The Senate recently considered legislation called the Better Care Reconciliation Act of 2017 (BCRA), proposed on June 22, 2017 and revised on July 13, 2017 and July 20, 2017. This bill differs in some ways from the American Health Care Act (AHCA) that passed in the House in May 2017 but maintains a similar overall framework in its treatment of Medicaid. While referred to as legislation to repeal and replace the Affordable Care Act (ACA), both the BCRA and the AHCA make more fundamental changes to Medicaid by phasing out the enhanced federal matching funds for the ACA Medicaid expansion and by setting a limit on federal funding through a per capita cap or, at state option, a block grant for some enrollees.

This brief provides national and state-by-state estimates of the reductions in federal spending for the period 2020-2029 and for 2029 in order to see the full effect of policy changes over a ten-year period. We chose these years because the major Medicaid policy provisions in BCRA begin in 2020, and the effect of federal funding policies changes over time. We analyze the effect of two main provisions of the BCRA:

• The phase-out of enhanced federal funding for the ACA expansion from 90% to the state’s regular federal share of Medicaid spending (called the federal medical assistance percentage, or FMAP)
• The use of a per enrollee cap on federal funds for most enrollees, including those covered through the ACA expansion.

We examine changes in federal spending under two possible scenarios of state responses to the BCRA: (1) states maintain their programs and fill in the loss of federal dollars, in which we show how much states would have to spend to make up the loss of federal dollars; and (2) states that expanded Medicaid under the ACA fully drop their expansions, in which we show the additional loss of federal dollars that the state would have received had it maintained its expansion. This analysis thus differs from the estimates produced by the Congressional Budget Office (CBO), which assumes future coverage expansions and accounts for varied behavioral responses from both individuals and states. An overview of the methods underlying the analysis is provided in the “Methods” box at the end of the brief.

We estimate that reductions in federal spending over the 2020-2029 period could be $519 billion if states maintain coverage and fill in gaps in federal funding reductions as a result of the decrease FMAP for the expansion and the imposition of a per enrollee cap. Of this amount, $302 billion is attributable to the phase-out of the enhanced FMAP for the expansion population and $218 billion from the per enrollee caps applied to all eligibility groups, including expansion adults (Figure 1). However, the relative contribution of the changes in FMAP and per enrollee cap changes over time, with the cap accounting for a larger share of the decline in federal dollars as per enrollee caps become more binding. State-by-state changes would vary greatly depending on the current size of the state’s Medicaid program, whether or not the state expanded Medicaid under the ACA, and the FMAP for the state (Table 1). In addition, if in response to the reduction in federal support for the expansion, all states fully roll back coverage for the expansion population, federal funding would decline by an additional $685 billion over the 2020-2029 period to reach a change in federal funds of -$1.2 trillion and result in the loss of coverage for 19 million enrollees covered through the expansion(Table 3). Though it is unlikely that all expansion states would immediately fully eliminate the expansion, these estimates provide a projection of the federal funds at risk.

While this analysis provides estimates of the potential scope of changes under the law, actual state experiences may differ if key factors, such as the inflation factors used under the BCRA or baseline Medicaid growth, differ from current predictions. In addition, it is difficult to predict how states would respond to the financing changes. We did not model additional behavioral responses, such as elimination of high cost coverage pathways, cuts in provider rates or changes in scope of benefits, that could result in further reductions in spending and coverage compared to current law. Alternatively, some states could opt for the block grant and implement more significant reductions in coverage or benefits compared to current law. This analysis did not examine the potential implications of the optional block grant for expansion and/or other adults or the provisions to equalize state per enrollee spending over time.

Medicaid Changes under the BCRA and Possible State Responses

Our analysis examines the changes in the BCRA that would phase out the enhanced matching rate for the ACA Medicaid expansion and limit federal Medicaid spending to a capped amount per enrollee for five eligibility groups (expansion adults, other adults, children, the elderly and people with disabilities). First, under the BCRA, for states that adopted the expansion as of March 1, 2017, the enhanced federal match would phase out from 90% in 2020 to 85% in 2021, 80% in 2022, 75% in 2023 and then to the regular state match rate in 2024 and beyond. This phase out lowers federal Medicaid spending relative to current law, under which federal financing for the expansion population would remain at 90% in 2020 and in subsequent years.

Second, under the BCRA, federal Medicaid spending for most enrollees would be limited to a set amount per enrollee. To establish these limits, states would use data from FY 2014-2016 to develop base year per enrollee spending that would be inflated to 2019 based on the medical component of the consumer price index (CPI-M). Beginning in 2020, federal spending would be limited to the federal share of spending based on per enrollee amounts calculated by inflating the base year spending by CPI-M for children and adults and CPI-M plus one percentage point for the elderly and disabled. Beginning in 2025, all per enrollee limits would be increased by general inflation (CPI-U). Certain spending and populations would be excluded from the per enrollee caps, including enrollees who do not receive the full scope of Medicaid benefits.

States could respond to these changes in federal policy in several ways. We examine changes in federal Medicaid spending under two possible scenarios of state responses: (1) All states, both expansion states and non-expansion states, fill gaps in the loss of federal funding and maintain coverage, including the ACA Medicaid expansion coverage, and (2) states that expanded Medicaid under the ACA fully drop their expansions but maintain spending and coverage for other groups, resulting in declines in both federal and state spending. In the second scenario, we model the loss of federal dollars that the state would have received had it fully maintained its expansion.

Key Findings

Estimated Changes, 2020-2029

Our analysis shows that federal spending over the 2020-2029 period would be reduced by $519 billion if states fill in the loss of federal funds, a 10% reduction in federal funds compared to federal funding projections under current law. Of this amount, $302 billion is attributable to the phase-out of the enhanced FMAP for the expansion population and $218 billion from the per enrollee caps that apply to all enrollment groups, including expansion adults (Figure 2).

Examining the reductions by group shows that most of the federal reductions would be for spending for ACA expansion adults ($345 billion). This reduction is much larger than the reduction for other groups because it accounts for the phase-out of the enhanced matching funds as well as limiting growth on per enrollee spending. Together, these changes across all population groups would result in a 31% reduction in federal funds relative to spending under current law. Over the ten year period, per enrollee caps also would result in reductions in federal funding for all groups except for the aged (Figure 3).

Generally, prior to 2025, the per enrollee growth limits for the aged in the BCRA would be higher than anticipated growth in per enrollee costs under current law. This analysis assumes that states could use the higher amounts for the aged to offset lower spending in other groups.  However, because states still need to match federal spending under the BCRA, it is unclear whether this will occur. If states do not provide additional state matching dollars to access these funds, then overall federal reductions could be $73.4 billion lower over the 2020-2029 period.

