Drew Altman, Kaiser Family Foundation
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ACA mandate repeal may be less popular than GOP thinks

The tax bill that just passed the Senate eliminates the Affordable Care Act's individual mandate, and the House is likely to go along when Congress writes the final version. With the tax legislation moving so quickly and the mandate lost in the maze of so many other consequential provisions, we are not likely to have much public debate about this big change in health policy.

Reproduced from Kaiser Family Foundation Health Tracking Poll, Nov. 8-13, 2017; Note: Question wording abbreviated, "Don't know"/"refused" responses not shown; Chart: Axios Visuals

Why it matters: If we did, even though the mandate has never been popular, our polling shows that the public does not necessarily want to eliminate it as part of tax reform legislation, once they understand how it works and what the consequences of eliminating it might be.

The back story: Republicans have targeted the ACA mandate because they want the $318 billion in savings the Congressional Budget Office says they would get to help them pay for their tax cuts. (The change would save money because fewer people would get federal subsidies on the ACA marketplaces or apply for Medicaid coverage.)

They have also targeted the mandate because they think it's so unpopular. Our polls have consistently shown that the mandate is the least popular element of the ACA and in the abstract, more Americans (55%) would eliminate the mandate than keep it (42%).

Yes, but: When people know how the mandate actually works, and are told what experts believe is likely to happen if it's eliminated, most Americans oppose repealing it in the tax plan.

  • When people learn that they will not be affected by the mandate if they already get insurance from their employer or from Medicare or Medicaid, 62% oppose eliminating it.
  • When people are told that eliminating the mandate would increase premiums for people who buy their own coverage, as the CBO says it will, they also flip, with 60% opposing eliminating the mandate.
  • And when they're told that 13 million fewer people will have health coverage – another CBO projection – 59% oppose eliminating the mandate.

The bottom line: Many people change their minds when they learn more about facts and consequences, which happens as the lights shine brighter on them in legislative debates. This happened to the “skinny repeal" proposal, and it would happen to single payer.

But as the tax legislation rushes through Congress and heads to the final negotiations, there is almost no chance for the public to grasp the tradeoffs that would come from eliminating the mandate and who is affected and who is not. If they did, the polling suggests, eliminating the mandate might prove far less popular than Republicans seem to think it is.

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The biggest health issue we aren’t debating

Thanksgiving is always a time to think about those in need. How about, then, a group we don't worry about enough: the many lower and moderate income Americans who can't cover their cost sharing if they get sick? It raises the question: How much cost sharing is too much?

Reproduced from Kaiser Family Foundation analysis of the 2016 Survey of Consumer Finance; Note: Liquid assets include the sum of checking and saving accounts, money market accounts, certificates of deposit, savings bonds, non-retirement mutual funds, stocks and bonds. Chart: Axios Visuals

The bottom line: High deductible plans, which require people to pay large amounts out of pocket before their medical bills are covered, are a good deal for some middle and upper income people. But many lower and moderate income Americans simply don't have $1,500 to $3,000 to pay for the colonoscopy that might save their life, or a stress test that might reveal the heart disease which is the cause of their chest discomfort.

The details: The chart, drawn from a new study, tells the tale: More than four in in 10 households with private coverage and incomes between 150% and 400% of the federal poverty line do not have enough liquid assets to cover a deductible of $1,500 for single people and $3,000 for families.

  • That's not a high deductible plan, but about the average in an employer-provided insurance plan.
  • Sixty percent couldn't cover deductibles double those amounts, which are not uncommon, especially in the individual insurance market.
  • Ninety percent of insured households with incomes of 400% of poverty or more could meet a typical employer insurance deductible, but just 37% of lower income household with incomes under 150% of the poverty level could.

For many families, even if they have insurance, any significant illness could wipe out all their savings, making impossible to fix a broken car to get to work, or pay for school, or make a rent or mortgage payment.

Congress has passed no law declaring that the country will go with high deductible coverage as its main approach to health insurance. There has been no meaningful debate about its pros and cons. But as deductibles and other forms of cost sharing have inched up year by year, the nature of insurance has changed.

