare varied greatly across the country (Figure 6; Table 3). In some counties, such as Los Angeles, CA, San Bernardino, CA, Wayne, MI (Detroit), and Cuyahoga, OH (Cleveland), beneficiaries who enrolled in Medicare Advantage plans in 2016 had significantly lower traditional Medicare spending in 2015 ( ≥$3,000 lower) than beneficiaries in the county who remained in traditional Medicare in 2016.

In other counties, such as Allegheny, PA (Pittsburgh), Baltimore City, MD, Mecklenburg, NC (Charlotte), Erie, NY (Buffalo), and Multnomah, OR (Portland) beneficiaries who enrolled in Medicare Advantage plans in 2016 had higher prior year traditional Medicare spending ( ≤-$1,000) than beneficiaries in the county who remained in traditional Medicare in 2016. These differences across counties suggest that the selection bias into Medicare Advantage may vary across markets.

Discussion

This analysis examines whether beneficiaries who choose to enroll in Medicare Advantage plans have lower spending and use fewer services – before enrolling in Medicare Advantage – than similar people in traditional Medicare. The study found that beneficiaries who chose to enroll in a Medicare Advantage plan in 2016 had average expenditures in traditional Medicare (in 2015) that were $1,253 less, on average, than similar beneficiaries who remained in traditional Medicare. Similar differences in spending were found across all demographics and chronic conditions, even after adjusting for health risk factors. The results suggest that favorable self-selection into Medicare Advantage plans is occurring, even among traditional Medicare beneficiaries with similar health conditions. The findings raise questions as to why beneficiaries who are higher utilizers are less likely to go into Medicare Advantage and instead remain in traditional Medicare.

Other studies have examined services used by people while they were enrolled in Medicare Advantage plans, based on limited data, and have generally found that beneficiaries in Medicare Advantage plans use fewer services than those in traditional Medicare.^9 ,10 ,11  Notably, the authors of these studies almost universally attribute differences in service utilization to care management by the plans – rather than to pre-existing differences in care seeking behavior and use of health services. This study suggests that differences in health care use, and spending, are evident before beneficiaries decided to enroll in Medicare Advantage plans or remain in traditional Medicare, raising questions about the extent to which plans are actually lowering spending or managing care.

It is not clear whether the differences in spending observed in this study increase, decrease, or persist over time as beneficiaries age, which has implications for whether a similar difference in spending could be assumed for all Medicare Advantage enrollees.¹²  Likewise, it is not clear how this difference in spending will change as the share of counties with the majority of beneficiaries in Medicare Advantage plans grows. This missing information could have important implications for Medicare spending. Potential overpayments could amount to billions in excess Medicare spending over a ten-year period if the observed differences in spending hold up as beneficiaries age and Medicare Advantage enrollment continues to rise. To illustrate, if the difference in average Medicare spending ($1,253) applied to just 10 percent of all Medicare Advantage enrollees in 2016, or 1.8 million enrollees, it would amount to more than $2 billion in excess spending in one year alone.

Policymakers could consider adjusting payments to reflect Medicare Advantage enrollees’ prior use of health care services, which could lower total Medicare spending and in turn reduce Medicare Part B premiums and deductibles for all beneficiaries. With more than 20 million enrollees in Medicare Advantage plans and Medicare payments to plans projected to reach $250 billion in 2019, the stakes are high for making payments to plans as accurate as possible.^13 ,14 

This analysis focuses on beneficiaries in traditional Medicare who were enrolled in both Medicare Part A and Medicare Part B in 2015, examining average adjusted 2015 Medicare Part A and B spending for these beneficiaries, based on their 2016 enrollment in Medicare Advantage plans or traditional Medicare. Beneficiaries who enrolled in Medicare Advantage plans at any point during the 2016 calendar year were categorized as Medicare Advantage enrollees.

