Sunday, December 15, 2013

December Trends in Obamacare Opinions (2013)

After some brutal polling numbers in November for the Affordable Care Act in connection with the glitch-filled website for signing up and the controversy over President Obama's "If you like your plan..." promise, the December numbers have rebounded a bit, but are still not great. In the remainder of this post, I draw from Polling Report's summary of Health Policy polling and other sources to highlight some key findings from the latest batch of polls.

The November polls with the harshest judgments against the ACA almost certainly were those conducted by CBS News and Quinnipiac University. Below, I've plotted the approval and disapproval numbers for the ACA from the last several polls conducted by CBS News (either with or without its frequent polling partner, the New York Times), the time frame of which encompasses both the original October 1 launch of online sign-ups and the December 1 relaunch. Whereas the absolute levels of approval and disapproval might be somewhat misleading because opposition includes some people on the left who don't think the ACA has enough government involvement, the trends over time seem pretty clear.




In the first three CBS/NYT polls shown (mid-September, early-October, and mid-October), disapproval exceeded approval by roughly 10 percentage points, give or take. In the mid-November poll (Nov. 15-18), the margin had ballooned to 30 points. However, as of the December 5-8 survey, the difference between approval and disapproval is now back to around 10 points.

The November 6-11 Quinnipiac Poll asked respondents if they "believe[d] the problems with the website will be fixed by November 30, or don't you think so?" Whereas 29% of respondents said yes, they thought the website would be fixed, a whopping 61% did not think it would be fixed. The Quinnipiac respondents' pessimism regarding the website did not appear to be well founded, as the functionality of the website does appear to be improving, based upon both news reports and polling results.

Regarding the latter, the early-December CBS/NYT Poll found nearly three times as many people (36%) saying they thought the sign-up process for the Obamacare exchanges was "getting better," than saying it was "getting worse" (13%). Forty-four percent claimed it was "about the same" as before. It is not clear to me if the part of the survey about the website was administered to all respondents or only those who had tried to sign up for insurance via the ACA exchanges. Most Americans already have health insurance and would not need to use the exchanges.

There have been suggestions by some in the media that Obamacare implementation has turned the corner and taken full repeal by the Congress -- whatever its chances were in the past -- off the table now. In looking at the aforementioned Polling Report compilation on health-policy polls, the only November 2013 poll I could find with a question on repeal was that by CBS News (Nov. 15-18). In this survey, 43% endorsed the view that, "The law has so much wrong with it that it needs to be repealed entirely." That is a very high pro-repeal figure compared to the 2012 presidential exit polls and other previous polls (except for Rasmussen polls, which I think have a strange wording). It must be remembered, though, that the mid-November CBS poll was taken amidst the furor over the malfunctioning website and people losing their existing individual-market coverage.

Based on the small number of December 2013 polls I could find that included a repeal item, support for such a move is back in line with what one would have found prior to the October-November 2013 controversies. Gallup (Dec. 3-4) found 32% of respondents endorsing "repeal the health care law entirely." The NBC/Wall Street Journal Survey (Dec. 4-8) found the following percentage breakdown (original wordings of choices shown):

Is working well the way it is ............................. 4 
Needs minor modifications to improve it ......... 36 
Needs a major overhaul ................................... 31 
Should be totally eliminated ............................. 26

Focusing on the combined percentages who favored minor or major modifications to the ACA, Chris Matthews, host of the nightly MSNBC cable show "Hardball," said the following on his December 12 broadcast:

...after all this negative P.R., all the foul-ups, the screwups, the rollout, the whole thing, and still two-thirds put their heart and their mind on the need to have adequate affordable health care for their families. They don`t like the screwups, but they want the program to work and be fixed. That`s a powerful inducement for Democrats not to turn tail.

Another positive sign for the ACA comes from a recent poll (Dec. 3-8) by the Democratic Party-affiliated group Democracy Corps. The poll was conducted not of the nation as a whole, but of likely voters residing in U.S. House districts deemed "most competitive" for next year's midterm elections (50 Republican-held and 36 Democratic-held). Democracy Corps gave respondents the choice between "implement and fix" vs. "repeal and replace" the ACA. In the 86 districts combined, implement and fix prevailed 49-44 (note that the overall sample is likely GOP-leaning, given that more of the seats are held by Republicans).