State-by-state changes would vary greatly depending on the current size of the state’s Medicaid program, its case mix of enrollment across eligibility groups, and whether or not the state expanded Medicaid under the ACA (Table 1).

Estimated Changes, 2029

In the last year of our analysis, 2029, we estimate that the reductions in federal funds would be $114 billion (a 16% decline) if states maintain their programs. Of this amount, $50 billion is attributable to the phase-out of the enhanced FMAP for the expansion population and $64 billion from the per enrollee caps for all groups, including the expansion population (Figure 4 and Table 2).  The relative contribution of the changes in FMAP and per enrollee cap changes over time, with the cap accounting for a larger share of the decline in federal dollars as per enrollee caps become more binding. This result is similarly seen in the estimates by eligibility group under Scenario 1 (Figure 5), which show that the reductions across groups in the last year would be a higher percentage reduction than over the ten-year period for all groups except the aged. Limits or caps in per enrollee spending for the aged would still not be binding in 2029, although caps would likely become binding for this group very soon after 2029 as growth per enrollee is limited to the CPI-U inflation factor. (Figure 5)

Estimated Changes if States Drop the ACA Medicaid Expansion

If states that expanded their Medicaid programs drop the expansion in response to the loss of enhanced federal financing, the change in federal funds to states relative to current law would be even larger. We estimate that states could forgo an additional $685 billion over the 2020-2029 period due to dropping their expansion (Figure 6 and Table 3), bringing the total decline in federal funds to $1.2 trillion. This total would be a 22% decline in federal spending relative to what would happen under current law. These estimates assume no other state responses to the law, such as cuts in provider rates or changes in scope of benefits; if states made other changes to their Medicaid programs, changes in federal spending relative to current law could be even larger. In 2029, states would forgo about an additional $80 billion in federal funds if they drop their expansion, leading to a total decline in federal funds of $194 billion. By 2029, we estimate that nearly 19 million people who would be covered in the expansion group could lose Medicaid coverage if states roll back the expansion, about a 19% drop in Medicaid enrollment. While some of these people may be able to purchase coverage through the individual market, it is likely that such coverage would have prohibitively high deductibles or cost sharing.

Discussion

This analysis presents estimates of changes in federal Medicaid funds under the BCRA based on several assumptions. Actual outcomes under the proposed law may differ greatly due to a number of factors.

Uncertainty in inflation index projections. First, increases in federal per enrollee spending limits under the BCRA are based on the consumer price index. While we used current estimates of CPI-M and CPI-U in our analysis, there is uncertainty over what future inflation indices will actually be. If these inflation factors differ from current estimates, changes in federal Medicaid spending could be larger or smaller.

Uncertainty in future Medicaid growth. Similarly, there is substantial uncertainty around future growth rates in Medicaid under current law. We attempted to address this uncertainty by incorporating multiple projections of future growth in Medicaid enrollment and spending per enrollee by eligibility group into our estimates. One limitation of doing so is that existing projections for future Medicaid enrollment and spending are for all enrollees. Our analysis includes only full-benefit enrollees, as partial-benefit enrollees are exempt from the per enrollee caps under BCRA. In the past, per enrollee growth rates for full-benefit enrollees have been higher than those for all enrollees; if this pattern holds in the future as well, our estimates would be conservative, as future spending under current law would be higher than our estimates (leading to greater differences between current law and the BCRA).

We also applied the same growth rates to all states even though historical data indicates state variation in enrollment and spending growth rates. State-by-state changes in Medicaid spending are highly variable and reflect not only state environment but also one-time policy shifts; thus, future state-by-state changes in Medicaid spending are difficult to predict.

Other discretionary changes in BCRA. We do not model all Medicaid provisions in the BCRA, such as the exemption from the per enrollee cap for children who qualify for Medicaid based on a disability, the optional block grant for expansion and/or other adults, or the provisions to equalize state per enrollee spending over time. Several of these provisions give a great deal of discretion to states or to the Secretary, and it is difficult to predict how they will be implemented.

Additional behavioral responses. Finally, our analysis assumes no other changes in state Medicaid programs as a result of the BCRA other than those explicitly modeled. For example, if states spend over their federal limits under BCRA, they face subsequent penalties and thus have an incentive to stay within the limits. These incentives could lead states to make further reductions in Medicaid (in benefits or other spending) that we did not model. In addition, under a per capita cap, states have incentives to increase enrollment of “lower cost” enrollees in a given group and to decrease enrollment of “high-cost” enrollees. It is unclear how these incentives would affect overall Medicaid enrollment or spending patterns. While we examine two scenarios around the Medicaid expansion decision, it is possible that states would phase-out the expansion or end coverage at different times. These decisions would have national as well as state-by-state implications for federal funding.

While changes to Medicaid under the proposed legislation will be driven by choices at state level, state economies, and other factors going forward, these estimates provide a way to assess the policy challenges states would face if the BCRA provisions were enacted. In the early years of the new policy, declines in federal Medicaid dollars would be concentrated among expansion states largely due to the phase out of the enhanced funds for the ACA expansion. Over time, however, per enrollee caps become more binding, especially in later years when inflation rates are set at the same amount for all groups and all states, and cuts in federal spending affect all states.

1. Congressional Budget Office. The Budget and Economic Outlook: 2017 to 2027; January 24, 2017. ↩︎
2. Congressional Budget Office. Cost Estimate: H.R. 1628, Better Care Reconciliation Act of 2017; June 26, 2017. ↩︎

This partnership poll from The Washington Post and the Kaiser Family Foundation examines the views and experiences of people living in small towns and rural areas across the United States, and how they are similar or different from those in urban and suburban settings. It is the 31^st in a series of surveys dating back to 1995 that have been conducted as part of the Washington Post/Kaiser Family Foundation Survey Project. In part, the survey was designed to shed light on the political views of those living in rural counties where Donald Trump scored a 26-percentage-point victory over Hillary Clinton in the 2016 presidential election, a substantial increase from Mitt Romney’s 16-point margin over Barack Obama in 2012. In addition to politics, the survey gauges rural Americans’ views of their communities, their sense of shared values, their economic concerns, and their views on issues of race and immigration.

This brief explores where health care fits in rural residents’ political views and also examines how rural Americans’ health care experiences compare with their urban and suburban counterparts. In addition to the survey, Kaiser and The Post conducted two focus groups with rural voters in Ashtabula County, Ohio. Focus group findings related to health care are incorporated in this report; a Washington Post video compilation of the focus groups is available here.