The people to worry about most are the ones who are least equipped to deal with that change. There may be someone who fits that bill around your Thanksgiving table.


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How the elections could put the brakes on anti-ACA plans

The most important issue in an election is sometimes, but seldom, the factor that actually determines the outcome of the election. That's what we saw happen in Virginia this week. Health was the top issue in the Virginia race, according to exit polls, but it was only one of many factors that drove the election.

The bottom line: The election may have been more of a referendum on President Trump than health care — but the results in Virginia and in the Maine referendum on Medicaid expansion will still have a practical impact on what happens next, including the appetite for Affordable Care Act repeal and for cutting Medicaid to pay for tax cuts.

Data: Fox News voter analysis, Nov. 7; Chart: Axios Visuals

The details: Voters in Virginia named health care as far and away their top issue in the election in the network exit poll. It's not surprising that the issue was at the top of their minds; they have been hearing all about the ACA in the news for months and about Medicaid expansion in their state.

Yes, but: Notably, the exit poll did not include the economy on the list of issues voters could choose. Fox News did ask about the economy and, as the chart shows, it and health were statistically tied in their poll.

Between the lines: When voters rank health care as a top issue in an election, it does not necessarily mean health care drove their vote. Voters' views of the candidates themselves are generally a bigger factor. The candidates were also proxies for voters' feelings about President Trump, and many more voters in Virginia said they were voting to express opposition to Trump than their support for him (34% vs. 17%).

Most voters who chose health care as their top issue in Virginia voted for Northam, possibly signaling that Democrats may be able to campaign on health care and the ACA in upcoming elections.

What to watch: The Maine vote on Medicaid expansion was a different story. Maine voters cast their ballots on a specific referendum to expand the Medicaid program, and it won resoundingly. The result speaks to a lesson learned in the repeal and replace debate: Medicaid and Medicaid expansion are far more popular than Republicans seem to think they are, largely because Medicaid now covers 74 million Americans and matters to a broad cross section of the American people.

The impact: The immediate political implication is that it will be much tougher to cut Medicaid to help pay for tax cuts. Another lesson is that expanding Medicaid could be a winner in other states, especially with the federal government picking up 90 percent of the costs and the Trump administration ready to let red states put a conservative stamp on their programs. Medicaid is not Social Security or Medicare yet, but politically it is a lot closer than Republicans may realize.

A lot can and probably will happen between now and 2018. But for now, the prominence of health care in the Virginia election could throw a scare into moderate Republicans about continuing to pursue ACA repeal. And the Maine referendum on Medicaid expansion could make them more cautious about cutting Medicaid.

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One big thing people don’t know about single payer

It is generally assumed that the biggest obstacle to a national health plan like Medicare for All will be the large tax increase needed to pay for it. But new polling shows another challenge: Almost half of the American people don't know that they would have to change their current health insurance arrangements if there was a single-payer plan.

Data: Kaiser Family Foundation Health Tracking Poll conducted Oct. 5-10, 2017; Chart: Chris Canipe / Axios

Why it matters: Current insurance plans leave a lot to be desired for many people, and it is entirely possible that some people would want to switch to a Medicare for All style plan. But the public has resisted being forced to change their health care in the past — don't forget the uproar over the cancelled plans at the launch of the Affordable Care Act.

So requiring people to change could trigger blowback and would certainly provide a talking point to help opponents scare people about single payer.

The details: Overall, the general idea of a national health plan is pretty popular, with 53% of the American people favoring a national health plan — 30% strongly favoring it and 23% somewhat favoring it. On the other side, 31% strongly oppose it and 13% somewhat oppose it. Democrats and Republicans split on the idea, as expected.

But as the chart shows, somehow, 47% of the American people think they would be able to keep their current health insurance — even though a single payer Medicare for All style plan would do away with employer-based insurance.

  • 52% of Democrats, the group most supportive of single payer as an idea, think they will be able to keep their plan.
  • Notably, 44% of people with employer-based insurance think they would be able to keep their current plan.

Advocates of single payer consider it a virtue that employer-based health insurance would be eliminated. Health reformers on the right would also do away with employer-based insurance, but they would replace it with tax credits for private insurance, not a government plan.