Finally, as discussed on HuffPost/Pollster, two somewhat conflicting pictures emerged regarding young adults' views of the ACA. The Harvard Institute of Politics poll of 18-29 year-olds, conducted from October 30-November 11, found generally negative views toward the health care law, including sub-40% approval ratings. In stark contrast, a CNN poll conducted November 18-20 pegs 18-34 year-olds' support for the law at 48% and that doesn't include another 12% who say they oppose the law because it is not liberal enough. In other words, 60% of 18-34 year-olds either like Obamacare or wish more liberal provisions had been enacted, according to the CNN poll.

Included in what Harvard IOP describes as its "5 Key Findings" of this year's poll, "Among the 18-29-year olds currently without health insurance, less than 1/3 say they're likely to enroll in the exchange (13% say they will definitely enroll, 16% say they will probably enroll); 41% say they are 50-50 at the moment." As has been widely discussed in health-policy circles, it is important for large numbers of young, healthy people (sometimes known as the "invincibles") to sign up for health insurance, to balance the costs of treating people with pre-existing conditions who now have greater access to insurance under Obamacare.

In fact, Washington Post policy analyst Ezra Klein argues that the actuarial soundness of the ACA enrollee pool (in terms of age and healthiness distributions) is more important than the total number of people who sign up. Thus, if the Harvard IOP numbers on young people's intent to sign up turn out to be accurate, the ACA could face difficulties.

Monday, November 11, 2013

Resurgent Republic Looks at Self-Insured Voters

The conservative-leaning group Resurgent Republic examines the demographic and attitudinal characteristics of self-insured voters, that is, those who purchased their own (pre-Obamacare) coverage on the individual market, rather than getting it from an employer. Though these individuals appear to have attributes favorable to the Republicans -- well-off economically, more likely to live in suburbs than cities -- they did not support the GOP in 2012 as strongly as they might have. The piece concludes that, "If Republicans can effectively speak to the anxiety caused by Obamacare, they’ll find an attentive audience, especially in battleground 2014 states."

I have a few quibbles and comments on the Resurgent Republic analysis. First, the article notes that, "Three-fourths (77 percent) of those self-insured are either very or somewhat satisfied with their plan." The "anxiety" alluded to above thus would stem from such highly satisfied customers having their policies cancelled. I would have liked to see the breakdown into the separate choices of "very" and "somewhat" satisfied. Second, by some estimates, roughly half of people who had their individual policies cancelled will pay less for replacement policies, which provide greater benefits. Assuming the glitches with the purchasing websites are rectified sometime soon, individual-market voters may not react as negatively to having to change insurance policies as the article suggests. Finally, Resurgent Republic cites "sticker shock" estimates from the Manhattan Institute. The Washington Post's Ezra Klein argues here that the Manhattan Institute figures are flawed.

Tuesday, October 22, 2013

Washington Post-ABC Poll Latest to Show Increasing Popularity of Obamacare

Continuing a trend that I began discussing here, the latest Washington Post-ABC News poll shows an uptick in support for the Affordable Care Act (aka Obamacare). Three times in 2013 has the Post-ABC asked the question, "Overall, do you support or oppose the federal law making changes to the health care system?" Here are the results...

Post-ABC
July
SeptOct
Support
42
4246
Oppose
49
5249
Difference
-7
-10-3

According to this Post article accompanying the poll, "Support has rebounded since July among moderate and conservative Democrats, while Republican opposition has also softened."

The improvement may only seem like a few percentage points. However, the fact that two other recent polls -- NBC/Wall Street Journal and Democracy Corps -- have also shown an uptick in support for the ACA suggests the change is likely authentic (for now, at least).

The rise in support seems surprising in the context of difficulties with the federal website for people to sign up. However, some of the state websites (where such are available) seem to be working well.

The larger driver of public opinion toward Obamacare may be the unpopularity of the Republicans' actions during the recent federal-government shutdown. Paradoxically, in seeking to register their staunch opposition to the ACA, the GOP may actually have made it more popular! It is perhaps for this reason that former Florida Gov. Jeb Bush, a Republican, was calling on his party to exercise more "self-restraint."

Monday, October 21, 2013

Demographic Differences in Pew Poll

The Pew Research Center is out with a new poll (in the field October 9-13), gauging public reactions to the second week of the roll-out of the online Obamacare marketplaces. The overall sample views the roll-out unfavorably. To the question "How well are online health insurance exchanges working?," 46% answered not too well or not at all well, whereas only 29% said very or fairly well (the rest said "don't know"). Young adults (18-29), who are getting a lot of media attention on the health-care issue, are split at 37-37 between the relatively favorable and unfavorable responses.

