Axios Vitals

Democrats' health care message is resonating with critically important blocs of midterm voters, according to the latest Axios/SurveyMonkey polling.

The big picture: Democrats are moving left on health care. Embracing the Affordable Care Act is now a given, and candidates are increasingly embracing a bigger role for the federal government.

• The voters they'll need most this fall — including white suburban women and millennials — are largely on board.

By the numbers: We asked five groups of voters whether Congress should expand the ACA, leave it alone, shrink it, or repeal it altogether.

• "Change it so it does more" was the most popular option among African-American women (at 50%); millennials (41%); white suburban women (47%) and #NeverHillary independents (47%).
• President Trump got low marks from the same populations: Majorities of each said they disapproved of how he has approached health care.
• Rural voters were the exception on both counts. They were split on Trump, and a plurality supported repealing the ACA.

Why it matters: This is why Democrats want to be talking about health care this fall — and it's also why the progressive wing of the party feels so comfortable staking out a more liberal position on health care, whether that's the revival of a public insurance option or some form of "Medicare for All."

Go deeper: Medicare for All is a winner in Democratic primaries.

It's not just that voters seem to agree with Democrats on health care when they're asked — it's also been surging as a priority in recent polling. And that means it probably will be a decisive issue in the midterms, the Kaiser Family Foundation’s Drew Altman writes this morning.

• The key numbers from recent Kaiser polling: 33% of Democrats pick health care as the top factor that will decide their vote, while 30% said Trump is the main issue.
• In fact, health care actually ranks higher now for Democrats than it did for Republicans in the anti-ACA elections of 2010 and 2014, when it ranked third on their list of issue priorities.

The bottom line: The ACA helped Republicans win those midterm elections — and now the repeal effort has given the Democrats a weapon to use to motivate their base and reach out to independents.

Go deeper: Read the column in the Axios stream.

Two things are true about the prospect of switching to a single-payer health care system:

• It could easily be less expensive than the system we have now.
• It would require substantial tax increases.

Driving the news: The libertarian Mercatus Center made waves yesterday with a report that said Sen. Bernie Sanders' version of "Medicare for All" would require about $32.6 trillion in new federal spending over its first 10 years.

• Other estimates of Sanders' proposal have landed on roughly the same price tag.

Yes, but: It's still less expensive than what we're projected to spend now. If Mercatus' estimates are correct, Sanders' plan would cost about $2 trillion less, over 10 years, than the status quo.

The difference is where the money comes from. We spend a ton of money right now on health care — about $3.3 trillion in 2016, which comes out to more than $10,000 per person. That’s far more than any other industrialized nation.

• Those expenses are spread across taxes (to fund Medicare and Medicaid), premiums (from both individuals and employers), and out-of-pocket spending.

Between the lines: Countries with established single-payer systems spend a lot less than the U.S. on health care now, but Sanders' proposal is more generous than some of those systems. That puts it on the most expensive end of the spectrum.

• Mercatus assumes that Sanders' new federally run program would only pay doctors and hospitals Medicare rates (as his plan calls for). If a future Congress compromised with those powerful lobbies, as Congress often has in the past, the savings would diminish.

People who don’t receive the ACA’s premium subsidies are fleeing the individual insurance market, leaving it smaller and more concentrated, according to the latest data from the Kaiser Family Foundation.

By the numbers: Total enrollment in the individual market fell by about 12%, or 2 million people, from the first quarter of 2017 to the first quarter of 2018.

• All of that decline came from people who are either outside the ACA’s exchanges or who used the exchanges but aren’t eligible for subsidies.
• Subsidized enrollment grew by about 500,000 people.

This shouldn’t be a big surprise. As premiums have risen — in large part because of the actions of the Trump administration and congressional Republicans — the burden has mostly fallen on unsubsidized people who have to pay the whole cost on their own.

The big picture, from Kaiser: “The availability of premium subsidies … is likely sufficient to keep the individual insurance market financially sustainable ... However, based on the current trajectory, the market is likely to be increasingly dominated by lower-income people and those with pre-existing conditions.”

Ascension and Centene are creating a new Medicare Advantage plan together in 2020. But, as my colleague Bob Herman notes, there are no details about how it would function or how it would affect prospective enrollees.

Why it matters: Hospital systems (like Ascension) and insurance companies (like Centene) increasingly are partnering on Medicare Advantage, the private sector’s take on Medicare coverage, which is growing in popularity. But the companies' economic interests may not align with patients’ coverage options.

The big questions: The companies would not say whether Ascension hospitals and doctors would be the only in-network providers, or how much it would cost members if they go to providers outside of the plan’s networks.

• They also would not disclose ownership stakes in the new plan. “We aren’t conducting interviews or commenting beyond the news release,” an Ascension spokesperson said.

Between the lines: This is an exercise of hospitals collecting new sources of revenue, while health insurers offload some of the risk associated with operating insurance plans.