There are also more targeted public insurance proposals for people who can't get Medicaid or marketplace coverage — including a government-run public option, a Medicare buy-in for 50-64 year olds, or a Medicaid buy-in option on the ACA marketplaces. They wouldn't threaten people's current health care arrangements, but they are far from the rallying cry for some progressives Medicare for All may be, and they're no slam dunks in the current political environment.

The bottom line: There is no sweeping health reform plan without tradeoffs, as we learned with both the ACA and the Republican repeal-and-replace plans. The fact that so many people don't know that a national health plan would require them to change their insurance arrangements underscores the challenge of making the transition from a popular idea to a reality for a single-payer national health plan.

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Keeping the Alexander-Murray health care bill in context

As the debate unfolds about the bipartisan bill by Senators Lamar Alexander and Patty Murray to repair the Affordable Care Act marketplaces, the public could be just as confused as they have been about the ACA's marketplaces. That's why it's important to debate it in the right context: It's aimed at an urgent problem affecting a relatively small sliver of the health insurance system, not all of the ACA and not the entire health system.

The bottom line: It's a limited measure that will never give conservatives or liberals everything they want.

Data: Kaiser Family Foundation Health Tracking Poll conducted Oct. 5-10, 2017; Chart: Chris Canipe / Axios

Reality check: Many people will think it affects their insurance when, in actuality, it will have no impact on the vast majority of Americans who get their coverage outside of the relatively small ACA marketplaces.

The chart based on our new Kaiser Tracking Poll shows the confusion. Just 23% of the American people know that rising premiums in the ACA marketplaces affect only people who buy their own insurance. More than seven out of 10 wrongly believe rising premiums in the marketplaces affect everyone or people who get coverage through their employer.

The public will be susceptible to spin and misrepresentation of the limited goals of Alexander-Murray: a bipartisan effort to stabilize the marketplaces by funding the cost-sharing reduction subsidies, providing more resources for open enrollment outreach, and expediting state waivers.

President Trump has added to the confusion. He recently pronounced the ACA "dead", adding, "there is no such thing as Obamacare anymore." Possibly that's because he wishes it was dead. More likely, he was referring to the problems in the ACA marketplaces, which he has exaggerated.

Like thinking your whole house is falling down when just a part of the foundation needs shoring up, both he and the American people have an inaccurate picture of where the marketplaces fit in the ACA and where the ACA fits in the health system.

A few facts:

  • There are just 10 million people enrolled in the ACA marketplaces.
  • The law's larger Medicaid expansion and consumer protections are popular and working well.
  • The far larger Medicare and Medicaid programs and employer based health system combined cover more than 250 million people, and are largely unaffected by developments in the ACA marketplaces.
  • Premiums for the 155 million people who get coverage through their employers rose a very modest 3% in 2017.

Some conservatives in Congress will hold out for repeal, and they'll resist any legislation that they view as propping up Obamacare. But for everyone else, it's important to understand the problem and get the facts.

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The medical bill score: How the public judges health care

We track a lot of numbers in health care: how much we spend on health as a share of our economy; the number of uninsured; and the share of the federal budget allocated to health programs. What we don't track — and a number the Congressional Budget Office cannot score — is the statistic that means the most to the American people: the share of the public having problems paying their health care bills.

Data: Kaiser Family Foundation/New York Times Medical Bills Survey (conducted August 28-September 28, 2015); Chart: Lazaro Gamio / Axios

The bottom line: The “medical bills score" is the single most important measure of how we are doing in health care from the public's perspective. And ultimately, if Congress ever passes a new health care bill, it is how the public will evaluate that plan — from Graham-Cassidy to Medicare for All and everything in between.

The numbers that matter: As we found in a Kaiser Family Foundation poll in February:

  • 31% of Americans age 18-64 report they or a family member face problems paying their health care bills.
  • But that number shoots up to 57% for people who are sick.

It makes sense that people who use more care have more health care bills, but it also reveals how poorly our system performs from a consumer perspective when people who need care the most are protected the least by insurance coverage.

