Few Have Heard About State Decisions on Exchanges and Medicaid Expansion

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1 Public Opinion on Health Care Issues March 203 Three years after the passage of the Patient Protection and Affordable Care Act (the ACA), but still many months away from the implementation of most of its major provisions, the latest Kaiser Health Tracking Poll finds that a majority of Americans are unsure how the law will impact them, and few are paying attention to the details of state level decisions about implementation. Though opinion on the law overall remains nearly evenly divided, opponents attacks seem to have taken a toll on the public s expectations, and Americans are now more likely to think the law will make things worse rather than better for their own families. While most of the law s individual provisions remain popular, many of the most well liked elements are the least well known among the public. Public knowledge of the ACA s provisions has not increased since 200, and awareness of some key provisions has declined somewhat since the law s passage when media attention was at its height. On another health policy topic that has been in the news, while national data shows that health care cost growth has slowed down in recent years, a majority of the public perceives that the country s health costs have been going up faster than. PUBLIC NOT PAYING MUCH ATTENTION TO STATE DECISIONS ON EXCHANGES, MEDICAID EXPANSION While state and federal policymakers are busy making decisions about the Medicaid expansion and working out the logistics of their health insurance exchanges before 204, the public at large hasn t been paying much attention to either of these topics. Asked how much they have heard about their own state s decision on whether to create a state run exchange, roughly half the public (48 percent) reports hearing nothing at all, while just over one in five have heard a lot (7 percent) or some (5 percent). Further, when asked what they know about their governor s decision on whether to expand Medicaid in their state, the vast majority (78 percent) say they haven t heard enough to say whether the governor has announced a decision or what that decision is. This is equally true in states where the governor has stated that they will expand Medicaid (80 percent say they haven t heard enough to say) and in those whose governor has said they will not move forward with the expansion (74 percent). Few Have Heard About State Decisions on Exchanges and Medicaid Expansion How much, if anything have you heard about your state s decision on whether to create a state-run health insurance exchange or marketplace where people who don t get coverage through their jobs can shop for insurance? Some 5% Only a little 29% A lot 7% Nothing at all 48% As far as you know, has your state s governor announced that your state will expand Medicaid, announced that your state will not expand Medicaid, not announced their decision, or have you not heard enough about this to say? Has not announced Announced state will not expand Medicaid 7% Announced state will expand Medicaid 7% decision 6% Dk/ Ref. 2% Not heard enough to say 78% SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted March 5-0, 203)

2 When asked whether they think their state should implement the Medicaid expansion, with the federal government picking up most of the cost, the survey finds that more Americans are in favor of expanding Medicaid in their state (52 percent) than oppose it (4 percent), shares that have remained similar since last July. A familiar partisan divide is evident, with two thirds of Republicans wanting to keep their state s Medicaid program as it is today, three quarters of Democrats wanting to expand it, and independents nearly evenly divided. More Favor Expanding Their State s Medicaid Program Than Oppose As you may know, the health care law expands Medicaid to provide health insurance to more low-income uninsured adults. The federal government will initially pay the entire cost of this expansion, and after several years, states will pay 0 percent and the federal government will pay 90 percent. The Supreme Court ruled that states may choose whether or not to participate in this expansion. What do you think your state should do? Keep Medicaid as it is today Total Democrats Independents 4% 46% Expand Medicaid to cover more low-income people 76% 52% 44% Republicans 67% 26% NOTE: Other/Neither (vol.) and Don t know/refused answers not shown. SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted March 5-0, 203) Public: What Health Cost Growth Slowdown? Over the past few years, would you say the cost of health care for the nation as a whole has been going up faster than, going up slower than, or going up abut the same amount? slower than 4% Dk/Ref. 7% about the same amount as 3% faster than 58% slower than 2% SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted March 5-0, 203) Would you say the amount