To conduct this analysis, we excluded beneficiaries who: (1) became Medicare beneficiaries after 2013 or were not in traditional Medicare with both Part A and Part B in 2013, 2014, and 2015 (5.8 million people) because three years of claims data were required for each person to collect sufficient information about chronic conditions; (2) died prior to January 2016 (1.5 million people) because they would not have had the same opportunity to enroll in Medicare Advantage as other beneficiaries; (3) had end-stage renal disease in 2015 or 2016 (290 thousand people) because the vast majority were not eligible to enroll in a Medicare Advantage plan in 2016; (4) were unlikely to have actively selected (and instead may have been passively enrolled in) a Medicare Advantage plan, including beneficiaries who enrolled in Medicare-Medicaid Plans (MMPs) and employer group health plans (183 thousand people); (5) lived in Puerto Rico and other territories because some elements in the Medicare claims data are not as reliable or accurate for these beneficiaries; (6) enrolled in cost, Medical Savings Account (MSA), or PACE plans in 2016 (21 thousand people) because these plans are paid differently than Medicare Advantage plans; and (7) enrolled in a Special Needs Plan for people with specified chronic conditions (C-SNP; 13 thousand people) because the design of these plans may disproportionately attract healthier people with chronic conditions. When we relaxed the first inclusion requirement, for beneficiaries to be in traditional Medicare with both Part A and Part B in 2013, 2014, and 2015, and instead only required included beneficiaries to be in traditional Medicare with Part A and B in 2014 and 2015, the findings did not materially change, with the adjusted percent difference in spending remaining 13%. Similarly, when we included people in C-SNPs, the adjusted percent difference in spending did not change. In total, the primary analysis included 24 million beneficiaries who were in traditional Medicare in 2015.

The brief uses claims data from a five percent sample of Medicare beneficiaries from the Master Beneficiary Summary Files of CMS’s Chronic Conditions Data Warehouse for 2013 through 2016. The analysis first examined the bivariate differences in spending and use of services by demographics, chronic conditions, and other factors. To control for differences in health status and other factors that could account for the difference in Medicare spending, a multivariate generalized linear log link model with a gamma distribution was developed that mimics as closely as possible the CMS-HCC Risk Adjustment Model, which is used to risk-adjust payments to Medicare Advantage plans. The model for this study includes the same structure of the demographic variables and interaction terms as the HCC Risk Adjustment Model. This study’s model also includes the only available (although imperfect) variable to indicate whether someone who used a Part D covered drug was residing in a long-term care facility at any point during the year; this approach misses information about institutional residency status for the people who do not take drugs covered under Part D.

This study examined bivariate differences in traditional Medicare spending across counties, for those county residents who enrolled in Medicare Advantage compared to those who did not. The data used in the study did not include a sufficient number of people to adjust these county-level values for health risk factors. Future studies could examine whether the observed bivariate differences across counties hold, after adjusting for health risk factors.

The model used in this analysis does not include the HCCs in the Risk Adjustment Model that are not recorded as chronic conditions in the Chronic Conditions Data Warehouse, the majority of which are HCCs for acute or relatively rare conditions. The margins command, with values as observed, was used to generate the adjusted spending values. Alternative models for this analysis also included as covariates the per capita traditional Medicare spending for each county, beneficiaries’ race/ethnicity as defined by the RTI race variable, and additional chronic conditions, with no meaningful change in the results. We also looked at the sensitivity of the findings to the inclusion criteria; when we included beneficiaries who were in traditional Medicare with Part A and B in 2014 and 2015 but either were not in traditional Medicare or did not have both Part A and Part B in 2013, the findings did not materially change, with the risk adjusted difference in spending rising from $1,253 to $1,298.