The impact: People are not just whining about necessary cost sharing. In a survey we did with the New York Times, we found that:

  • 70% of people with problems paying medical bills report cutting back on food, clothing and other basic necessities.
  • 59% report using up most of their savings.
  • 41% say they've taken an extra job to help pay for their health care.

Not surprisingly, the uninsured (41%) are more likely to have problems paying medical bills. But this is not a problem limited to the uninsured: 30% of the insured – think voters — have problems with medical bills.

The back story: The share of the public reporting problems paying their medical bills has not moved much in recent years. The Affordable Care Act has extended coverage and better financial protection to tens of millions, but it doesn't have much of an impact on affordability beyond people covered by the Medicaid expansion and the marketplaces.

In the far larger employer-based health insurance sector, deductibles and other forms of cost sharing have been growing about five times faster than wages, and deductibles have been growing especially sharply for people who work for smaller employers. .

What to watch: Health care is a pocketbook issue for most of the public and the American people have their own scoring system. They may give this or that mostly partisan response about a health reform idea on a poll, but until they see how they'll get help paying their health care bills, they will ultimately be disappointed by every health reform plan.

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How single payer helps Republicans change the subject

Since the collapse of the GOP effort to repeal and replace the Affordable Care Act, single payer has gained new life on the left. Sen. Bernie Sanders released his “Medicare for all" plan yesterday, and a majority of House Democrats have signed on to another version proposed by Rep. John Conyers.

Data: Kaiser Family Foundation Polls; Note: 2008-09 is an average of 7 polls; Chart: Andrew Witherspoon / Axios

The big picture: Politically, single payer — the idea of having the government pay for health care rather than private insurers — can help rally the left much like the prospect of repealing the ACA rallied the right. But it could also help Republicans, who own the problems in health care now, switch the target to the Democrats and their sweeping new health reform plan.

The pros for Democrats:

  • As the chart shows, single payer is popular among Democrats, with about two thirds in favor. But it has also gained popularity among independents in recent years, with over half supporting it. Republicans, not surprisingly, aren't so crazy about it.
  • Single payer is a big idea many Democrats can rally around. It excites the base and party activists by establishing health care as a right, achieving universal coverage, and eliminating insurance companies. This analysis is about politics, but most advocates of single payer advance the idea because they believe in it, not as a political calculation.

The cons for Democrats:

  • They could lose a one-time opportunity to tar Republicans with the damage their ACA replacement plan would have done to millions of people, according to the multiple analyses that showed lost coverage and higher premiums for vulnerable people.
  • By campaigning on their own sweeping health reform plan, Democrats could give Republicans a fighting chance to change the subject.
  • More targeted policy ideas, such as Medicaid buy-in options for the ACA marketplaces and a Medicare buy-in for 50-64 year olds, could also be popular on the left and the center, while offering far smaller targets than a sweeping single-payer plan would.

Reality check: Single payer is popular, but polling today doesn't tell us much about where the public will be if there is a national debate about actual single-payer legislation in the Congress. ACA repeal had the support of about half the public in Kaiser Family Foundation polling in late 2016 and early 2017, but fell to closer to 30 percent once there was an replacement plan under the microscope.

Support for single-payer falls by 10 to 20 percentage points when people are read common criticisms, such as that it will increase taxes or give the government too much control over health care. Arguments in favor, including that single payer will make health a basic right or reduce administrative costs, increase support by similar amounts.

We cannot simulate what will happen in a real debate, which depends on the actual details of the legislation and the power of the arguments made.

Be smart: This is more than just a health policy debate. It is also a proxy debate about the future of the Democratic Party. The party can swing left trying to build energy in the base, or it can move to the center, trying to capture the votes of many of the more conservative working people who voted for President Trump.

Don't forget: Most Americans are far less focused on sweeping health policy ideas than they are on lowering their out-of-pocket costs. Health reformers – left, right, or center – who make the connection between their policy ideas and these pocketbook concerns may capture the most voters.

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How to keep ACA stabilization narrow

When Congress returns next week, the health debate will shift from trying to pass sweeping legislation to stabilizing the non-group insurance market. This will be a different debate about a thorny but smaller problem. The weaknesses that need to be fixed are fairly specific, and they don't affect the majority of Americans.