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Introduction

In partnership with The Washington Post, the Kaiser Family Foundation conducted the Survey of Rural America to gauge the views and experiences of people living in small towns and rural areas across the United States, and how they are similar or different from those in urban and suburban settings. In part, the survey was designed to shed light on the political views of those living in rural counties where Donald Trump scored a 26-percentage-point victory over Hillary Clinton in the 2016 presidential election, a substantial increase from Mitt Romney’s 16-point margin over Barack Obama in 2012. In addition to the survey, Kaiser and The Post conducted two focus groups with rural voters: one with people who voted for Mr. Trump in the general election and one with people who voted for Mrs. Clinton or someone else.¹  The groups were held in Ashtabula County, Ohio, a rural county that President Obama won by 12 percentage points in 2012 and President Trump won by 19 points in 2016.

This brief explores where health care fits in rural residents’ political views and also examines how rural Americans’ health care experiences compare with their urban and suburban counterparts.

Survey Findings

Health Care as a Problem Facing Rural Communities

When residents of small towns and rural areas are asked about the biggest problem facing their communities, health care is not high on the list. Lack of jobs is overwhelmingly seen as the top problem in these areas (named by 21 percent in an open-ended question), followed by drug abuse (14 percent) and general concerns about the economy (8 percent). Just 2 percent name the cost or availability of health care as the most pressing problem.

This concern about lack of job opportunities and drug abuse as the main challenges for rural areas was echoed in the focus groups, where participants overwhelmingly mentioned economic decline and drug addiction as the biggest problems in their community. A common theme in both groups was the inability to find jobs paying more than minimum wage, and most participants said they knew someone who had problems with heroin or prescription painkillers.

While health care access is not top-of-mind for most residents as the biggest problem in their community, people in small towns and rural areas are more likely than those in urban and suburban areas to report various health care challenges. For example, rural residents are more likely than other Americans to think that their community does not have enough doctors or enough hospitals to serve the needs of local residents² , to say it is very difficult to afford to pay the cost of their family’s health care, and to describe their own health as only fair or poor. Within rural counties, the uninsured, those with lower incomes, and racial and ethnic minorities are more likely than their counter parts to report struggling with health care access and cost (see Appendix A).

Economic anxiety about affording health care was also echoed in the focus groups.

The Politics of Health Care and Support for ACA Repeal Efforts

Before examining rural Americans’ views on health care policy, it’s important to acknowledge that partisan identification tends to lean more Republican in rural areas than it does in the country as a whole. About three in ten (29 percent) rural residents identify as Republicans – higher than the shares in suburban and urban areas – while about a quarter (26 percent) of those in rural areas consider themselves Democrats (similar to suburban areas but significantly lower than the 37 percent of urban residents who call themselves Democrats).

Not surprisingly given their differing partisanship, rural residents are more likely than urban and suburban residents to say they approve of the way Donald Trump is handling his job as president; 54 percent of those living in rural areas say they approve, compared with 44 percent in suburban areas and 32 percent in urban areas. However, rural residents express more confidence in the president’s policies when it comes to preserving freedoms and preventing terrorism than they do in the areas of jobs and health care. While six in ten rural residents say they are very or somewhat confident that President’s Trump’s policies will protect their individual freedoms (61 percent) and keep the country safe from terrorism (57 percent), fewer say they are confident his policies will create jobs (51 percent) or improve health care (47 percent) where they live. Not surprisingly, on each of these measures, Republicans in rural areas are much more likely than Democrats to say they are confident that President Trump’s policies will lead to improvements.

Reflecting their partisan orientation, rural residents are also more likely than urban and suburban residents to say they support Republican efforts to repeal and replace the Affordable Care Act (ACA).³  Just over half (54 percent) of rural Americans say they support such efforts, compared with closer to four in ten of those living in suburban and urban areas (42 percent and 37 percent, respectively).

While partisanship is the biggest divider in how Americans view the ACA, the survey finds that among Democrats and independents, rural residents are more likely than their urban and suburban counterparts to support Republican efforts to repeal and replace the law. About half (52 percent) of rural independents say they support such efforts, compared with 38 percent of independents in urban and suburban areas. And while most Democrats are opposed, 23 percent of rural Democrats say they support the Republican efforts to repeal and replace the ACA compared with just 12 percent of urban and suburban Democrats.

In the focus groups, which were held in the evening on the same day the House of Representatives passed the American Health Care Act, few participants were aware of any details about the Republican plan, and only one participant in each group knew that the House had voted that day. In the Trump voter group, frustration with the ACA centered around the high cost of premiums and high deductibles (though one Trump voter mentioned that he had coverage purchased through an ACA exchange and was very happy with the coverage).

Rural Residents’ Views of Medicaid

Other research has shown that Medicaid plays a central role in helping to fill gaps in health insurance coverage in rural areas.⁴  The survey finds that rural residents perceive this importance, with two-thirds (68 percent) saying that Medicaid is “very important” for their local community and another 27 percent saying it is “somewhat important.” The share saying Medicaid is very important is somewhat higher in rural areas than in suburban areas (59 percent) but similar to urban areas (66 percent).

At the same time that rural residents see Medicaid as important for their community, they also express concerns about abuse of government benefits in general. Roughly two-thirds (64 percent) of rural residents say it is more common in America for irresponsible people to get government help they don’t deserve, while one-third (32 percent) say it’s more common for needy people to go without government help. Suburban residents also lean towards thinking it is more common for irresponsible people to get undeserved help (55 percent versus 40 percent), while urban residents are more evenly split (48 percent versus 47 percent).

The concern about abuse of government benefits in rural areas is largely driven by Republicans, 83 percent of whom say it is more common for irresponsible people to get government help they don’t deserve. Still, about two-thirds (64 percent) of rural independents and over four in ten (44 percent) rural Democrats express the same view.

Concern about abuse of government benefits in general – and in Medicaid in particular – was expressed in the focus groups by both those who voted for President Trump and those who did not.