1. Medicare Payment Advisory Commission, “Medicare Advantage encounter data,” Presentation to Commissioners, March 7, 2019. Available at: http://www.medpac.gov/docs/default-source/default-document-library/ma-encounter-data-march-2019.pdf ↩︎
2. Neuman, Patricia and Gretchen Jacobson. “Medicare Advantage Checkup” New England Journal of Medicine 2018; 379: 2163-2172 Available at: https://www.nejm.org/doi/full/10.1056/NEJMhpr1804089 ↩︎
3. Medicare Payment Advisory Commission, “Improving risk adjustment in the Medicare program,” June 2014. Available at: http://www.medpac.gov/docs/default-source/reports/jun14_ch02.pdf ↩︎
4. Newhouse, Joseph P., J. Michael McWilliams, Mary Price, et al., “Do Medicare Advantage Plans Select Enrollees in Higher Margin Clinical Categories?” Journal of Health Economics. 2013 December; 32(6) ↩︎
5. Newhouse, Joseph P., Mary Price, J. Michael McWilliams, et al., “How Much Favorable Selection is Left In Medicare Advantage?” American Journal of Health Economics. 2015 1(1):1-26 ↩︎
6. McWilliams, J. Michael, John Hsu, and Joseph P. Newhouse, “New Risk-Adjustment System Was Associated With Reduced Favorable Selection In Medicare Advantage,” 2011. Vol. 31, no. 12. ↩︎
7. We examined health care service utilization in 2015 among beneficiaries who switched to Medicare Advantage in 2016 vs. those who remained in traditional Medicare. As might be expected based on the finding of lower average spending, we found lower rates of utilization among those who switched to Medicare Advantage. The difference in percent of beneficiaries using services, was largest for Part B drugs, evaluation and management, imaging, tests, and physician visits, respectively. Among beneficiaries who used the specific services, the quantities used were not appreciably different. This analysis was conducted at the bivariate level. ↩︎
8. Kaiser Family Foundation, “Medicare Advantage 2019 Spotlight: First Look,” October 2019. Available at: https://modern.kff.org/report-section/medicare-advantage-2019-spotlight-first-look-tables/ ↩︎
9. Raetzman, Susan O., Anika L. Hines, Marguerite L. Barrett, and Zeynal Karaca, “Hospital Stays in Medicare Advantage Plans Versus the Traditional Fee-for-Service Program, 2013,” HCUP Statistical Brief #198. December 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb198-Hospital-Stays-Medicare-Advantage-Versus-Traditional-Medicare.pdf. ↩︎
10. Landon, Bruce E., Alan M. Zaslavsky, Robert C. Saunders, et al., “Utilization of Services in Medicare Advantage versus Traditional Medicare since the Passage of the Medicare Modernization Act,” Health Affairs. 2012; 31(12): 2609-2617. ↩︎
11. Ayanian, John Z., Landon, Bruce E., Newhouse, Joseph P. et. al. “Analysis of Medicare Advantage HMOs Compared with Traditional Medicare Shows Lower Use of Many Services During 2003-09.” Health Affairs, 31, 12 (December 2012): 1-9. ↩︎
12. A recent study found that death rates were initially lower among beneficiaries who enrolled in Medicare Advantage than those who stayed in traditional Medicare but the rates began to converge over time, raising questions about the differences in case mix between traditional Medicare and Medicare Advantage, and how potential overpayments would change over time. See Newhouse, Joseph P., Mary Price, J. Michael McWilliams, et al., “Adjusted Mortality Rates Are Lower For Medicare Advantage Than Traditional Medicare, But The Rates Converge Over Time,” Health Affairs, 38, 4 (April 2019). ↩︎
13. Congressional Budget Office, “Medicare Baseline,” April 2018. Available at: https://www.cbo.gov/system/files?file=2018-06/51302-2018-04-medicare.pdf ↩︎
14. Kaiser Family Foundation, “A Dozen Facts About Medicare Advantage,” November 2018. Available at: https://modern.kff.org/medicare/issue-brief/a-dozen-facts-about-medicare-advantage/ ↩︎

Kaiser Family Foundation has a long record of measuring the public’s attitudes on reproductive health care issues, including several in-depth surveys of women of reproductive age (between the ages of 18 and 44). In this poll, KFF examines public opinion towards many different facets of reproductive health care, with a focus on recent changes to federal reproductive health policy made by the Trump administration. In particular, the administration recently finalized major changes to the Title X program, which provides federal funding for family planning services for lower-income people. If implemented, these changes would prohibit federal Title X funds from going to any family planning organization that also provides abortion services or referrals.  The new regulation could also channel federal family planning funds to “non-traditional” organizations that only offer natural family planning methods or promote abstinence and do not provide other contraceptive services. The implementation of the new rule was recently halted by court order, but litigation continues. The Trump administration also recently expanded the Mexico City Policy, which restricts federal funding to organizations abroad if they provide abortion services or counseling or referrals for abortions.

This poll also examines public attitudes toward laws that have been recently passed by a number of states prohibiting abortions after a fetal heartbeat has been detected and before many women even know they are pregnant. The poll continues KFF’s tracking of the public’s awareness of provisions related to women’s health that are part of the 2010 Affordable Care Act (ACA).