Uninsured people with incomes too high to qualify for Medicaid need to consult the exchanges in order to fulfill the individual mandate to have health insurance. Some people with insurance may be interested in whether the exchanges offer a better deal that what they currently pay. The survey found that nearly two-thirds of the uninsured either have visited (22%) or plan to visit (42%) the exchanges; however, with the subsample of uninsured people numbering only 181, the margin of error is around +/- 7, a wider-than-usual interval. Among those with insurance, around one-third either have visited (12%) or plan to visit (19%). An interesting, even paradoxical finding is that:

Among those who have visited an exchange website, more say the exchanges overall are not working well by a 56%-37% margin. Yet when asked about their own experience on an exchange website, a 56% majority say they personally found the site to be very or fairly easy to use, while 40% say it was difficult to use.

Wednesday, October 16, 2013

Democracy Corps Poll Shows Good News for ACA Supporters

Democracy Corps, a polling/advising group headed by Democratic Party stalwarts Stan Greenberg and James Carville, has released a new health care survey in conjunction with the organization Women's Voices, Women's Vote (hat tip to Political Wire). Although clearly party-aligned, Democracy Corps has a good record for accuracy, nailing President Obama's four percentage-point victory margin last year over Mitt Romney. The newly released health care poll was in the field October 6-8, coinciding with the early stages of both the roll-out of the Obamacare online exchanges and the government shutdown. To see the full set of poll results, go here first. You'll then be able to click on links for results in the form of memos, the questionnaire, and graphs.

The report is entitled "38 Percent," referring to the estimated proportion of American voters who "clearly oppose the Affordable Care Act." Democracy Corps presents results for both its total sample (which appears to be comprised of registered voters) and a likely-voter sample. The results are very similar for the two samples, so I'll just cite figures for the total sample.

On the initial item assessing attitudes toward "the health care reform law that passed in 2010," support and opposition each drew 45% of respondents. However, subtracting respondents who answered on a subsequent question that they opposed the ACA because it "doesn't go far enough," one ends up with the aforementioned figure of 38% assumed to dislike Obamacare for conservative reasons.

Several other findings are worth noting:
  • Despite the tendency of some to jump to quick conclusions, the American public seems in large part to hold a wait-and-see attitude toward the ACA. Among four possible answer choices on current perceptions of the law, 46% of respondents said it was "too early to tell" how things would turn out, 20% saw it as making things "harder for me," 17% said they could not yet see any ways in which the law was helping, and 14% were "beginning to see benefits."

  • Positive shifts in attitude toward the ACA were seen in several subgroups from 2010 to the latest poll. For example, White voters without a college education, who have been generally hostile to Obama, have gone from hating the law in 2010 (opponents outnumbering supporters by 31 percentage points) to merely being in sizable opposition (opponents being more numerous by 18 percentage points). White older women have gone from -23 to only -4. And groups that were moderately supportive have become wildly supportive, such as unmarried women, who shifted from +9 to +29.

  • Good will toward the ACA appears premised to a large extent on the idea that the law can and will be refined and improved over time. That is how I read the results of a mini-experiment embedded within the Democracy Corps survey, at least. Some respondents were asked to choose between "We should implement and fix the health care reform law" and "We should repeal and replace the health care reform law." The clear winner was the "implement and fix" alternative, 58-38 percent. However, when the choice (given to a different set of respondents) was between "We should implement the health care reform law" (without reference to fixing the law) and "We should repeal the health care reform law," repeal was preferred 51-46.

This new Democracy Corps/Women's Voices, Women's Vote poll follows two other recent ones seemingly showing an upturn for the ACA: a late September survey by The Morning Consult/Survey Sampling International; and an NBC/Wall Street Journal poll showing that the amount by which the ACA was "underwater" (percentage saying it was a "bad idea" exceeding the percentage saying it was a "good idea") had shrunk from 13 percentage points in September to only 5 percentage points in October.

Whether people really are becoming more favorable toward the ACA/Obamacare is questionable, especially with the prolonged difficulties people are having using the websites to sign up. Another possibility is that the disrepute into which the Republicans have fallen over the government shutdown has transferred over into disdain for positions held by the GOP (such as opposition to Obamacare).

Friday, October 11, 2013

First Polling Results on Roll-Out of Exchanges

Based on news reports since the October 1 opening of the online health-insurance exchanges, two dominant -- and likely inter-related -- themes have been the high volume of response and the technical glitches plaguing the federal exchange site, healthcare.gov. Where governors opted to have their respective states create their own exchanges rather than having their citizens use the federal site as a fallback, there seems to be variation in how smoothly the websites are working (compare, for example, New York to Maryland).