Conclusion

Rural Americans express deep concerns about forces they see as eroding their communities, including economic decline, job losses, and an increase in drug abuse and addiction. Health care does not top their list of concerns, yet there are signs that residents of rural counties face particular struggles when it comes to health care access and costs. While partisanship divides rural residents’ views on health care policy just as it does in the rest of the country, rural Democrats and independents appear more open to Republican plans to repeal and replace the ACA than their counterparts in urban and suburban areas. This may be due in part to a more conservative orientation among rural Americans and their relatively greater concern about abuse of government benefits. For example, focus group participants across partisan lines expressed frustration about lower-income people being able to access Medicaid while those with slightly higher incomes struggle to afford coverage. Focus group findings also suggest that while partisanship divides rural residents on questions of health care politics, they are more united in their concern about the high cost of health care, a finding that echoes the results of many previous Kaiser surveys of the nation as a whole.⁵ 

Researchers use different definitions of urban and rural areas depending on the purpose of their research. For this project, we used the National Center for Health Statistics’ Urban-Rural Classification Scheme for Counties, which was developed for use in studying associations between urbanization and health, and for monitoring the health of urban and rural residents.⁶  The classification breaks counties into 6 categories, ranging from the most urban to the most rural. For purposes of this analysis, the 3 most rural categories (noncore, micropolitan, and small metro) were considered rural or small town (in this report, the term “rural” encompasses both rural areas and small towns).⁷  Just under one-quarter (23 percent) of the U.S. population lives in counties meeting this definition.

Compared with those living in urban and suburban areas, rural residents are more likely to be ages 65 and older, and less likely to have a 4-year college degree. They are also less racially diverse than urban and suburban residents; roughly eight in ten are non-Hispanic whites.

The survey also finds that those who live in rural areas report somewhat poorer health than their urban counterparts. Almost six in ten urban residents (58 percent) rate their own health as “excellent” or “very good” compared with 47 percent of those in rural areas, while rural residents are more likely than urban residents to say their health is “only fair” or “poor” (23 percent versus 15 percent).

Survey Methodology

The Washington Post/Kaiser Family Foundation Survey Project is a partnership combining survey research and reporting to better inform the public. The Post-Kaiser Survey of Rural America, the 31st in this series, was conducted by telephone April 13 – May 1, 2017, among a random representative sample of 1,070 adults age 18 and older living in rural counties, 303 adults in urban counties, and 307 in other counties that were considered suburban. Interviews were administered in English and Spanish, combining random samples of both landline and cellular telephones. Sampling, data collection, weighting and tabulation were managed by SSRS in close collaboration with The Washington Post and Kaiser Family Foundation researchers.

Respondents’ metropolitan status was operationalized using the CDC’s 2013 NCHS Urban-Rural Classification Scheme for Counties. Respondents were asked for their county of residence (or zip code if they were unsure) and classified into one of 6 codes in the classification scheme. Those in groups 4-6 (Small Metropolitan, Micropolitan, and Noncore) were considered Rural, those in group 1 (Large Central Metropolitan) were considered Urban, and the rest (Large Fringe Metropolitan, Medium Metropolitan) were considered Suburban.

The sampling procedures were designed to oversample those living in rural areas, with minimum goals for reaching rural residents who were between the ages of 18-34; Hispanic; black residents of Southern states; and residents of the rust belt states of Iowa, Michigan, Minnesota, Ohio, Pennsylvania, and Wisconsin. Some respondents were reached by calling back those living in rural areas who had previously completed an interview on the SSRS Omnibus poll and indicated they fit one of these oversample criteria. The dual frame landline and cellular phone sample was generated by Marketing Systems Group (MSG) using random digit dial (RDD) procedures.

All respondents were screened to verify that they belonged to the correct metropolitan classification. 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.

A multi-stage weighting design was applied to ensure an accurate representation of the population of each race group, within each of the three metropolitan areas and for both the cell phone and landline frames. The first stage of weighting involved corrections for sample design, including accounting for non-response for the re-contact sample. In the second weighting stage, demographic adjustments were applied to account for systematic non-response along known population parameters. Population parameters included gender, age, race, Hispanicity, education, region, and phone status (cell phone only or reachable by landline). The rural sample was also weighting based on metropolitan subgroup (category NCHS code 4, 5, or 6). Population parameters were derived using Census-based estimates provided by Nielsen Pop-Facts through Marketing Systems Group. Estimates of phone status were derived from the SSRS Omnibus 2016-2017 data.

All sampling error margins and tests of statistical significance have been adjusted to account for the survey’s design effect, which is 2.5 for results based on the full sample. The design effect is a factor representing the survey’s deviation from a simple random sample, and takes into account decreases in precision due to sample design and weighting procedures. Sample sizes and margin of sampling errors for key groups are shown below; 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.

This questionnaire was administered with the exact questions in the exact order as appears in the survey topline document. If a question was asked of a reduced base of the sample, a parenthetical preceding the question identifies the group asked. Some questions were only asked of those in rural areas.

Since some of the demographic questions could be sensitive and due to the nature of the survey content, interviewers were given specific instructions on how to cope with respondents who refused questions, including a statement reaffirming that answers were recorded confidentially for the sole purpose of research.

The Washington Post and the Kaiser Family Foundation each contributed financing for the survey, and representatives of each organization worked together to develop the survey questionnaire and analyze the results. Each organization bears the sole responsibility for the work that appears under its name. The project team from the Kaiser Family Foundation included: Mollyann Brodie, Ph.D., Liz Hamel, and Bryan Wu. The project team from The Washington Post included: Scott Clement and Emily Guskin. Both The Washington Post and the Kaiser Family Foundation public opinion and survey research are charter members of the Transparency Initiative of the American Association for Public Opinion Research.

Focus Group Methodology

As part of this project, the Kaiser Family Foundation and The Washington Post conducted two focus groups in Ashtabula County, Ohio. Participants were residents of Ashtabula County who reported voting in the 2016 presidential election. One group of 8 participants reported voting for Donald Trump and the second group of 8 participants reported voting for Hillary Clinton or another candidate (in the final group selected, 7 participants reported voting for Mrs. Clinton and one reported voting for Gary Johnson). Respondents were recruited by telephone, and screening criteria were used to exclude those who:

• had lived in the county for less than one year;
• themselves or a family member were employed by an elected official, political campaign, market research company, or media organization;
• had participated in a focus group in the previous three months;
• had an annual household income of $100,000 or more;
• reported a race other than white if they were a Trump voter; or
• reported a score lower than 7 when asked how comfortable they were voicing their opinions in a group setting on a scale from 1 to 10.

Each session was held at a restaurant in Jefferson, Ohio on May 4, 2017, and each lasted approximately one hour and 40 minutes. Each respondent received $100 for their participation. Both sessions were audio and video recorded for reporting purposes. The groups were moderated by Kaiser Family Foundation staff, and both Kaiser and The Post contributed financing for the recruiting and recording. The group discussion guide is available upon request.