Key Findings:

• The poll continues to find strong support for federal government funding for reproductive health services for lower-income women, known as Title X funding. Majorities of Democrats and independents think it is important that the federal government provides this funding for lower-income women to access reproductive health services, as do a majority of Republican women (62 percent).
• Earlier this year, the Trump administration made major changes to federal rules regarding the Title X family planning program. The final rule included several changes, most notably blocking federal funding from any family planning provider that either offers or refers abortions to pregnant people – even though the federal funds do not pay for abortions. On these changes, public opinion largely falls along party lines with most Democrats and independents opposing these changes. Republicans are divided with similar shares supporting the Trump administration’s changes as opposing them. The rules have been challenged by numerous family planning organizations, providers, and state attorneys general and are currently temporarily blocked by court orders.¹ 

  68% of Americans say they are concerned new #TitleX family planning regulations would limit access to women’s reproductive health and preventive care services.

• Most Americans – including three-fourths of women ages 18-44 – say they are concerned (either “very” or “somewhat”) that access to women’s reproductive health and preventive care services may be limited by the new rules that don’t allow clinics that provide abortions or refer for abortions to receive federal funding.
• The poll finds agreement across party lines on the issue of federal funding to groups that promote abstinence-only or natural family planning methods. At least half of Democrats, independents, and Republicans say they oppose federal funding going to organizations that do not provide a full array of contraceptive services. Majorities – across party identification – also oppose allowing federal funding to go to organizations that promote abstinence as the only option and do not teach young people about contraception and STD prevention.
• The poll also gauges awareness and attitudes towards restrictions on U.S. funding for foreign non-governmental organizations that provide abortions or counsel or refer for abortions, using their own funds, known as the Mexico City Policy. While the majority of the public does not support such restrictions, views diverge along partisan lines, with most Democrats and independents opposing them and most Republicans supporting the actions by the Trump administration.
• In addition to the recent Trump administration’s actions on reproductive health care, there have also been state-level activities – including passing laws banning abortions after a fetal heartbeat can be detected (normally six weeks into a pregnancy). Opinions towards this type of legislation are largely partisan with Democrats (65 percent) opposing their state passing a similar ban and Republicans supporting it (70 percent) – including three-fourths of Republican women.
• The implementation of the Affordable Care Act (ACA) had major implications for women’s health, but this survey finds there is still confusion about what the 2010 health care law actually does in terms of women’s health care. Less than half of the public are aware the ACA eliminates out-of-pocket costs for birth control (38 percent) and prohibits insurance companies from charging women more than men (36 percent).

Trump Administration and Reproductive Health Care

The Trump administration has pursued a far-reaching strategy aimed at changing the federal government’s position on domestic and international reproductive health policy. On February 22, 2019, the Department of Health and Human Services released the final rule regarding use of Title X federal funds for family planning clinics. These regulations affect nearly 4,000 clinics, which provide health care services to lower-income women in all 50 states.

Partisans Hold Differing Views towards Federal Funding Going to Organizations that Provide Both Contraception and Abortion Services

The Title X program funds clinics across the country to provide family planning services to lower-income women. The program has always prohibited federal funding to be used for abortions; but the new regulations expand these restrictions so that funding cannot go to any organizations that provide contraceptive services if they also provide abortions or refer for abortions. Majorities of the public oppose changing the regulations to exclude any organization that provides abortions (60 percent) or referrals for abortions (56 percent).

These attitudes are largely partisan with about seven in ten Democrats (68 percent) opposing the restrictions on federal funding to organizations that either provide abortions or referrals for abortions while Republicans are divided with similar shares saying they support (47 percent) and oppose (48 percent) the new rule. A larger share of independents say they oppose the new rule (57 percent) than say they support it (40 percent).

Public Perceptions of the Implications of Title X Rule

Overall, seven in ten (including 87 percent of Democrats, two-thirds of independents, and nearly half of Republicans) are concerned (either “very” or “somewhat”) that access to women’s reproductive health and preventive care services may be limited by the new rules that don’t allow family planning clinics that also provide abortions or refer for abortions to receive federal funding. In addition, three-fourths of women ages 18-44 (76 percent) say they are concerned that access to reproductive health and preventive care services may be limited by the new rules.

In addition, KFF continues to find strong support for federal government funding for reproductive health services for lower-income women. Three-fourths of the public say it is important (either “very” or “somewhat” that the federal government provides funding for reproductive health services including family planning and birth control for lower-income women. While a large majority of Democrats (83 percent) and six in ten independents say this is “very” important, the share is much smaller among Republicans (29 percent). This is consistent with previous KFF polling which found majorities of both women and men reporting that it is important that this funding continues.