Data: Kaiser Family Foundation; Chart: Andrew Witherspoon / Axios

The bottom line: If Congress can keep the focus on market stabilization and doesn't get mired in another divisive debate about health reform, and the news media can keep this relatively manageable problem in perspective for the public, there is at least a decent chance for bipartisan cooperation and a successful outcome.

The problem: Premiums in the Affordable Care Act marketplaces have been rising sharply, with the average increase for the benchmark "silver plan" up 21% this year. Proposed rates for next year will range from a 49% increase in Wilmington, Delaware to a 5% decrease in Providence, Rhode Island.

But the non-group market is actually fairly small, covering about 18 million people, with about 10 million of them in the ACA marketplaces which have received so much attention.

The perception: A Kaiser Family Foundation poll this month found that when people read headlines or hear about "premiums soaring" in the ACA marketplaces, most Americans — 76% — they think they are hearing about their own premiums, even though the vast majority of Americans are not in the individual insurance market and are not affected. (A smaller but sizeable percentage believe they are affected when they hear about counties with no or limited insurance options in the ACA marketplaces.)

There are several reasons for this, and the media bears some of the responsibility. Health journalists have generally done an outstanding job covering the issue, but sloppy cable headlines, commentary from pundits, and spin from politicians have too often implied that everyone in America is affected when they are not.

For context: In fact, the rest of the health system where most Americans get their coverage looks very different from the non-group market. As the chart shows:

  • Average premiums in the employer insurance market, where 151 million Americans get their health coverage, rose by an average of just 3% last year. And we're expecting continued moderation this year.
  • Likewise, per capita spending for Medicaid is projected to grow a modest 3% in 2017, with per capita Medicare spending growing by just 2 percent.

The back story: Insurers and regulators have been struggling with a unique set of issues in the non-group market, most especially a sicker than expected risk pool and the uncertainty surrounding Trump administration policies. The most important areas of uncertainty have been whether the administration will continue to pay out the $7 billion in cost sharing subsidies and enforce the individual mandate.

But even before the ACA, the non-group market was also the weak link of the insurance system, with sick people priced out or excluded from coverage altogether.

What to watch: Some think a deal on stabilizing the non-group market could be as narrow as an agreement to appropriate the $7 billion in federal cost sharing subsidies in exchange for greater flexibility for states under the ACA. That might not be a slam dunk if that flexibility trips over third rail issues, such as endangering coverage for people with pre-existing conditions.

But whether the formula for a bipartisan deal is that one or another one, policymakers will have a better chance of addressing the problems in the marketplaces if they forge a narrow agreement. And the debate stands a better chance of not spinning out of control if the news media works overtime to help the public understand who is affected and who is not.

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The ACA stability "crisis" in perspective

The big questions about the stability of the Affordable Care Act marketplaces have focused on how fast premiums will rise, and how many plans will participate. But an equally important question, and the heart of the matter politically, is: How many people will be affected by the sharp premium increases?


Data: Kaiser Family Foundation analysis of data from Mark Farrah Associates, Healthcare.gov, and KFF Survey of Nongroup Health Insurance Enrollees; Chart: Andrew Witherspoon / Axios

The bottom line: The answer is about 6.7 million Americans who buy coverage in the non-group market in and out of the exchanges, and do not receive premium subsidies. That is a significant number of people, and an urgent policy problem requiring congressional attention and action by the administration, but it's not a system-wide health insurance crisis. The non-group market has always been the most troubled part of the insurance system, and it was far worse before the ACA.

The breakdown:

  • 17.5 million in the non-group insurance market, including:
  • 10.3 million enrolled in the ACA exchanges
  • Approximately 7.2 million buying insurance off the exchanges
    • Most of this group buys ACA-compliant plans
    • About 1.2 million in "grandfathered" plans purchased before the ACA's market reforms took effect

Yes, 17.5 million is a sizeable number, and what happens to their health insurance coverage and costs is important. But, to put it in perspective:

  • 156 million get their primary coverage through an employer, where premiums rose a modest 3% last year for family coverage
  • More than 74 million are covered by Medicaid and CHIP.

