Kaiser Health Tracking Poll - June 2017: ACA, Replacement Plan, and Medicaid

KEY FINDINGS:

• As the Senate prepares to hold a vote on a plan to repeal and replace the Affordable Care Act (ACA), a majority of Americans say they have an unfavorable view of the plan (55 percent) while three in ten have a favorable view. In the past month, support for the replacement plan has decreased among Republicans (from 67 percent in May to 56 percent currently) and among supporters of President Trump (from 69 percent to 55 percent).
• Over the past year, Kaiser Health Tracking Polls have found a modest increase in support for the ACA and this month’s poll finds about half of the public (51 percent) expressing favorable views of the ACA while 41 percent hold an unfavorable view. This is the first month that favorability has tipped over the 50 percent mark since Kaiser Family Foundation began tracking attitudes on the law in 2010 and continues the trend found last month with the public more favorable towards the ACA than the replacement plan (51 percent vs. 30 percent).
• Large shares of the public overall, and majorities across parties, support the federal government’s role in prohibiting health insurance companies from charging individuals with pre-existing conditions more for their coverage and requiring health plans to cover a certain set of benefits, while fewer would want to turn these decisions over to the states.
• Few Americans, regardless of party identification, say repealing and replacing the 2010 Affordable Care Act should be the “most important priority” for President Trump and Republicans in Congress (7 percent of Democrats, 9 percent of independents, and 8 percent of Republicans). Another two in ten (22 percent) say it is “very important but not the most important” priority. Republicans are much more likely to see repealing the ACA as a very important or top priority (50 percent) than Democrats (18 percent) or independents (28 percent).
• The majority of the public – regardless of partisanship – hold favorable views of Medicaid, the government health insurance and long-term care program for low-income adults and children. Three-fourths (74 percent) of the public say they have a favorable view of the program, including four in ten (37 percent) who have a “very favorable” view. In addition, six in ten say the program is working well for most low-income people nationally (61 percent) and seven in ten say the program is working well for most low-income people in their state (67 percent).
• When asked about proposed changes to the Medicaid program, a majority of the public support allowing states to impose work requirements on non-disabled adults (70 percent) or drug testing as a condition of enrollment (64 percent). However, fewer support changes that would cut funding or alter the funding structure. For example, about one-third support reducing funding for Medicaid expansion or limiting how much money each state gets from the federal government each year.
• The public is more likely to blame health insurance companies rather than the actions of the current or previous administration for insurers deciding not to sell insurance in certain ACA marketplaces. About four in ten (42 percent) say the problems are mainly due to profit-driven decisions by health insurance companies while fewer say the problems are due to either the way the law was designed by the Obama administration and Democrats in Congress (28 percent) or uncertainty brought on by the actions of President Trump and Republicans in Congress (22 percent).

Affordable Care Act vs. Replacement Plan

With the U.S. Senate currently discussing a plan to repeal and replace the Affordable Care Act (ACA), the most recent Kaiser Health Tracking Poll examines the public’s attitudes towards this proposed legislation as well as the 2010 Affordable Care Act it seeks to replace.

Most of The Public Views The ACA Replacement Plan Unfavorably

The June Kaiser Health Tracking Poll finds a majority of Americans (55 percent) continue to hold unfavorable views of the replacement plan, while three in ten say they have a favorable view. Similar to last month, an enthusiasm gap persists with a larger share saying that they have a “very unfavorable” view (38 percent) than saying they have a “very favorable” view (11 percent). Democrats overwhelmingly say they have an unfavorable view of the replacement plan (85 percent) and more independents say they have an unfavorable view than a favorable view (52 percent vs. 30 percent). On the other hand, more Republicans say they have a favorable view than an unfavorable view (56 percent vs. 25 percent).

A Decrease in Support for the ACA Replacement Plan Among Republicans

Last month’s survey found that the ACA replacement plan had solid support among the Republican base with two-thirds of Republicans saying they had a favorable view of the plan. This month’s survey finds an 11 percentage point decrease in support among Republicans, with 56 percent of Republicans now saying they have a “favorable view” of the Republican replacement plan. There is also a decrease in support among those who say they approve of President Trump (from 69 percent to 55 percent). The share of Democrats and independents who view the replacement plan favorably has remain unchanged (8 percent and 30 percent, respectively).