A majority of women (85 percent) say it is important the federal government provides this funding including seven in ten who say it is “very important.” Support is consistent across women with majorities of women, regardless of party identification, age, and income, saying this funding is at least somewhat important.

Most Oppose Allowing Federal Funding To Go To Groups That Promote Natural Family Planning or Abstinence-Only

While views towards the new rules prohibiting Title X funds from going to organizations that provide both contraceptive and abortion services are largely partisan, there is some consensus across political parties towards other changes to the Title X program.

One of the major changes in the Trump administration’s final Title X rule is removing the requirement that organizations that receive federal Title X funding must provide counseling to pregnant women that “includes abortion, adoption, and prenatal care referrals.” The new Title X regulation permits and encourages the participation of “non-traditional” organizations that only offer natural family planning (NFP) (such as fertility awareness or the rhythm method), or promote abstinence, and do not necessarily provide contraceptive services.

A majority of the public – including a majority of women – oppose these changes to the federal funding structure. About seven in ten (68 percent) oppose allowing federal funding to go to organizations that only provide counseling on NFP methods, such as the rhythm method. Two-thirds oppose (65 percent) allowing federal funding to go to organizations that do not counsel pregnant people about all of their choices, including prenatal care, adoption, and abortion; and about six in ten (59 percent) oppose federal family planning funding to support organizations that do not provide contraception or birth control.

At least half of Democrats, independents, and Republicans say they oppose federal funding to go to organizations that do not provide a full array of reproductive health care services.

A majority of women ages 18-44 oppose allowing federal funding to go to organizations that only provide counseling on natural family planning methods (73 percent), do not counsel pregnant people about all of their choices including prenatal care, adoption and abortion (66 percent), or do not provide contraception or birth control (64 percent).

Similarly, the public largely opposes federal funding for abstinence-only education for teenagers. The Trump administration recently announced new guidelines for funding programs to prevent teenage pregnancy. These new guidelines promote organizations that teach abstinence-only or emphasize “sexual risk avoidance.”

About seven in ten adults (72 percent) oppose allowing federal funding to go to organizations that promote abstinence as the only option and do not teach young people about contraception and STD prevention. Majorities of Democrats (77 percent) and independents (75 percent) oppose, as do a majority of Republicans (59 percent).

More generally, about six in ten Americans (63 percent) think teenagers should be able to get confidential health services such as STD tests, birth control, or pregnancy tests without their parent’s involvement and 61 percent say this is either “very important” or “somewhat important.” A majority of Democrats (78 percent) and independents (62 percent) and fewer Republicans (39 percent) think it is important for teenagers to be able to access these types of health services without parental involvement.

Mexico City Policy

While U.S. law (the Helms Amendment) restricts the use of foreign aid from paying for abortions, in early 2017, the Trump administration reinstated the Mexico City Policy, which further restricts the use of U.S. funding. Specifically, it restricts U.S. funding from going to foreign non-governmental organizations that “perform or actively promote abortion as a method of family planning” using their own money; this includes providing abortions as well as counseling and referrals for abortions. The policy, first announced by President Reagan, has been rescinded and reinstated by subsequent administrations – depending on the President’s political party. Previously, when in place under prior Republican administrations, the Mexico City Policy had only applied to foreign organizations receiving U.S. global family planning funding. The Trump administration expanded it to nearly all U.S. global health funding, greatly increasing its scope.

Overall, most (60 percent) of the public are aware that U.S. government funding to foreign groups that provide reproductive health care and family planning services cannot be used to pay for abortions although about one-fourth (26 percent) incorrectly believe it can be used to pay for abortions.

When asked whether they support or oppose the federal government expanding these restrictions so that no U.S. funding can go to foreign groups that provide abortions or counseling or referrals for abortions, even with their own funding, a larger share of the public oppose this expansion of U.S. policy than support it. More than half oppose expanding these restrictions so that U.S. funding cannot go to foreign groups that provide abortions (56 percent) or referrals for abortions (54 percent) even with their own funds. More than half of women oppose these restrictions while men are more divided.

Similar to views of domestic spending, views of international policy in this area fall along largely partisan lines. Majorities of Democrats oppose expanding restrictions on U.S. funding to any foreign group that provides ether abortions or counseling or referrals for abortions (73 percent), while most Republicans support these restrictions (64 percent). Independents are more divided with 53 percent opposing the federal government expanding these restrictions and 42 percent supporting.