you and your family are paying for health care and health insurance has been going up over the past few years, going down, or staying about the same? (If going up) Would you say your health care costs have been going up faster than, slower than, or about the same amount? Dk/Ref. 4% Staying about the same 32% about the same amount as 24% Going down 2% faster than 34% PUBLIC: WHAT HEALTH COST GROWTH SLOWDOWN? Analysis of national data has shown that, while health care cost growth continues to outpace inflation, the rate of growth in national health expenditures has slowed markedly in recent years. The public s perception of the cost trajectory is quite different, however. Nearly six in ten adults (58 percent) say that over the past few years, the cost of health care for the nation as a whole has been going up faster than, while just 4 percent say it has been going up slower than and three in ten (3 percent) think it s been going up by about the same amount. When it comes to their own experiences with rising costs, about a third of Americans (34 percent) report that their own family s health care costs have been going up faster than, while roughly a quarter say they ve been going up about the same amount as (24 percent), and 32 percent say their costs have held steady in recent years. Only small shares say their costs have been going up more slowly than (2 percent) or that their costs have actually come down (2 percent). M Hartman, AB Martin, J Benson, A Catlin, and the National Health Expenditure Accounts Team, National Health Spending in 20: Overall Growth Remains Low, But Some Payers and Services Show Signs of Acceleration, Health Affairs, January 203, 32:

3 At Three Years, Opinion On ACA Remains Divided As you may know, a health reform bill was signed into law in 200. Given what you know about the health reform law, do you have a generally favorable or generally unfavorable opinion of it? 80% 60% ACA signed into law on March 23, Favorable Unfavorable Don't know/refused % PUBLIC OPINION ON THE ACA REMAINS DIVIDED AT 3 RD ANNIVERSARY Since the ACA was signed into law in March 200, overall opinion of the law has stayed within a relatively narrow band, with roughly equal proportions saying they feel favorable and unfavorable towards it. This division of opinion continues on the 3 rd anniversary of the ACA, with 37 percent holding a favorable view and 40 percent unfavorable. The share of the public who declined to offer an opinion on the law remains high this month, at 23 percent. 0% AprMayJun Jul AugSepOctNovDec Jan FebMar AprMayJun Jul AugSepOct NovDec Jan FebMar AprMayJun Jul AugSep Oct Nov SOURCE: Kaiser Family Foundation Health Tracking Polls 23 23% mandate (5 percent), and concerns about government involvement in health care (3 percent). FebMar Asked about the reasons behind their views, the most common response among those who view the law favorably has to do with expanded access to health care and insurance (58 percent), while those who view the law unfavorably are most likely to cite cost considerations (30 percent), opposition to the individual Three Years Later, Public Still Divided by Party Percent who say they have a favorable opinion of the health reform law: 80% 60% ACA signed into law on March 23, Democrats Independents Republicans % 32 3% 0% % AprMayJun Jul AugSepOct NovDec Jan FebMarAprMayJun Jul AugSep Oct NovDec Jan FebMarAprMayJun Jul AugSepOctNov FebMar SOURCE: Kaiser Family Foundation Health Tracking Polls Last month s drop in the share of Democrats viewing the law favorably leveled off this month, and views by party continue to be as divided as ever, with most Republicans (68 percent) viewing the law unfavorably, a majority of Democrats (58 percent) viewing it favorably, and independents more negative than positive (3 percent favorable, 45 percent unfavorable). The intensity of opinion on the law still lies with the GOP, another aspect of opinion that has been true throughout the last three years of Kaiser polling on the ACA. About half of Republicans (53 percent) say they have a very unfavorable view, compared to three in ten Democrats (3 percent) who say they have a very favorable view. 3

4 MOST REPORT NO PERSONAL EXPERIENCE WITH LAW YET Thus far, most Americans report having no direct experience, either positive or negative, with the ACA. A little over two in ten say someone in their family has been negatively affected by the law (22 percent), with the most commonly cited reason being increased costs, followed by cuts to benefits. A slightly smaller share feel they ve personally benefited (7 percent), either through expanded benefits and access to care, lower health care costs, or the provision that allows parents to keep their children under the age of 26 on their insurance plan. Still, the majority of the public 62 percent reports that they have not felt any impact either way, a number that has stayed relatively steady since December 200. Most Report No Experience With Law So Far