Here at the Health Care Polls blog, we're interested in public opinion toward, and reaction to, the Affordable Care Act and its component parts, such as the exchanges (also known as marketplaces). And we now have what is, to my knowledge, the first major survey on the topic, from AP-GfK. The poll was conducted from October 3-7, thus gauging immediate reaction to the unveiling of the exchanges. A Huffington Post article on the poll is available here, whereas the AP-GfK technical report is here.

AP-GfK surveyed 1,227 adults, for which the margin of error (MoE) is said to be 3.4 percentage points for the 95% confidence level. According to the Huffington Post article:

Overall, the poll found, 40 percent of Americans said the launch of the insurance markets hasn't gone well, 20 percent said it's gone somewhat well and 30 percent didn't know what to say. Just 7 percent said the launch had gone "very well" or "[extremely] well."

(The article had a typo about the final 7 percent, which I corrected based on the technical report.)

Seventy-six individuals from the original 1,227 respondents, or 7%, reported that they or someone in their household had "tried to sign up for health insurance coverage through this market." With the stated 3.4% MoE around the 7% estimate, we could say (assuming accurate responses) that between 3.6 and 10.4 percent of the U.S. public as a whole had tried the exchanges.

However, the MoE varies slightly depending on whether the sample is relatively evenly divided on an issue (e.g., 50/50, 55/45) or relatively unanimous (e.g., 90/10), with the margin being smaller (more precise) the closer to unanimity. My impression is that pollsters usually report the MoE assuming a 50/50 breakdown on the survey items, so if AP-GfK did so, then the MoE around the 7% who claimed to have used the exchanges would be tighter than 3.6 to 10.4 percent.*

Those 76 exchange users were asked a variety of questions. Quoting from the above-linked Huffington Post article, "Among those who've actually tested out the system, three-quarters of those polled said they've experienced problems trying to sign up. Only about 1 in 10 succeeded in buying health insurance." As the same article notes, however, the MoE for responses of just these 76 people is a whopping +/- 13.5%. Now that AP-GfK has provided an initial estimate of the proportion of Americans using the exchanges, they and other pollsters might consider obtaining oversamples of exchange users in future surveys, so that estimates from this group can have greater precision.

One area in which the AP-GfK poll appears to be somewhat out-of-whack is the 37% job-approval rating for President Obama, compared to other polls from around the same time that peg the President's approval between 40-51%. Assuming that attitudes toward the Affordable Care Act and the exchanges are correlated with support for Obama, then evaluations of the ACA and exchanges may be biased somewhat in a negative direction by the AP-GfK poll.

---
*The margin of error with 95% confidence is calculated from:

+/- 1.96 X square root (pq/n)

where p = the percentage of respondents who answered in one way (e.g., "yes" on a yes/no question), q = the percentage who answered with the other choice, and n = sample size. (Readers with some statistical training may recognize +/- 1.96 as the values that cut off the upper and lower 2.5% of the "bell curve" distribution, thus leaving 95% of the distribution.)

Using the AP-GfK's reported sample size of 1,227, a 50/50 division on a question (i.e., p and q each equal .50), would yield a margin of error of:

1.96 X square root (.25/1,227) = .028 or 2.8%

(I do not know why there is the slight discrepancy between AP-GfK's reported MoE of 3.4% and my calculation of 2.8%; if AP-GfK has a cluster-sampling component to its work, that would raise the MoE.)

Anyway, using the conventional MoE formula with a breakdown of .07 and .93 for usage vs. non-usage of the health-insurance exchanges, the calculation is...

1.96 X square root (.065/1,227) = .014 or 1.4%

An online margin-of-error calculator, which corrects for population size, is available here. You might enter 200,000,000 for the population size, which is roughly how many adults there are in the U.S. With any large population, the middle term in the larger equation tends toward 1, so has no effect when used to multiply the other elements of the equation.

Wednesday, October 2, 2013

Monday, September 30, 2013

New Poll from "The Morning Consult"

Via Political Wire, I learned of a new poll on attitudes toward the Affordable Care Act. The poll was released by a publication call The Morning Consult, with surveying done from September 25-28 by Survey Sampling International. I was not previously familiar with either of these entities. As best I can tell, the Consult is a business-oriented, center-right outlet. Its founder, Michael Ramlet, is described on this webpage as having done some work for Republican organizations and being affiliated with the bipartisan Purple Strategies group.

Regarding TMC/SSI's methodology, the poll's report claims that, "The interviews were conducted online... The data were post-stratified to match a target sample of registered voters based on age, race, gender, education and region." Post-stratification is a form of adjusting the amount of weight given to different demographic groups, to make the sample as a whole conform to known population parameters (e.g., from the U.S. Census).