According to our new analysis of proposed 2018 premium changes in the exchanges, double-digit increases for benchmark silver plans are quite common, though the range across major cities is large, from a 5% decrease in Providence, R.I. to a 49% increase in Wilmington, Del.

A big reason for these increases is the uncertainty in the market surrounding Trump administration policies, especially whether they will let the $7 billion in cost-sharing reduction (CSR) subsidies flow and whether the individual mandate will be enforced.

Who's getting hit: 84% of the enrollees in the marketplaces – about 8.7 million people – receive premium subsidies under the ACA and are insulated from these premium hikes.

However, roughly 6.7 million people — the ones who buy ACA-compliant plans inside or outside the marketplace and aren't subsidized — will feel the full brunt of premium increases. They'll be hit if the uncertainty is not resolved and the rates do not come down before they are finalized.

In many cases, there is as much as a 20 percentage point swing or more in rates depending on whether the CSRs are paid.

The big picture: Dealing with this uncertainty is an urgent situation, particularly since it may result in some counties having no insurers at all, as well as coverage that is unaffordable for millions of Americans. But it is far from a crisis affecting most Americans and their health insurance.

The media needs to take great care to put this problem in perspective — otherwise they could unduly alarm the public and drive people to support the wrong policy solutions. Already, most Americans wrongly believe that premium increases in the relatively small non-group market affect them. So the headline should be: "Premiums Spike for SOME Americans."

The danger in Congress is that discussion will spread too far beyond the immediate need to stabilize the non-group market, opening up all the old wounds surrounding the ACA and producing stalemate.

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GOP may not be punished if it can't pass repeal

The GOP base will punish Republicans in upcoming elections if they fail to deliver on their promise to repeal the Affordable Care Act, or at least make an all -out effort to do so. That's the conventional wisdom, right? It was the political motivation behind Republican efforts to pass a widely unpopular repeal-and-replace plan, and then to consider a risky repeal-and-delay plan in the Senate.

Except for one problem: When you look at the polling, the idea that the base will rise up and punish Republicans if they don't repeal the ACA appears to be exaggerated, and possibly even a political fiction.

Data: Kaiser Family Foundation Health Tracking Poll (Nov. 15-21, 2016); Chart: Andrew Witherspoon / Axios

Consider:

  • As the chart shows, health care was not the top concern for Trump voters and Republican voters in the 2016 presidential election. It ranked far behind their general concerns about the direction the country is headed in, jobs and the economy, and their feelings about Hillary Clinton. Just 7% of Trump voters and a paltry 5% of Republican voters picked health care as the biggest factor in their vote.
  • Focus groups with Trump voters reinforce this picture; they are focused much more on making ends meet and, when health comes up, getting help with paying their premiums and deductibles. They hoped candidate Trump would find a way to help them pay their health care bills. Just like Democratic voters, and all voters, they care more about their health care costs than the partisan Washington debate about the ACA.
  • Republicans also don't show high levels of intensity on the issue. For example, in July, just 25% of Republicans said they had a "very favorable" view of the Republican ACA replacement plans, while 52% of Democrats said that about the ACA.
  • About half (52%) of Republicans have supported the idea of repealing the ACA now and replacing it later, but that is hardly an overwhelming mandate. (Just 26% of the public overall supported the idea.) Still, most Republicans do want to keep trying. In July, 80% said they don't want to give up on efforts to repeal and replace the ACA.
  • The most conservative Republicans who advocate repeal come from safe districts. They have little to worry about, whether the ACA is repealed or not.

Republicans don't like the ACA, and there is no doubt voting for repeal would be a real plus with the Republican base as well as with big campaign contributors. But the assumption that Republicans will be punished if they fail to repeal the law is a different thing altogether; it has become unexamined conventional wisdom. Republican voters have other things on their minds that matter to them more than health care.

The next election is not until 2018, and the agenda could switch to taxes or a foreign conflict or the Trump administration's continuing problems. In fact, the one thing most likely to keep the ACA on the agenda now would be an effort by the administration to undermine it, and it's far from clear who benefits and loses politically from that.