Planned Parenthood

The Trump administration’s new final rule would also mean that Title X funding to Planned Parenthood, the nation’s largest family planning providers, would be blocked.²  In addition to Title X funding, Planned Parenthood clinics participate in the Medicaid program, which reimburses them for family planning services they provide to millions of lower-income people across the U.S. Nearly four in ten (38 percent) women report having ever visited a Planned Parenthood clinic.

While no federal funding to Planned Parenthood is used to pay for abortions, some states have proposed stopping all payments to Planned Parenthood for any family planning services, such as contraception or STI testing. Seven in ten (69 percent) would like their state to continue making payments to Planned Parenthood while about three in ten (29 percent) say all state payments to Planned Parenthood should be stopped. Views towards state payments to Planned Parenthood are largely partisan with nearly nine in ten Democrats (86 percent) and three-fourths of independents (74 percent) wanting to see state payments continue, while nearly six in ten Republicans (57 percent) want state payments to stop. Sizable majorities of women, overall (76 percent), and those 18-44 years old (87 percent) also support continuing state payments to Planned Parenthood. Republican women are divided with similar shares saying their state should stop payments (50 percent) as say the payment should continue (48 percent).

Attitudes towards continued state payments to Planned Parenthood seem somewhat malleable with about one-tenth of the public, on either side of the argument, changing their minds after hearing counter-arguments. For example, one-fourth (7 percent overall) change their minds and now want to see the state payments to Planned Parenthood continue after hearing that this change would make it difficult for many lower-income women to access certain health services. This brings the total share who want to see their state payments to Planned Parenthood continue up to three-fourths of the public (76 percent). On the other side of the argument, 12 percent (8 percent of overall) change their minds after hearing that while the funding does not go directly to abortions, the organization does provide or refer for abortion (bringing the share who want to see state payments stop up to 37 percent).

Challenges to Roe v. Wade

In addition to the Trump administration’s actions, there have been other state-level challenges to reproductive health care access.³  For example, Ohio lawmakers recently banned abortions after a fetal heartbeat can be detected. There are similar laws in 14 other states.⁴ 

When asked about their own state passing a similar “heartbeat” ban, the public is divided with a slightly larger share supporting such a law (50 percent) while 44 percent are opposed. There are stark partisan differences with seven in ten Republicans saying they support their state passing a ban on abortions once a fetal heartbeat is detected while nearly two-thirds of Democrats (65 percent) are opposed. Independents are more divided with similar shares supporting (53 percent) and opposing (44 percent) a ban. Among women ages 18-44, about half (52 percent) oppose their state passing a law restricting abortions once a fetal heartbeat is detected while 42 percent support passing this type of law.

While generally Republicans are more supportive of their state passing similar legislation, Republican women are more supportive than any other group. Three-fourths (77 percent) of Republican women support their state passing a ban on abortions once a fetal heartbeat is detected, compared to 64 percent of Republican men.

Opponents argue that restricting abortions once a fetal heartbeat is detectable may effectively ban abortions six weeks into pregnancy and before many women know they are pregnant. About one-fourth of those who support a ban (12 percent of total) change their minds after hearing that this ban would restrict abortions before many women know they are pregnant – bringing total opposition up to 56 percent overall.

With multiple states passing bills aimed at restricting access to abortions, many legal scholars believe that the U.S. Supreme Court will be forced to take up one of these cases, thereby forcing the Court to revisit Roe v. Wade, the 1973 U.S. Supreme Court case which established a woman’s constitutional right to have an abortion. Overall, two-thirds of the public (65 percent) do not want to see the Supreme Court overturn Roe v. Wade, while about one-third (32 percent) would like to see the decision overturned.

Unsurprisingly, attitudes are largely partisan with a majority (56 percent) of Republicans wanting to see Roe v. Wade overturned, while eight in ten Democrats and about seven in ten independents (68 percent) do not want the decision overturned. Two-thirds of women overall and seven in ten women ages 18-44 say they would like to see Roe v. Wade stay in place.