According to the TMC/SSI report, 48% of respondents approve of "the health care legislation passed by Barack Obama and Congress in 2010" (21% strongly, 27% somewhat). The overall approval reported by TMC/SSI is thus about 10 percentage points higher than obtained by other recent polls. TMC/SSI provide extensive subgroup statistics, so we can look "under the hood" a bit at their recent poll. Partisan composition of the TMC/SSI poll certainly raises some questions:

519 Republican-leaning respondents (26.3% of sample, of whom 15% support ACA)
836 Democratic-leaning respondents (42.3% of sample, of whom 75% support it)
620 Independent respondents (31.4%, of sample, of whom 38% support it)

The TMC/SSI party-ID numbers are clearly out of whack with those of other survey firms. If one looks at HuffPost/Pollster's party ID averages (using the selection tool to limit the results to registered-voter samples, which is what TMC/SSI used), the percent of Americans identifying as Democrats is 37.9% and the percent identifying as Republicans is 33.7%, dramatically closer to each other than in TMC/SSI's partisan breakdown.

Relative party-ID proportions are not the only reason TMC/SSI reports higher approval for the ACA than do other polls. Even looking at self-identified party subgroups one at a time, TMC/SSI shows greater support for Obamacare in some instances than do other pollsters. Take, for example, a recent CNN/Opinion Research Corporation poll, which found 38% approval overall for the law. Approval from self-identified Democrats was virtually identical in the TMC/SSI (75%) and CNN/ORC (74%) polls. However, self-identified Republicans reported greater support to TMC/SSI (15%) than to CNN/ORC (7%). The same pattern occurred among self-described Independents: 38% approval in the TMC/SSI poll vs. 27% in the CNN/ORC survey.

Having said all of this, what first caught my eye about the TMC/SSI poll was response to the item, "What would you like to see Congress do when it comes to the health care law?" Response options were: "expand the law," "let the law take effect," "make changes to improve the law," "delay and defund the law," and "repeal the law." Among the full sample, a collective 67% endorsed the first three alternatives, all of which seem, at the least, accepting of the ACA (even the third category, though not representing a ringing endorsement, conveys a "mend it but don't end it" outlook). The two most anti-Obamacare categories -- delay/defund and outright repeal -- together comprised only 33% of the sample.

One way to put the apparent Democratic slant of the sample aside and escape the partisan lens is to focus directly on Independents. Among Independents, the combined percentage advocating delay/defund and repeal is only 37%. In contrast, 63% favored one of the supportive/accepting alternatives.

It would be interesting to see more pollsters offer the "make changes to improve the law" response option to their participants.

Saturday, September 28, 2013

Kaiser Foundation Survey Project Focuses on California

The Kaiser Family Foundation has released the first of four planned surveys over the next two years of California residents currently without health insurance. The just-released survey provides baseline data on respondents' knowledge and attitudes regarding insurance coverage, in anticipation of the October 1 start of the sign-up period for the health-insurance exchanges (or marketplaces) under the Affordable Care Act (aka Obamacare). Kaiser will attempt to re-survey members of the initial sample of 2,000 respondents three more times over the course of the project; conducting multiple interviews with the same people over time is known as a panel study. As the exchanges go into effect and data from the later phases of the survey are gathered and released, we will learn the rate at which California's eligible uninsured sign up for Obamacare and the characteristics of those who do and do not.

Wednesday, September 25, 2013

Recent Distillations of Health Care/Obamacare Polling

Via Huffpollster, here are some recent commentaries on what the polls are showing about the Affordable Care Act (aka Obamacare) and government's role in helping people obtain health insurance:
  • Liberal columnist Jonathan Alter argues that, when opposition from the left to the ACA (i.e., for falling short of single-payer) is taken into account, well below a majority of Americans accept conservative arguments against Obamacare. The phenomenon of opposition from the left was discussed previously on this blog here.
  • Republican pollster Bill McInturff summarizes what he sees as some key themes, such as considerable opposition to the ACA from subgroups of the population (e.g., those dissatisfied with their current health care) who might be expected to be supportive, and the persistently low levels of understanding of the law reported by the public.
  • Public support for a government role in helping provide health insurance for people who cannot afford it is not as high as it once was, but is still pretty high.