ACA is Viewed More Favorably than the Replacement Plan

In addition, the public is more likely to express a favorable view of the ACA than of the plan to repeal and replace the ACA. Half (51 percent) of the public view the ACA favorably compared to three in ten who view the replacement plan favorably.

While attitudes towards both the ACA and the Republican replacement plan are driven by partisanship, there is a partisan intensity gap. About half of Democrats (53 percent)  have a “very favorable” view of the ACA, while far fewer Republicans – about one-fifth (21 percent) –have a “very favorable” view of the Republican replacement plan.

Views of the ACA Over Time

Over the past year, Kaiser Health Tracking Polls have found a modest increase in support for the ACA. This month’s poll finds about half of the public (51 percent) expressing favorable views of the ACA– this is the first month that favorability has tipped over the 50 percent mark since Kaiser Family Foundation began tracking attitudes on the law in 2010 and an increase of nine percentage points since June 2016.

More Americans Think They will be Better Off if Obamacare remains the Law of the Land

A larger share of the public (50 percent) think they and their family will be better off if the ACA remains the law of the land than think they will be better off if the ACA is repealed and replaced with the Republican plan (36 percent). There are distinct party differences with three-fourths (74 percent) of Republicans saying they will be better off with the Republican alternative while eight in ten Democrats say they will be better off under the ACA. Independents remain in the middle, but still a larger share say they and their families will be better off under the ACA (50 percent) than under a Republican alternative (35 percent).

Few Support Proposed State Waivers

Majority of the Public Opposes Two Fundamental Changes to Health Insurance System

While the Senate continues working on their version of plan to repeal and replace the ACA, this month’s Kaiser Health Tracking Poll examines attitudes towards possible changes to the health insurance system that would allow states to apply for waivers to federal requirements that prohibit insurance companies from charging people with pre-existing conditions more than others for their health insurance and that require health insurance plans to cover a specific set of benefits.

Majority of the Public Opposes State Waivers To Allow Insurers to Charge More for Those with Pre-Existing Conditions

The pre-existing condition waiver would allow states to permit insurers to charge people with pre-existing health conditions a higher rate if they don’t maintain continuous coverage. Seven in ten say the federal government should continue to prohibit health insurance companies from charging individuals with pre-existing health conditions more for their coverage while one-fourth (26 percent) say that states should be able to decide whether insurers can charge people with pre-existing conditions more. A majority of Democrats (84 percent), independents (68 percent), and Republicans (59 percent) want continued protection for people with pre-existing conditions from the federal government.

Individuals Living in Households Without Pre-Existing Conditions

One of the purposes of allowing insurers to charge individuals with pre-existing conditions more if they have not had continuous coverage is to reduce health insurance costs for individuals without pre-existing conditions. Yet, the Kaiser Health Tracking Poll finds that even among those who are living in households without an individual with a pre-existing condition, a majority support continued federal protections.

Majority of the Public Opposes State Waivers To Allow Insurers to Waive Essential Health Benefits

Another type of waiver that was included in the House-passed version of the ACA replacement plan would allow states to modify the essential health benefits provision of the ACA, meaning health insurance companies could sell plans that cover fewer benefits than are currently required by federal law. The poll finds support for the status quo with two-thirds of the public saying they want the federal government to continue to require health insurance companies to cover a certain set of benefits while about three in ten (31 percent) say states should be able to decide whether insurers can sell plans that cover fewer benefits than currently required. There are party differences with a large majority of Democrats supporting the status quo (81 percent) compared to fewer, but still a majority, of independents (65 percent) and Republicans (52 percent).

The Politics of Health Policy

Few Think Repealing and Replacing the ACA Should Be the Top Priority for President Trump and Republicans in Congress

The most recent Tracking Poll finds few Americans, regardless of party identification, say repealing and replacing the 2010 Affordable Care Act should be President Trump and Republicans in Congress’ “most important priority” (7 percent of Democrats, 9 percent of independents, and 8 percent of Republicans). Another two in ten (22 percent) say it is “very important but not the most important” priority. Among Republicans, half say it is either the “most important priority” or “a very important priority but not most important.” Six in ten Democrats (58 percent) say repealing and replacing the ACA should “not be a priority” while a four in ten independents (42 percent) say it should be “one of many priorities” for Trump and Republicans in Congress.