1. All participants in the second group reported voting for Mrs. Clinton with the exception of one who voted for Gary Johnson. ↩︎
2. This perception matches up with previous research documenting hospital closures in rural areas. See J Wishner, P Solleveld, R Rudowitz, J Paradise, L Antonisse, A look at Rural Hospital Closures and Implications for Access to Care: Three Case Studies. https://modern.kff.org/medicaid/issue-brief/a-look-at-rural-hospital-closures-and-implications-for-access-to-care/. ↩︎
3. The survey was in the field April 13-May 1, after the House of Representatives began discussing the American Health Care Act but before the bill passed the House on May 4. ↩︎
4. J Foutz S Artiga, R Garlfield, The Role of Medicaid in Rural America, Kaiser Family Foundation. https://modern.kff.org/medicaid/issue-brief/the-role-of-medicaid-in-rural-america/. ↩︎
5. See for example A Kirzinger, B DiJulio, E Sugarman, M Brodie, Kaiser Health Tracking Poll – Late April 2017: The Future of the ACA and Health Care & the Budget, Kaiser Family Foundation. http://modern.kff.org/health-reform/report/kaiser-health-tracking-poll-late-april-2017-the-future-of-the-aca-and-health-care-the-budget/. ↩︎
6. U.S. Department of Health and Human Services, 2013 NCHS Urban–Rural Classification Scheme for Counties, April 2014. https://www.cdc.gov/nchs/data/series/sr_02/sr02_166.pdf. ↩︎
7. Throughout this report, the term “rural” is used as a shorthand to describe both rural and small town areas. ↩︎

The United States is facing an unprecedented opioid epidemic. In 2015, over 2 million people had a prescription opioid addiction and 591,000 had a heroin addiction.¹  The epidemic has resulted in increased health care services utilization and a surge in opioid overdose deaths throughout the country, particularly in Appalachia and New England.

Medicaid plays an important role in addressing the epidemic, covering 3 in 10 people with opioid addiction in 2015. Medicaid facilitates access to a number of addiction treatment services, including medications delivered as part of medication-assisted treatment, and it allows many people with opioid addiction to obtain treatment for other health conditions. As of July 2017, 32 states have expanded Medicaid, with enhanced federal funding, to cover adults up to 138% of the federal poverty level ($16,643/year for an individual in 2017). This expanded Medicaid coverage has enabled many states to provide addiction treatment and other health services to low-income adults with opioid addiction who were previously ineligible for coverage.

However, the GOP’s Better Care Reconciliation Act (BCRA) proposes to restructure the Medicaid program through a per capita cap or block grant, to phase out the enhanced federal funding for the Medicaid expansion population, and to remove the requirement that Medicaid expansion plans cover addiction treatment. The BCRA also appropriates $4.972 billion each year over 9 years for state grants for substance use disorder and mental health treatment and recovery support services. However, even with the additional grant funding, the reduced federal funding for Medicaid could lead to reductions in Medicaid eligibility and coverage of services, affecting state efforts to address the opioid epidemic.

This issue brief provides information on the number of Medicaid enrollees with opioid addiction, Medicaid spending on these enrollees, and the implications of the BCRA as states work to combat this public health crisis. Drawing on state-level data available for FY 2013, this brief provides insight into Medicaid’s role, but from a time predating the expansion and current focus on the opioid epidemic. Thus effects shown here will undoubtedly understate Medicaid’s role today, but provide insight into the scope of Medicaid’s impact on the opioid addiction challenge.

How many Medicaid enrollees have opioid addiction?

In FY 2013, there were 636,000 people enrolled in Medicaid with opioid addiction² , amounting to a prevalence of 889 per 100,000 (Table 1 and Figure 1). The number of Medicaid enrollees with opioid addiction ranged from a low in South Dakota of under 300 people to a high in New York of over 114,000 people. The prevalence of opioid addiction within the Medicaid population also varied across states, ranging from fewer than 300 per 100,000 enrollees in Arkansas, South Dakota, Texas, Nebraska, and California to over 3,000 per 100,000 enrollees in Vermont, Connecticut, Maine, and Massachusetts (Table 1). However, these counts are from before Medicaid expansion took effect; since the expansion likely extended coverage to many people with opioid addiction, a larger number of people with this problem are likely now covered by Medicaid in states that expanded their programs.

How much does Medicaid spend on enrollees with opioid addiction?

Medicaid covers a broad range of services for people with opioid addiction, spending $9.4 billion on their care in FY 2013. Medicaid provides both addiction treatment services, such as inpatient detoxification, intensive outpatient treatment, and medication-assisted treatment, as well as other services for health conditions either associated with or independent from opioid addiction.³  Many of these services are complex and often expensive. Approximately one-third (31.9%) of this spending was for payments to Medicaid managed care organizations. The remaining spending was through fee-for-service (FFS) arrangements and included inpatient treatment (21.4%); outpatient treatment (14.5%); prescription drugs (9.7%); long-term care (8.3%); physician, laboratory, and x-ray services (5.8%); and other FFS acute care services (8.5%) (Figure 2). Because these data are also from before the Medicaid expansion, total Medicaid spending on enrollees with opioid addiction has likely increased since 2013 as more people with the problem gained coverage in recent years.

How would the BCRA affect states’ ability to address the opioid epidemic?

Medicaid remains on the front lines for treatment of opioid addiction providing $9.4 billion in spending for enrollees with opioid addiction in 2013 and undoubtedly more today as the epidemic increases and coverage of the expansion population boosts Medicaid’s role. On July 13th 2017, the Senate released a revised discussion draft of the BCRA, which would change the structure of the Medicaid program substantially. Currently, the federal government matches state Medicaid spending with no pre-set limit. The BCRA would significantly reduce federal spending provided to states for the Medicaid program through a per capita cap, or at the state option, a block grant for expansion adults and other non-elderly non-disabled adults.⁴  It would also phase out enhanced federal financing for the Medicaid expansion population and remove the requirement that all Medicaid expansion plans cover addiction treatment. These changes will likely lead to decreases in eligibility, coverage, provider payments, and access to care.

In 2015, 1 out of 5 people with opioid addiction were uninsured, in part because many of these people lived in states that had not expanded Medicaid.⁵  Ending the federal enhanced support for the expansion and imposing a per capita cap on Medicaid will not facilitate expanding coverage to the uninsured. The Senate proposed $4.972 billion appropriation per year for 9 years will likely not fill this hole.