So far, would you say you and your family have [personally benefited from/been negatively affected by] the health reform law, or not? 80% 60% 0% 66% Percent who say someone in their family has personally benefited from the health reform law Percent who say someone in their family has been negatively affected by the health reform law Percent who say they have not been personally impacted yet 7% 68% 69% 68% 7% 8% 8% 8% 5% 4% 3% 4% 5% 72% % Dec Feb Mar May Jul Nov Mar Aug Mar SOURCE: Kaiser Family Foundation Health Tracking Polls 67% 2% 4% 64% 9% 9% 62% 22% 7% TABLE : IN THEIR OWN WORDS Among the 7% who say their family has personally benefited from the health reform law: In what ways would you say you have benefited from the health reform law? My birth control is now free We've been able to continue coverage for our child that has graduated from college and we don't have to pay co pays for well visits Great difference, I don't have to pay as much as I did There is a provision where people with Medicare get a wellness annual checkup and I think that's a good idea. And I have had mine and it was very helpful Just ease of mind Because I didn't have insurance and now I do Makes businesses give insurance to employees Yearly increase has been lower than in the past 0 years Removal of some caps of number of visits a year, specifically for mental health I would have been denied insurance for a pre existing condition and now I m not Among the 22% who say their family has been negatively affected by the health reform law: In what ways would you say you have been negatively affected by the health reform law? Don't care for the government intrusion My doctor will no longer take Medicare patients like he did before. Now he limits the time he will see Medicare patients and they don't pay as well as they did before I received a bill for blood work which I have never received before My mother is a small business owner and she cannot afford to pay for health care for the employees even though the employees already have health care It s costing me more money for less coverage Taking the money out of Medicare to help ObamaCare Some of my family members hours have been cut so the businesses don't have to participate When my husband gets his checks it keeps taking out more The taxpayers will have to pay whether they are covered or not, we are covered we should not pay Because we don't have all the details yet PARTS MORE POPULAR THAN THE WHOLE While the public is divided on the law as a complete package, many of its component parts are quite popular, some on a bipartisan basis. Majorities of the public are favorable towards the law s tax credits for small businesses who offer their employees insurance (88 percent, including 53 percent very favorable), closing the Medicare doughnut hole (8 percent, 52 percent very favorable), and the provision allowing young adults to stay on their parents health plans up to age 26 (76 percent, 54 percent very favorable). Three of the hallmark features of the law the health insurance exchanges, subsidies to help individuals purchase insurance, and the Medicaid expansion are also popular, with between seven and eight in ten Americans favoring each (80 percent, 76 percent, and 7 percent, respectively). But consistent with previous polls, the individual mandate falls at the bottom of this list, with six in ten feeling unfavorable about this provision of the law. 4

5 Even some of the law s most fervent opponents like many of the things the ACA has done or will do. A majority of Republicans feel favorable towards seven of the provisions asked about in the March poll, with seven in ten or more favoring tax credits to small businesses, closing the Medicare doughnut hole, and the exchanges. Less popular among the GOP: the highly politicized Medicaid expansion (42 percent favorable), increased Medicare payroll tax for those with higher incomes (37 percent), the employer and individual mandates (36 percent and 2 percent, respectively). TABLE 2: MANY ELEMENTS OF ACA CONTINUE TO BE POPULAR ACROSS PARTIES Percent who say they feel favorable about each of the following elements of the health reform law Total Dem Ind Rep Tax credits to small businesses to buy insurance 88% 96% 87% 83% Close Medicare doughnut hole Create health insurance exchanges Extension of dependent coverage Subsidy assistance to individuals Medicaid expansion Guaranteed issue Medical loss ratio Increase Medicare payroll tax on upper income Employer mandate/penalty for large employers Individual mandate/penalty Note: Question wording abbreviated. For full question wording, see topline: GAPS IN KNOWLEDGE PERSIST Three years after passage, a majority of Americans (57 percent) say they do not have enough information about the ACA to understand how it will affect them. Perhaps more importantly, this share rises to two thirds among some of the key groups the law was designed to help: the uninsured (67 percent) and those with incomes below $40,000 (68 percent). Majority Say They Don t Understand How ACA Will Impact Them, Including Two-Thirds of Uninsured and Low-Income Do you feel you have enough information about the health reform law to understand how it will impact you personally, or not? Yes, have enough information No, do not have enough information Total 4% 57% Uninsured (under age 65) 33% 67% Household income less than $40,000 30% 68% NOTE: Don t know/refused answers not shown. SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted March 5-0, 203) 5