If the U.S. Supreme Court overturns Roe v. Wade, it would leave the legality of abortion up to individual states⁵ . In recent years, a number of states including Arkansas, Louisiana, North Dakota, South Dakota, and Mississippi have passed “trigger laws” which would make abortion illegal in the state if the Roe v. Wade decision is overturned. Overall, half of adults (50 percent) think abortion would continue to be legal in their state, while 42 percent think it would no longer be legal. And notably, 63 percent of those who live in states that have passed or have introduced legislation that would enact a “trigger law” think abortion would not be legal in their state if the Supreme Court overturned Roe v. Wade. Conversely, 59 percent of Americans in states which have no proposed “trigger laws” think abortion would remain legal in their states should the Supreme Court overturn the decision.⁶ 

Public Still Largely Unaware Of Key ACA Reproductive Health Care Provisions

The implementation of the Affordable Care Act (ACA) had major implications for women’s health and access to care with requirements such as mandatory maternity care, coverage without cost-sharing for preventive services such as contraception, and a prohibition on gender rating – charging women more than men for the same coverage.⁷  While some changes took several years to implement, many of these requirements were implemented more than nine years ago. The poll finds there is still some confusion of what the 2010 health care law actually does. Six in ten (62 percent) are aware the law requires insurance plans purchased by individuals to include a minimum package of benefits including maternity care while about half (48 percent) are aware the law prohibits insurance companies from denying coverage based on a person’s medical history or that the law eliminates out-of-pocket costs for preventive health care services (48 percent). Less than half are aware the ACA eliminates out-of-pocket costs for birth control (38 percent) and prohibits insurance companies from charging women higher premiums than men (36 percent).

Overall, a larger share of women than men are aware of most of these provisions. For example, 45 percent of women overall are aware the ACA eliminated out-of-pockets for birth control (including 54 percent of women 18-44 years old) compared to three in ten men.

At the same time, misconceptions about the law remain. About one-third (33 percent) of the public incorrectly believe the ACA requires health insurance plans to cover abortions including 36 percent of men and about three in ten women overall and between the ages of 18 and 44 (29 percent). The misconception is more common among Republicans (41 percent). The ACA actually allows states to ban the sale of plans that offer abortion coverage through their ACA marketplaces and has special rules to separate the costs of abortion coverage for plans in states that still permit abortion coverage.

This KFF Poll: Public Opinion and Knowledge on Reproductive Health Policy was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted April 23^rd -28^th 2019, among a nationally representative random digit dial telephone sample of 1,200 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 253 respondents reached by calling back respondents that had previously completed an interview on the KFF Tracking poll more than nine months ago. Computer-assisted telephone interviews conducted by landline (305) and cell phone (895, including 643 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 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. 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. P. Belluck. “Judge Temporarily Blocks Trump Rule on Abortion Referrals. The New York Times. April 25, 2019. Available at https://www.nytimes.com/2019/04/25/science/title-x-injunction-abortion-referrals.html ↩︎
2. Planned Parenthood clinics serve about 40 percent of the 4 million patients who receive care in clinics that receive Title X funding each year. https://kffhealthnews.org/news/hhs-finalizes-rule-seeking-to-expel-planned-parenthood-from-family-planning-program/ ↩︎
3. According to a report released by Planned Parenthood Federation of American and Guttmacher Institute. Full report available at https://www.plannedparenthood.org/uploads/filer_public/71/bc/71bc6e9b-dff8-4201-8ed3-141df7dce0e2/190325-media-state-abortion-bans-snapshot-v6.pdf ↩︎
4. B. Farmer and J. Fortier. “Heartbeat Bills Give State Lawmakers Pause on Anti-Abortion Tactics.” Kaiser Health News. April 16, 2019. Available at https://kffhealthnews.org/news/heartbeat-bills-give-state-lawmakers-pause-on-anti-abortion-tactics/ ↩︎
5. J. Rovner. “If High Court Reverses Roe V. Wade, 22 States Poised To Ban Abortion.” Kaiser Health News. July 10, 2018. Available at https://kffhealthnews.org/news/if-high-court-reverses-roe-v-wade-22-states-are-likely-to-ban-abortion/ ↩︎
6. States with enacted trigger laws: Arkansas, Kentucky, Louisiana, Mississippi, South Dakota, North Dakota; states with proposed trigger laws: Georgia, Tennessee, Oklahoma, South Carolina, Missouri, Indiana, Texas, Washington. ↩︎
7. Previous KFF polling has found that large majorities of the public say it is important for the ACA’s requirements affecting women be kept in place.   ↩︎