In addition to the Medicaid provisions, the BCRA also appropriates $4.972 billion each year from FY 2018 through FY 2026 to provide grants to states for substance use disorder treatment and recovery support services for individuals with substance use disorder or mental illness.⁶  The $4.972 billion per year for 9 years is an increase from $2 billion for state grants for FY 2018 alone, as proposed in the original draft of the BCRA released in June 2017. Several senators from states more heavily hit by the opioid epidemic had taken issue with the $2 billion appropriation in the BCRA, saying that it would not meet the amount needed to adequately address this public health crisis.⁷  These funds would increase capacity to address the epidemic but will likely fall short of the financing that accompanies increased coverage through Medicaid or other means.

People with opioid addiction often have health issues that abetted in, have been borne from, or are independent from their substance use and misuse. These include heart conditions, hypertension, asthma, hepatitis, sexually transmitted infections, and mental illnesses, such as depression.⁸  The $9.4 billion that Medicaid spent in FY 2013 was for a broad range of services, not solely for addiction treatment, reflecting the complex health profile of a person with opioid addiction. However, state grants from the appropriation are intended only for addressing substance use disorder treatment services and recovery support services for substance use disorders and mental illness, and would most likely be awarded to providers that are unable to address other health issues.

Of particular note, the $9.4 billion that Medicaid spent on enrollees with opioid addiction in FY 2013 does not include any of the very expensive drugs that effectively cure hepatitis C, such as Sovaldi, Harvoni, and Viekira Pak, as these drugs launched after FY 2013. Because these drugs cost tens of thousands of dollars per treatment per person and because the disease is prevalent among those addicted to opioids,⁹  spending on people with opioid addiction is very likely higher in FY 2014 than in FY 2013, even before taking into account the increase in the number of people with opioid addiction during this period. Hepatitis C is a blood borne virus, most frequently now spread through shared intravenous needles.¹⁰  Although drugs are now on the market that effectively cure hepatitis C, a person can contract the virus again if reintroduced, allowing the virus to continue to spread.¹¹  As a result, addressing hepatitis C without addressing the opioid epidemic will allow the virus to live on, not only allowing for unfavorable health outcomes, but adding avoidable costs to the entire health care system.

Looking Ahead

The opioid epidemic has led to substantial health complications, increased health care services utilization, and considerable societal costs. Medicaid has played a critical role in addressing the epidemic by facilitating access to addiction treatment services, including medication-assisted treatment. Medicaid has also facilitated access to other health services for enrollees with opioid addiction, many of whom have complex health and psychosocial needs.

However, proposed changes to the Medicaid program in the BCRA could significantly affect states’ ability to combat this issue. In response to decreases to federal Medicaid financing, states may limit Medicaid eligibility, trim benefit packages and remove optional services, or decrease provider payment rates, all of which may limit access to medical, mental health, and addiction treatment services for individuals with opioid addiction. Although the BCRA allots additional funding for addiction treatment and recovery support services, this funding may not adequately compensate for the decreases in Medicaid spending proposed in the bill. As a result, there may be substantial unmet need for treatment among individuals with opioid addiction, further exacerbating this public health crisis.

1. Center for Behavioral Health Statistics and Quality, Results from the 2005 National Survey on Drug Use and Health (Rockville MD, Substance Abuse and Mental Health Services Administration, September 2016), https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.pdf. ↩︎
2. We use the phrase “opioid addiction” in this paper.  The medical community also refers to it as “opioid use disorder.” ↩︎
3. Julia Zur, “Medicaid’s Role in Addressing the Opioid Epidemic,” (Washington DC: Kaiser Family Foundation, June 2017), http://modern.kff.org/infographic/medicaids-role-in-addressing-opioid-epidemic/. ↩︎
4. The BCRA does allow the HHS Secretary to exclude up to $5 billion of spending nationally on public health emergencies from the allotted amounts calculated through states’ per capita caps from 2020 through 2024, although the Secretary of HHS must declare both the emergency as applicable and the amount excluded as appropriate. This amount is shared among all states and among all types of public health emergencies. ↩︎
5. Julia Zur, “6 Things to Know about Uninsured Adults with Opioid Addiction,” (Washington DC: Kaiser Family Foundation, May 2017), http://modern.kff.org/uninsured/fact-sheet/6-things-to-know-about-uninsured-adults-with-opioid-addiction/. ↩︎
6. H.R. 1628, Discussion Draft, Title II Section 202, https://www.budget.senate.gov/imo/media/doc/BetterCareJuly13.2017.pdf. ↩︎
7. Sarah Karlin-Smith, “Critics pan opioid cash designed to deliver moderates,” Politico, June 29, 2017, http://www.politico.com/story/2017/06/29/opioids-cash-senate-health-bill-240071. ↩︎
8. Kaiser Family Foundation analysis of the 2015 National Survey on Drug Use and Health. ↩︎
9. Susan Scutti, “New hepatitis C infections triple due to opioid epidemic,” CNN, May 11, 2017, http://www.cnn.com/2017/05/11/health/hepatitis-c-rates-cdc-study/index.html. ↩︎
10. “Viral Hepatitis C FAQs for Health Professionals,” CDC, accessed July 12, 2017, https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm. ↩︎
11. Scutti, op cit. ↩︎

KEY FINDINGS:

• The July Kaiser Health Tracking Poll finds that most Americans (61 percent) continue to hold unfavorable views of the plan to repeal and replace the Affordable Care Act (ACA), including over four in ten (44 percent) who say they have “very unfavorable” view. The share of the public with negative views of the law has increased slightly in the past month, from 55 percent to 61 percent. Views of the Republican plan to repeal and replace the ACA continue to vary widely by party and a large intensity gap remains, with Democrats being nearly three times as likely to hold a “very unfavorable” view as Republicans are to hold a “very favorable” view (71 percent versus 25 percent, respectively).
• Nearly two-thirds of the public opposes (65 percent) major reductions in federal funding for Medicaid as part of a plan to repeal and replace the ACA, and most continue to oppose these reductions even after hearing arguments in support of them. About half of Republicans and those who approve of President Trump support major reductions in federal funding for Medicaid.
• Seven in ten (71 percent) Americans would rather see Republicans in Congress work with Democrats to make improvements to the ACA but not repeal the law, while one-fourth (23 percent) say they would rather Republicans continue working on their own plan to repeal and replace the ACA. Large shares of Democrats (91 percent) and independents (72 percent) would like to see Republicans in Congress work across the aisle to make improvements to the ACA. Trump supporters are divided with similar shares saying Republicans in Congress should continue working on their own plan (47 percent) as saying they want them to work with Democrats on improving the ACA (46 percent). Slightly more than half of Republicans (54 percent) want Congressional Republicans to continue working on their own plan to repeal and replace the 2010 health care law.
• The majority of the public thinks the current replacement plan being discussed does not fulfill most of the promises President Trump has made about health care.
• About one-third (35 percent) of the public say they have heard or read about the report by the C.B.O. in the past month concerning the proposed health care plan that would repeal and replace the ACA, and few are aware of the details of the C.B.O. report. For example, just about one in five are aware that the report said the Senate health plan would increase the number of people without insurance and one in ten are aware that it would decrease the federal budget deficit over the next ten years. However, at least half of the public say that hearing certain estimates about the impact of the Senate legislation from the C.B.O. may make them “less likely” to support the plan.