6 While a majority of the public has an accurate perception of how much of the law has been implemented (67 percent say that some provisions have been put into place thus far), many continue to have false impressions about which provisions are actually included in the law and which are not. Among the public, the most widely recognized element is the unpopular individual mandate, which three quarters (74 percent) of the public say is part of the law. The employer requirement, that companies with 50 or more full time employees offer insurance or pay a fine, closely follows (7 percent). Large shares are also aware that the law allows adult children to stay on their parents insurance until age 26 (69 percent), provides subsidies to help low and moderate income Americans purchase insurance (62 percent), gives states the option of expanding their Medicaid program (59 percent), and creates insurance exchanges where people can shop for coverage (58 percent). Among the items that are less familiar to the public: just about half recognize that the law increases the Medicare payroll tax for upper income Americans (54 percent); prohibits insurance companies from denying coverage to people with pre existing conditions (also known as guaranteed issue, 53 percent); and provides tax credits to small businesses who cover their workers (52 percent). Even less well known are the law s provisions to close the Medicare prescription drug coverage gap, or doughnut hole (46 percent) and the medical loss ratio provision that requires insurance companies to give rebates to customers if they spend too little on health care services and too much on administrative costs and profits (40 percent). TABLE 3: AWARENESS OF PROVISIONS INCLUDED IN THE HEALTH CARE LAW (TRUE STATEMENTS) CORRECT INCORRECT To the best of your knowledge, would you say the health reform law does or does not do each of the following? Yes, law does this No, law does not do this Don t Know/ Refused Individual mandate/penalty 74% 7% 9% Employer mandate/penalty for large employers 7 7 Extension of dependent coverage Subsidy assistance to individuals Medicaid expansion Health insurance exchanges Increase the Medicare payroll tax on upper income Guaranteed issue Tax credits to small businesses to buy insurance Close Medicare doughnut hole Medical loss ratio Note: Question wording abbreviated. For full question wording, see topline: At the same time, many Americans hold misimpressions about the law s contents. Just under six in ten (57 percent) mistakenly think the law creates a government run health plan (the so called public option ). And close to half (47 percent) say the law allows undocumented immigrants to receive financial help from the government to buy health insurance, when in fact they are not eligible for subsidies. Many (40 percent, including 35 percent of seniors) continue to hold on to the myth that the law allows a government panel to make decisions about end of life care for people on Medicare (the so called death panels ) and another two in ten aren t sure (2 percent). TABLE 4: MISPERCEPTIONS ABOUT PROVISIONS NOT INCLUDED IN THE LAW (FALSE STATEMENTS) CORRECT INCORRECT To the best of your knowledge, would you say the health reform law does or does not do each of the following? No, law does not do this Yes, law does this Don t Know/ Refused Cut benefits for people in Medicare 43% 44% 4% Establish a government panel to make decisions about end of life care for people on Medicare Allow undocumented immigrants to receive subsidies to purchase insurance Public option Note: Question wording abbreviated. For full question wording, see topline: 6

7 As previous Kaiser polls have shown, some of the most popular provisions of the law are among the least widely recognized, and vice versa. For example, three quarters of Americans recognize that the individual mandate is part of the law, but only four in ten have a favorable view. Larger shares report having positive views of less well known provisions. For example, 88 percent of Americans favor providing tax credits to small businesses that offer health insurance, while just about half (52 percent) are aware the law includes such a provision. Most Popular Provisions Among Least Widely Recognized (And Vice Versa) Percent who say they feel favorable about each of the following and percent who say they are aware each is included in the health reform law: Percent with a favorable view of element Percent who are