Friday, September 20, 2013

Washington Post/ABC News Poll Examines Government-Shutdown Aspect of Obamacare Implementation

A few days ago, I wrote about a Pew Research Center/USA Today poll that attempted to gauge the intensity with which opponents of the Affordable Care Act ("Obamacare") truly detest the new law. Respondents were first asked if they supported or opposed the ACA, and then opponents were asked the follow-up question of whether they thought political leaders who opposed the law should try to make it work as effectively or possible or make the law fail. Only about a quarter of the sample opposed the law and said they wanted political leaders to try to make the law fail.

A new Washington Post/ABC News poll likewise tries to assess intensity of opposition to the ACA, but this time in a different way. With the possibility looming of a federal government shutdown due to disagreement between the Republican-majority House and the Democratic-majority Senate on how to fund government operations beyond October 1, the Post/ABC poll asked ACA opponents the following question:

Would you support or oppose Congress shutting down major activities of the federal government in order to try to prevent implementation of the health care law?

Presumably, if someone advocates closing down "major" federal government activities -- would which could include no new patients being admitted to some National Institutes of Health medical studies, some veterans' services being unavailable, and delays on processing passport applications -- as a way of blocking Obamacare, he or she must really dislike the law. So how many people want to use a government shutdown to delay, disrupt, or diminish the October 1 opening of the ACA exchanges (marketplaces) for people to sign up? Again, it's about one quarter of them. Overall, respondents to the Post/ABC poll break down as follows:
  • Forty-two percent of respondents support the ACA.
  • Twenty-seven percent oppose the law and want a federal government shutdown to enforce that opposition (i.e., the shutdown is supported by 52% of the 52% who opposed the law).
  • Twenty percent oppose the law, but don't want a shutdown.
  • Five percent oppose the law and are undecided on a shutdown.
  • Six percent had no opinion about the law in the first place.

Another salient theme of the Post/ABC survey is the pervasiveness of respondents' self-claimed lack of knowledge about what is in the law. When asked, "Do you feel that you personally do or do not have the information you need to understand what changes will occur as the new health care law takes effect?," only 35% said yes and 62% said no, with the rest undecided. One might expect a positive correlation between education and feeling informed, but such was not the case. The percentages of those feeling informed were virtually identical among participants with a high school or less education (34%), some college (35%), a completed college degree (38%), and postgraduate education (37%).

Another poll, by Rasmussen, finds stronger support than does the Post/ABC survey for shutting down the government in connection with the ACA: "51% of voters favor having a partial government shutdown until Democrats and Republicans agree on what spending for the health care law to cut." Note that Rasmussen's question-wording arguably softens the impact of the scenario, relative to the Post/ABC wording, in two ways: Rasmussen describes the shutdown as "partial" rather than "major," and asks about cutting spending on the health care law rather than preventing its implementation.

Monday, September 16, 2013

Pew Research Center/USA Today Poll Examines Range of Health Care Issues

With the sign-up period for uninsured people (who aren't otherwise eligible for Medicaid) to join health care marketplaces called "exchanges" beginning in about two weeks, the Pew Research Center and USA Today have released a jointly conducted poll on a wide range of health care issues.

Some Republican elected officials have been doing whatever they can in recent months to try to derail, delay, defund, or destroy the Affordable Care Act before one of its major provisions, the system of exchanges, goes into effect on October 1. Some have said they will not help their constituents sign up for the Obamacare exchanges, whereas others have tried to dissuade professional sports leagues from working with the Obama Administration on ACA-related outreach.

After asking survey respondents whether they supported or opposed the ACA, Pew-USA Today pollsters asked opponents of the law a follow-up question: Did they want Congressional detractors of the law to "Do what they can to make the law work as well as possible" or "Do what they can to make the law fail"? As a result of these questions, the American public (generalizing from the nationally representative survey sample) falls into the following camps (the percentages sum to 101% due to rounding):
  • Forty-two percent support Obamacare.
  • Twenty-seven percent oppose Obamacare, but want their leaders to try to make it work.
  • Twenty-three percent oppose the law, and want their leaders to try to make if fail.
  • Four percent oppose the law, but don't know what course of action they want their leaders to take.
  • Five percent were undecided on whether they supported or opposed Obamacare in the first place.

Though only about one-quarter of Americans, overall, endorse the "make it fail" position, 64% of those who identify as "Tea Party Republicans" do. Whereas GOP officeholders working feverishly to put the kibosh on Obamacare appear to be hugely out-of-step with the U.S. public, one must remember that in their home states and districts, they could well be very much in tune with local sentiments (and maybe even fearing a primary challenge from the right).