Repealing and Replacing the Affordable Care Act

As the U.S. Senate continues to debate their plan to repeal and replace the 2010 Affordable Care Act, the majority of the public (61 percent) continues to hold unfavorable views of the replacement plan, up slightly from 55 percent in June. This increase is driven by a rise in the share who say they have “very unfavorable” view, up from 38 percent in June to 44 percent in this month’s poll.

Attitudes Towards Repeal Efforts Vary by Partisanship, Support for President Trump

A majority of Republicans (60 percent) and those who say they approve of President Trump (54 percent) report  favorable views of the replacement plan, while large majorities of Democrats and those who do not approve of President Trump hold unfavorable views (86 percent and 82 percent, respectively). In addition, independents are more than twice as likely to report unfavorable views of the replacement plan as favorable ones (63 percent versus 28 percent). Rifts in the intensity of opinion remain with seven in ten Democrats (71 percent) reporting a “very unfavorable” opinion of the replacement plan compared to one-fourth of Republicans reporting a “very favorable” view. A similar pattern holds for Trump supporters and opponents.

The shares of Republicans and Trump supporters with favorable views of the replacement plan have not changed substantially this month after falling between May and June.

Why the Public Holds Favorable or Unfavorable Views of the Replacement Plan

When asked the reasons behind their views of the plan to repeal and replace the ACA (both favorable and unfavorable), one-third (32 percent) of those who favor the plan say it is because they generally disapprove of the ACA and the replacement plan repeals the ACA. This is followed by 21 percent who say they have a favorable view because they support insurance reform, more broadly, and 19 percent who say they think the replacement plan will make health care more affordable.  Among those who hold unfavorable views of the plan, one-fourth (23 percent) say it is because they think the replacement plan will have a negative impact on people, or because of financial or cost considerations (22 percent). Similar shares (15 percent) say they hold unfavorable views because it repeals or doesn’t fix the ACA or becauses it decreases access to health care or health insurance.

Is the Public Becoming More Negative in Their Views of the ACA Replacement Plan?

Public opinion toward major pieces of legislation can shift as debate unfolds and details of plans are released. Most Americans (69 percent) say they have been following discussions in Washington about efforts to repeal and replace the 2010 health care law at least somewhat closely, and while overall views of the plan remain negative, when the public is explicitly asked how their own opinions of the plan to repeal and replace the ACA have changed over the past month, two-thirds of the public – including a majority of Democrats, independents, and Republicans – say their opinion has not changed. About one-fourth (24 percent) say their opinion has become “more negative” while a smaller share (7 percent) say their opinion has become “more positive.” Among those who have been following the repeal and replace discussions closely, a larger share of Republicans (20 percent) say their opinions have become “more positive” over the past 30 days, which is similar to the share of Trump supporters (16 percent) who say their views of the replacement plan has become “more positive.” Nearly half of Democrats who have been following the debate closely say their views have become “more negative” in the past 30 days.

More Americans View The ACA Favorably Than The Replacement Plan

The Kaiser Family Foundation has been tracking public opinion on the ACA since its passage in 2010 and this month’s survey continues to find the public is more favorable than unfavorable in their views of the 2010 health care law, with 50 percent expressing a favorable view of the ACA compared to 44 percent expressing an unfavorable view.

As seen in previous months, more of the public views the ACA favorably than the plan to replace the 2010 health care law (50 percent compared to 28 percent).

In addition, Democrats are far more enthusiastic about the ACA than Republicans are about its replacement. Half (52 percent) of Democrats view the Affordable Care Act “very” favorably, twice the share of Republicans (25 percent) who say so about the replacement plan.

Next Steps for Repeal and Replace

Continue Working on Repeal or Work With Democrats on ACA Fixes

With the future of the current plan to repeal and replace the ACA uncertain, Senate Majority Leader Mitch McConnell and other Republicans leaders have suggested two ways forward for repeal and replacement efforts by either halting their own repeal efforts and working with Democrats on fixing the current problems facing the ACA or by continuing the Republican effort to repeal and replace the law. The majority of the public (71 percent) would rather see Republicans in Congress work with Democrats to make improvements to the ACA but not repeal the law, compared to one-fourth (23 percent) who say they would rather Republicans continue working on their own plan to repeal and replace the ACA.

Attitudes towards both of these proposed legislative avenues are largely partisan with the majority of Democrats (91 percent) and independents (72 percent) wanting Republicans in Congress to work with Democrats to make improvements to the ACA, while slightly more than half of Republicans (54 percent) want Congressional Republicans to continue working on their own plan to repeal and replace the 2010 health care law. Trump supporters are divided with similar shares saying Republicans in Congress should continue working on their own plan (47 percent) as saying they want them to work with Democrats on improving the ACA (46 percent).

Repeal Now and Replace Later or Continue Work on Replacement

Alternatively, some have suggested that Republicans go ahead and repeal the parts of the ACA they can immediately and then work on the replacement plan later. When asked what Congress should do, nearly four in ten say they want Congress to wait to vote to repeal the ACA until the details of a replacement plan have been worked out (37 percent), which is similar to the share who say they do not want Congress to repeal the ACA and would rather they move on to other priorities (33 percent). A smaller share – about one-fourth (26 percent) – say Congress should vote to repeal the parts of the law they can immediately and try to work out the replacement plan later – a strategy put forth by some Republican lawmakers.

About half of Republicans (52 percent) want Congress to repeal the parts of the law they can repeal immediately and try to work out the details of a replacement plan later, while 55 percent of Democrats want them to not vote to repeal the ACA and move on to other priorities. Trump supporters are split between wanting Congress to wait to repeal the parts of the law they can repeal immediately (45 percent) and wanting Congress to wait to vote until the details of a replacement plan have been worked out (40 percent). Fewer (10 percent) want them not to vote to repeal the ACA and move on to other priorities.