aware element is included in ACA Tax credits to small businesses to buy insurance 88% 52% Close Medicare "doughnut hole" 8% 46% Create health insurance exchanges 80% 58% Extension of dependent coverage 76% 69% Subsidy assistance to individuals 76% 62% Medicaid expansion 7% 59% Guaranteed issue 66% 53% Medical loss ratio 65% Increase Medicare payroll tax 60% 54% Employer mandate/penalty for large employers 57% 7% Individual mandate/penalty 74% NOTE: Items asked of separate half samples. Question wording abbreviated. See topline ( for complete wording. SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted March 5-0, 203) Public knowledge about these provisions has not increased since 200, and awareness of some of the most popular provisions has actually decreased. For example, compared with April 200, the shares who recognize that the law includes tax credits to small businesses to buy insurance, subsidy assistance for individuals, and guaranteed issue of health insurance are down 4, 3, and percentage points, respectively. TABLE 5: DECLINES IN AWARENESS OF SOME KEY PROVISIONS Percent who say the health reform law does each of the following: April 200 March 203 Tax credits to small businesses to buy insurance 66% 52% Subsidy assistance to individuals Guaranteed issue Medicaid expansion Health insurance exchanges Medical loss ratio Extension of dependent coverage Individual mandate/penalty 7 74 Note: Question wording abbreviated. For full question wording, see topline: 7

8 EXPECTATIONS OF THE LAW S IMPACT Three years after the ACA passed, and months away from the implementation of most of its major provisions, a plurality of Americans (40 percent) say they don t expect the law to make much difference for their families overall. Those who do expect to see an impact are more likely to say it will leave them worse off (29 percent) rather than better (2 percent). Like favorability, expectations of the law s personal impact have also bounced around within a narrow band, but in most months since 20, those saying they expect to be worse off have outnumbered those expecting to be better off, with the largest share saying they expect to see little difference in their own lives. Trend in Opinion on Personal Impact of ACA Do you think you and your family will be better off or worse off under the health reform law, or don t you think it will make much difference? 80% 60% 0% ACA signed into law on March 23, 200 Better off Won't make much difference Worse off % % AprMayJun Jul AugSepOct NovDec Jan FebMarAprMayJun Jul AugSepOct NovDec Jan FebMar AprMay Jul AugSepOct FebMar NOTE: Don t know/refused answers not shown. SOURCE: Kaiser Family Foundation Health Tracking Polls Expectations for ACA s Impact on Cost and Quality More Negative Than Positive Under the health reform law, do you think each of the following will get better, worse, or will it stay about the same? NATIONAL IMPACTS The cost of health care for the nation as a whole The quality of health care in the nation Consumer protections for the average person with private health insurance PERSONAL IMPACTS Access to health care for the uninsured The cost of health care for you and your family The quality of your own health care Your ability to get and keep health insurance NOTE: Items asked of half sample. Don t know/refused answers not shown. SOURCE: Kaiser Family Foundation Health Tracking Poll (conducted March 5-0, 203) Worse Stay about the same Better 28% 45% 39% 34% 28% 55% 49% 24% 46% 26% 36% 48% 8% 33% 2% 24% 6% 5% 5% Drilling down further into the specifics, the latest poll finds Americans expectations about the law s impacts on health care costs, quality, and consumer protections are also more negative than positive. The biggest area of concern is costs; more than half (55 percent) say the cost of health care for the nation as a whole will get worse under the law, and nearly as many (49 percent) say the same about their own personal health care costs. Americans are also much more likely to say things will get worse rather than better in terms of quality of care in the nation (45 percent vs. 24 percent) and consumer protections for the average person with health insurance (39 percent vs. 6 percent). When it comes to the quality of their own care and their ability to get and keep insurance, nearly half don t expect to see much change, but larger shares expect things to get worse rather than better. The one area asked about in the survey where the public s expectations are more positive is access to health care for the uninsured: 40 percent expect it to get better under the law, while 28 percent expect it to get worse. 8