From the perspective of Democratic officeholders and advocates of expanded health-insurance coverage, the key issue is potential enrollees' awareness of the exchanges and inclination to sign-up. Pew-USA Today also queried respondents on this topic. Here are some key findings (quoting from the above-linked report):

Awareness of the availability of health insurance exchanges is much lower in those states that have decided against state involvement in the exchanges. While about six-in-ten (59%) of those who live in states with state-based health care exchanges (or state-federal partnerships) say that exchanges will be available in their state, just 44% of those in states that have decided not to create their own exchanges say this (the federal government will run these state-level exchanges)...

Most people who do not have health insurance (63%) say they plan to get health insurance within the next six months... Nearly a third (32%) of those who currently lack health insurance have no plans to get coverage in the next six months.

Friday, August 23, 2013

Young Adults' Awareness of Insurance Exchanges

Health insurance exchanges, one of the two major mechanisms (along with expanded Medicaid coverage) for uninsured individuals to purchase insurance under Obamacare, are scheduled to become available on October 1. Ezra Klein has described the health care exchanges, which will be offered via the website healthcare.gov, as analogous to Amazon.com, but for purchasing health insurance rather than books. This article provides background information on how the exchanges are designed to work and the kinds of glitches that may arise.

Key to the success of Obamacare is getting people -- particularly in targeted demographics -- to sign up for health insurance using the exchanges. According to Talking Points Memo, the program “needs to get young and healthy people enrolled in coverage to make the law work financially. The Affordable Care Act prevents insurers from discriminating against sick and older people who want to get insured, a population that is likely to cost insurers more, so companies need young and healthy people to pay into the system to offset that new spending.”

It is in this context that the results of a new national survey  of 19-29 year-olds by the Commonwealth Fund are a potential danger sign for Obamacare. As shown in the following screenshot from the Commonwealth Fund's "chartpack," awareness of the exchanges in young adults is low (you can click on the graphic to enlarge it).



Overall, only 27% of young adults are aware of the exchanges. Arguably, however, the more relevant figure is the percent of uninsured young adults who know of the exchanges, as those already with insurance would not be looking for it. When the results are broken down by whether respondents were insured or uninsured, only 19% of the latter know about the exchanges (note from the graphic that the researchers used a definition of the "uninsured" that includes people who had insurance at the time of the survey, but were uninsured in the past year).

Some states will begin marketing the exchanges to their citizens (see here and here). Nationally, drugstore chains CVS and Walgreen's will be publicizing Obamacare. The president has also tried to publicize the exchanges through professional sports teams, with limited success thus far. Sports telecasts and in-person events are thought to be a good venue for reaching the young-adult demographic. Anecdotally, an information table at the Kentucky State Fair with free tote bags seems to have generated interest in KYnect, the state's exchange.

As efforts to promote the exchanges intensify in the coming months, it will be interesting to see if awareness of the program and favorability toward it increase as well, not only among young adults, but all segments of the population.

Tuesday, August 13, 2013

State Polls on Medicaid Expansion

One of the ways in which the Affordable Care Act (aka Obamacare) seeks to reduce the number of Americans without health insurance is by offering federal funds to states, so that states can expand their eligibility criteria for Medicaid and enroll more of their residents in the program.

Starting next January, individuals with income up to 133 percent* of the poverty level will be eligible for Medicaid. The pre-ACA thresholds for Medicaid differ by state and by participant category (e.g., pregnant women, children, parents), but are sometimes as low as 50% of the poverty line. Under current poverty definitions, a single person would be considered to be impoverished if he/she made $11,490 or less in a year, a two-person family/household would be considered in poverty at $15,510, and so forth, with the threshold rising roughly $4,000 for each additional person in the home.

Thus, prior to the ACA, some categories of individuals would be eligible for Medicaid only if their household earned less than half of these amounts of money (depending on family size). Starting in January, however, Medicaid eligibility will be extended to a broader group of individuals, all the way up to people whose earnings somewhat exceed the aforementioned poverty criteria (i.e., 133% of the poverty criteria or, for example, individuals in a two-person household that earns up to a combined $20,628; calculated as 15,510 times 1.33).

(There is, of course, variation in states' Medicaid eligibility criteria, allowing for alternative approaches. Wisconsin, for example, has among the nation's most generous thresholds; whereas states tend to give the highest priority to covering pregnant women, the disabled, and children, the Badger State even "provid[es] coverage to childless adults up to 200 percent of the federal poverty line." Thus, Wisconsin may be able to cover a comparable number of lower-income people by not accepting the federal Medicaid-expansion funds, as by accepting them.)