Politics of Voting for or Against the Republican Replacement Plan

While the future of the Republican replacement plan for the ACA is unclear, it is evident that there may be political consequences for Senators and Representatives voting on the plan. When asked how their own representative’s vote on the Republican replacement plan could affect their support for that individual, nearly one in three say their representative’s vote (either for or against) would have “no effect” on their likelihood of supporting them.  Yet, about half of Democrats say they would be “more likely” to support a representative who voted against the Republican replacement plan (51 percent) while six in ten (61 percent) Republicans saying they would be “more likely” to support a representative who voted for the Republican plan to repeal and replace the ACA. Independents are more divided on how their representative’s vote could impact their support. About one-third of independents saying they are “more likely” to support a representative who voted against the Republican replacement plan (35 percent) which is similar to the share (30 percent) who say they are “less likely” to support them if they voted against it.

While a majority of Republicans say will be “more likely” to support a representative who votes for the Republican replacement plan, it is less clear how a vote against the plan would affect support. Half of Republicans say that if their elected representative votes against the replacement plan, they would either be “more likely” (16 percent) to support them or it would have no effect on their support (35 percent), compared to 46 percent who say they would be “less likely” to support.

Possible Next Steps for Health Care Reform

If the most recent repeal efforts do not pass Congress, the public is divided on what they want President Trump and Republicans to do next, with similar shares saying they want lawmakers to keep working on a plan to repeal and replace the ACA (49 percent) as say they want them to stop working on health care and move on to other priorities (45 percent).

While Republicans are not overwhelmingly in favor of the ACA replacement plan, a large majority of them (80 percent) want President Trump and Republicans in Congress to keep working on a plan to repeal and replace the 2010 health care law if the replacement plan does not pass. This is compared to two-thirds of Democrats (67 percent) who want them to stop working on health care and move on to other priorities. Independents are divided with similar shares wanting them to keep working on replacement plan (49 percent) as want them to stop working on health care and move on to other priorities (45 percent).

Medicaid

As part of the ongoing discussions about repealing and replacing the ACA, Republicans have proposed significant cuts and changes to the current Medicaid program.

Large Majority of Americans Have Favorable View of Medicaid

Unlike attitudes towards the ACA or the Republican replacement plan, the public is less divided in their attitudes towards Medicaid, the government health insurance and long-term care program for low-income adults and children. Three-fourths (74 percent) of the public say they have a favorable view of the program, including four in ten (37 percent) who have a “very favorable” view. About one-fifth (19 percent) of the public reports an unfavorable view of Medicaid, including a larger share of Republicans (31 percent) than Democrats (11 percent).

In addition, six in ten of the public say the program is working well for most low-income people in the nation, overall (61 percent) and two-thirds say the program is working well for most low-income people in their state (67 percent). Majorities of Democrats, independents, and Republicans say Medicaid is working well both in the nation, overall (68 percent, 62 percent, and 52 percent, respectively) and in their state (72 percent, 68 percent, and 59 percent, respectively).

Four in Ten Are Aware House-Passed Replacement Plan Makes Major Reductions to Medicaid Spending

With the reduction in Medicaid spending largely not in the focus of discussions surrounding the ACA replacement plan, the survey finds about four in ten (38 percent) are aware that the House-passed replacement plan makes “major reductions” to federal funding for Medicaid over the next ten years. An additional one-fourth (27 percent) say the health care plan makes “minor reductions” to Medicaid, while 13 percent say it makes “no reductions.” A considerable share (20 percent) say they don’t know if the replacement plan makes any reductions to federal funding for Medicaid or not.

Attitudes Towards Proposed Changes to Medicaid

Currently Congress and the Trump administration are discussing changes to Medicaid and may allow more state flexibility around how the program is operated and who is eligible. The June Kaiser Health Tracking Poll finds a majority of the public support allowing states to impose work requirements for non-disabled adults (70 percent) or drug testing as a condition of enrollment (64 percent).  However, fewer support changes that would cut funding or alter the funding structure, such as imposing limits on the length of time people can be enrolled in the program (36 percent), reducing funding for Medicaid expansion (36 percent), changing the funding structure to limit how much money each state gets from the federal government each year (35 percent), or stopping federal Medicaid payments to Planned Parenthood for one year (30 percent). Even fewer (21 percent) support limiting federal funding for Medicaid coverage of long-term care for seniors and people with disabilities.