9 Not surprisingly, expectations about the law s impacts in each of these areas are also divided sharply by party, with Republicans far more likely than Democrats to think things will get worse, both for themselves and for the nation. For example, while 73 percent of Republicans say the quality of care in the nation will worsen, four in ten Democrats (39 percent) expect it to get better under the law. Similarly, more than half (53 percent) of Democrats expect the uninsured will have better access to care, while Republicans are divided as to whether access will get better (3 percent) or worse (33 percent). It s worth noting, however, that even Democrats, who favor the law for the most part, are divided as to whether the law will make things better or worse in terms of national health care costs (37 percent better vs. 34 percent worse), consumer protections (27 percent vs. 24 percent), and their own families health care costs (23 percent vs. 26 percent), with substantial shares saying it won t make much difference. TABLE 6: PARTISAN DIFFERENCES IN PERCEPTIONS OF LAW S IMPACTS Under the health reform law, do you think each of the following will get better, worse, or stay about the same? Total Dem Ind Rep NATIONAL IMPACTS The cost of health care for the nation as a whole Better 2% 37% 6% 6% Worse Stay about the same The quality of health care in the nation Better Worse Stay about the same Consumer protections for the average person with private health insurance Better Worse Stay about the same Access to health care for the uninsured Better Worse Stay about the same PERSONAL IMPACTS The cost of health care for you and your family Better Worse Stay about the same The quality of your own health care Better Worse Stay about the same Your ability to get and keep health insurance Better Worse Stay about the same

10 EXPECTATIONS OF CHANGES RELATED TO INDIVIDUAL MANDATE In another measuree of people s expectations about the law, the survey findss that just under three in ten Americans (28 percent) say they expect to make some sort of change to their current health insurance arrangements as a result of the ACA s individual mandate. Of those who say they will have to make different health care arrangements, most expect those changes to come in the form of needing to get new coverage or paying more for their current coverage. Not surprisingly, the group that is most likely to say they expect to change their arrangements are those who are currently uninsured (62 percent, versus 22 percent of the insured). Overall, people are more likely to say these changes will leavee them worse off (9 percent) than better ( 7 percent). However, the uninsured are somewhat more evenly divided on the impact of these new health care arrangements 23 percent say the changes will leave them better off, compared to 34 percent who say the changes will leave them worse off. TABLE 7: EXPECTATIONS OF IMPACTS RELATED TO INDIVIDUAL MANDATE When the requirement that nearly all Americans have health insurance goes into effect in 204, do you think you will have to change your current health insurance arrangements, or not? Do you think that change will leave you better off or worsee off? Yes, will have to change health insurance arrangements Better off Worse off Won t make much difference either way (VOL.) Don t know/refused No, will not have to change Don t know/refused Total 28% Insured Uninsured (under age 65) (under age 65) 22% 62% This Kaiser Health Tracking Poll was designed and analyzed by public opinion researchers at thee Kaiser Family Foundation led by Mollyann Brodie, Ph.D., including Liz Hamel, Claudia Deane, Sarah Cho, and Bianca DiJulio. The survey was conducted March 5 0, 203, among a nationally representative random digit dial telephone sample of,204 adults ages 8 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 (602) and cell phone (602, including 35 who had no landline telephone) weree carried out in English and Spanish by Princeton Data Source under the direction of Princeton Survey Research Associates International. The combined landline and cell phone sample was weighted to balance the sample demographics to match Census estimates for the national population on sex, age, education, race, Hispanic origin, nativity (for Hispanics only), region, and telephone usage. All statistical tests of significance account for the effect of weighting. The margin of sampling error including the design effect forr the full sample is plus or minus 3 percentage points. For results based on other subgroups, the margin of sampling error may be higher. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll. The full question wording and methodology of the polls can be viewed online at: This publication (#8425-F) is available on the Kaiser Family Foundation s website at The Henry J. Kaiser Family Foundation: Headquarters 2400 Sand Hill Road, Menlo Park, CA Phone: Fax: Washington Offices and Barbara Jordan Conference Center: 330 G Street N.W., Washington, DC Phone: Fax: The Kaiser Family Foundation, a leader in health policy analysis, health journalism and communication, is dedicated to filling the need for trusted, independent information on the major health issues facing our nation and its people. The Foundation is a non-profit private operating foundation, based in Menlo Park, California.