Few See Replacement Plan As Fulfilling President Trump’s Promises About Health Care

The majority of the public thinks the current replacement plan being discussed does not fulfill most of the promises President Trump has made about health care while 16 percent say it fulfills most or all of his promises.

This viewpoint is shared regardless of party identification with majorities of Democrats (81 percent), independents (75 percent), Republicans (56 percent), and Trump supporters (58 percent) saying the current plan fulfills some or none of the promises President Trump has made about health care.

In addition, the majority of the public (70 percent) – including most Democrats (75 percent), independents (73 percent), and Republicans (59 percent) – say that when it comes to health care, things in this country have pretty seriously gotten off on the wrong track. Fewer, about one in four (24 percent), say things are headed in the right direction. The share who say health care has pretty seriously gotten off on the wrong track is up slightly from earlier this year.

The share of Republicans who say health care is headed in the right direction is up slightly from April (37 percent compared to 29 percent), while the share of Democrats and independents who say it has pretty seriously gotten off on the wrong track has also increased (75 percent vs. 60 percent, 73 percent vs. 62 percent, respectively).

Impact of the Congressional Budget Office’s Report

As lawmakers propose plans to repeal and replace the ACA, the independent Congressional Budget Office (the C.B.O.) estimates how proposals could affect the uninsured rate and health care costs for people and for the nation as a whole. About one-third (35 percent) of the public say they have heard or read about the report by the C.B.O. in the past month. Among these individuals, 44 percent (15 percent of the public overall) say what they heard made them “less likely” to support the replacement while 7 percent (2 percent of public overall) said it made them “more likely” to support it. About half (16 percent of the public overall) say it did not have much effect either way.

Few are Aware of the Specifics from Most Recent C.B.O. Report

Among those who say they have heard or read anything about the C.B.O. report, half (53 percent, or 18 percent of the public overall) are aware that the report said the Senate health plan would increase the number of people without insurance over the next ten years and about one-third (11 percent of the public overall) are aware it would decrease the federal budget deficit over the next ten years.

Half Say New C.B.O. Estimates May Make Them Less Likely to Support

While the majority of the public has not heard or read anything about the most recent C.B.O. report and many are unaware of the specifics about the most recent estimates; at least half of the public say that hearing certain estimates about the impact of the Senate legislation from the C.B.O. may make them “less likely” to support the plan. The majority of Democrats and independents, as well as about half of Republicans say that they would be “less likely” to support the Senate health plan if they heard it would increase premiums for most people who purchase their own insurance on the marketplace. Overall, fewer – but still a majority of Democrats – say hearing that the Senate health plan would increase the number of uninsured people (either by about 15 million or more than 20 million) would make them “less likely” to support the plan. About half also say that hearing it would increase deductibles for people who purchase their own insurance on the marketplace would make them “less likely” to support it.

Even among Republicans and Trump supporters, about one-fourth say they currently hold favorable views of the replacement plan and would be “less likely” to support the Senate health plan if they heard from the C.B.O. that it would increase premiums for those who buy insurance on the individual marketplace. Slightly smaller shares say they currently hold favorable views of the replacement plan and would be “less likely” to support the Senate health plan if they heard it increased the number of uninsured people or increased deductibles for those who buy insurance on the marketplace.

Medicaid

Over the past few months, Kaiser Health Tracking Polls have consistently found that a majority of the public hold favorable views of Medicaid and oppose changes to the current Medicaid program including scaling back the Medicaid expansion.¹  This month’s poll finds that about half of the public are aware that the proposed health plan makes major reductions to Medicaid and the majority of the public oppose such a reduction.

Awareness of Changes to Medicaid

The current plan being discussed by Republicans proposes significant cuts and changes to the current Medicaid program. About half (45 percent) of the public are aware that the current replacement plan makes “major reductions” in federal funding for Medicaid over the next ten years. An additional one-fourth (26 percent) say the health care plan makes “minor reductions” to Medicaid, while 12 percent say it makes “no reductions.” A considerable share (16 percent) say they don’t know if the replacement plan makes any reductions in federal funding for Medicaid or not. The share who are aware the current replacement plan makes “major reductions” in federal funding for Medicaid is up slightly from the June Kaiser Health Tracking Poll (38 percent).

The Majority of the Public Oppose Major Reductions to Medicaid

When told about the reduction in federal funding for Medicaid, the majority of the public oppose (65 percent) major reductions to Medicaid as part of a plan to repeal and replace the ACA, while three in ten (28 percent) support such reductions. A large majority of Democrats (88 percent) and individuals who do not approve of President Trump (83 percent) oppose reducing Medicaid funding, as do a majority of independents (63 percent). Slightly more than half of Republicans (54 percent) and half of supporters of President Trump (51 percent) support a major reduction in federal funding for Medicaid as part of a plan to repeal and replace the ACA, while about four in ten do not.

Attitudes Towards Reducing Federal Funding for Medicaid are Somewhat Stable, With State Flexibility Being the Strongest Argument

Attitudes towards reducing federal funding for Medicaid are somewhat stable with some being persuaded from their opinions after hearing arguments for and against reducing federal funding. Among those opposed to a major reduction in federal funding for Medicaid as part of a plan to repeal and replace the ACA, about one-fourth (17 percent of the public overall) change their mind after hearing that this would decrease the amount of money given to states but would also give states more flexibility and control over their Medicaid programs. Fewer, 16 percent (11 percent overall) change their mind after hearing this would decrease the federal budget deficit and decrease federal spending in the future.

On the other hand, a small share of those who initially support a major reduction in federal funding for Medicaid shift their opinion after hearing that the majority of federal Medicaid spending was for nursing home care for low-income seniors and health care services for low-income people with disabilities (11 percent). A similar share (about one in ten overall) now oppose reducing federal funding after hearing that it could make it more difficult for states to address the prescription painkiller addiction epidemic.

This Kaiser Health Tracking Poll was designed and analyzed by public opinion researchers at the Kaiser Family Foundation (KFF). The survey was conducted July 5-10, 2017, among a nationally representative random digit dial telephone sample of 1,183 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). Computer-assisted telephone interviews conducted by landline (407) and cell phone (776, including 463 who had no landline telephone) were carried out in English and Spanish by SSRS of Media, PA. 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 2015 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 2016 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. 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. A Kirzinger, B DiJulio, L Hamel, B Wu, M Brodie. Kaiser Health Tracking Poll – June 2017: ACA, Replacement Plan, and Medicaid. http://modern.kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-june-2017-aca-replacement-plan-and-medicaid/   ↩︎