Republican Support for Most Proposed Changes to Medicaid

The majority of Republicans support most of the proposed changes to the Medicaid program including large majorities who support allowing states to impose work requirements (82 percent) and drug test requirements (82 percent). Fewer – but still a majority of Republicans– support changing the funding to a per capita cap system to limit federal spending (62 percent), allowing states to impose length-of-time restrictions (59 percent), and stopping federal payments to Planned Parenthood for one year (54 percent). A majority of Democrats (56 percent) and independents (77 percent) support allowing states to impose work requirements and a majority of independents also support allowing states to impose drug test requirements (65 percent). Few –regardless of party identification – support limiting federal funding for Medicaid coverage of long-term care for seniors and people with disabilities.

Table 1: Republicans More Likely to Support Proposed Changes to Medicaid
Percent who support the following specific changes to Medicaid currently being considered by Congress and the Administration:	Democrats	Independents	Republicans
Allowing states to require adults without disabilities to work or be looking for work in order to get health insurance through Medicaid	56%	77%	82%
Allowing states to require individuals to get a drug test before they are able to get and keep health insurance through Medicaid	47	65	82
Allowing states to impose limits on the length of time people can get health insurance through Medicaid	19	34	59
Reducing the federal funding that was included in the 2010 health care law for states that expanded Medicaid	25	35	51
Changing the funding for Medicaid to limit how much money each state gets from the federal government each year	17	32	62
Stopping federal payments to Planned Parenthood clinics for one year for health care services provided to people on Medicaid	14	29	54
Limiting federal funding for Medicaid coverage of long-term care for seniors and people with disabilities	14	20	28

Support for Medicaid Regardless of Whether Their State Expanded Medicaid

As noted in previous Kaiser Health Tracking Polls¹, Medicaid is popular among individuals living in states that have expanded their Medicaid program as well as those that have not. For example, as seen in the interactive below, 73 percent of individuals living in states without Medicaid expansion have a favorable view of the Medicaid program, 64 percent say Medicaid is working well in their state, and 61 percent say the program is working well in the nation overall. In addition, about one-third (35 percent) are aware that the House-passed Republican replacement plan makes major reductions to Medicaid spending.

Health Insurance Marketplaces

Over the past several weeks, there has been considerable attention given to decisions by health insurers to no longer sell insurance in some ACA marketplaces. Based on current insurer rate filings and news reports, it’s estimated that 48 counties (35,894 enrollees) are currently expected to have no insurer on the ACA marketplaces in 2018.²

Despite this impact being limited to a select number of counties and not affecting those with employer sponsored insurance, four in ten (43 percent) of the public believe that health insurance companies choosing to not sell insurance plans in certain marketplaces will have a negative impact on them and their families, while about half say they don’t think it will have any impact on them.

Americans are divided on how well they think the health insurance marketplaces are working with more than half (54 percent) saying the health insurance marketplaces are working well in their state and nearly half (46 percent) saying they are working well in the nation, overall. These findings are relatively unchanged from the April 2017 Kaiser Health Tracking Poll.³

Most Democrats say the marketplaces are working well in their own state (67 percent) and nationally (61 percent). More Republicans say the marketplaces in their own state are working well (35 percent) than nationally (26 percent). Independents are divided with 56 percent saying they are working well in their own state and about half (47 percent) saying they are working well in the nation overall.

Public is Most Likely to Blame Insurers for ACA Marketplace Problems

When asked who is to blame for the current problems affecting the ACA marketplaces, about four in ten (42 percent) say the problems are mainly due to decisions by health insurance companies driven by profits while fewer say the problems are due to either the way the law was designed by the Obama administration and Democrats in Congress (28 percent) or uncertainty brought on by the actions of President Trump and Republicans in Congress (22 percent). Republicans are more likely to place blame on the Obama administration and Democrats in Congress (57 percent), while about half of Democrats (51 percent) blame the problems on profit-driven decisions by insurance companies.