The costs of the expanded Medicaid participation will be covered almost entirely by the federal government for the first several years after the ACA goes into effect. According to this government document: "States will receive 100 percent federal funding for the first three years to support this expanded coverage, phasing down to no less than 90 percent federal funding in subsequent years."

As those of you who closely follow ACA-related developments have no doubt picked up on, the situation is not quite as simple as implied above. Though the ACA largely survived a U.S. Supreme Court challenge in the case of NFIB v. Sebelius, the decision did make it easier for states, acting through their governors and legislatures, to decline participation in the Medicaid expansion. As of July 26, 2013, a total of 28 states -- mostly, but not entirely, of the "blue," Democratic-leaning variety -- are said to be "moving toward expansion," as depicted in this map, whereas the rest are not.

This blog is, of course, concerned with polling and public opinion pertaining to the health care reform process and the resulting ACA. It struck me as an interesting question, therefore, what public opinion was in the various states. A Google search of keywords such as state polls medicaid expansion brought up several results. I have compiled results of such polls since roughly the beginning of the year in the following table, organized chronologically. You can click on the names of the states to be taken to the report of that state's results.

State Poll Date
Question Wording Support/
Favorable (%)
Kansas Dec '12 "... The federal health reform law allows states to expand Medicaid to cover individuals who have an income level up to $15,420 annually or 138% of the federal poverty level. It is estimated this expansion would provide coverage to an additional 122,000 Kansans. Do you support the expansion of Medicaid coverage in Kansas as I have just described?" 59.7
Iowa Jan
'13
"... Under the new federal health care law, [number of] people in [state] who are uninsured right now could get health care coverage through Medicaid starting in 2014. The governor and state elected officials can choose to accept federal dollars that have been allocated to cover these people in [state], or to turn the money down and not cover these people. The federal dollars cover 100% of the costs in the first few years, and 90% of the costs after that... What would you like your state to do? [accept/turn down] " 57
Florida " " 63
Kentucky " " 63
Michigan " " 63
New Jersey " " 70
New Mexico " " 65
Texas " " 58
Florida (FL Hosp Assoc) Jan '13 "In order to cover more uninsured adults, the federal government would cover all of the increased cost to expand health care coverage through Medicaid for the first three years. The federal government would then cover 90 percent of the increased costs permanently with the state of Florida paying ten percent. Knowing this, would you say the state should or should not accept the federal money to expand health care coverage through the Medicaid program to cover more uninsured adults?" (wording) 62
Florida (PPP) Feb '13 "You may have heard some things in the news recently about extending Medicaid. By investing $1.7 billion of state funds to extend health care coverage to at least one million, low-income Floridians who are children or working adults, Florida will receive nearly $28 billion from the federal government, while creating 56,000 new jobs in Florida. Do you support or oppose this approach to extending health insurance coverage?" 62
Florida (James Madison Inst.) Feb
'13
"At 21 billion dollars, spending on Medicaid currently represents about 30 percent of Florida's budget. If Florida should implement the Medicaid expansion, Medicaid would become an even higher percentage of overall state spending. Does this fact make you more likely or less likely to support expanding the Medicaid eligibility requirements in Florida?" 30
Texas Feb '13 “As part of the federal health care reforms, each state must decide if it is to participate in or reject Medicaid expansion. Based on what you know about it, should the state of Texas participate in or reject Medicaid expansion?” According to the linked article, this wording "was alternated with a question of the same phrasing, except that the choice was presented as 'reject or participate in,' which drew slightly stronger support for rejection." 54
Iowa Feb '13 "The new federal health care law allows states to expand their Medicaid programs, which in Iowa would provide health care coverage to tens of thousands more poor adults. Governor Branstad wants to opt out of this program, saying even though the federal government will pay at least 90% of the new cost, it is still expensive for the federal government and ultimately for Iowans. Do you agree with Governor Branstad's position or do you think Iowa should opt in to the expanded Medicaid program?" 47
Arkansas Feb '13 "In the current legislative session, the General Assembly is considering an expansion of Medicaid to cover medical expenses for individuals living just above the poverty level. The expansion would be fully funded for several years by the federal government with the state incurring up to 10% of the cost later. Arkansas has the choice whether or not to expand its Medicaid program to include an additional 250,000 Arkansas residents. Should Arkansas expand or not expand Medicaid?" 53.5
Michigan
(Hill Res.)
April
'13
"Changing the rules for Michigan Medicaid to allow more people to qualify for coverage under Medicaid " 49
Michigan (EPIC-MRA) April
'13
Respondents "heard a brief description of eligibility requirements and the number of working adults who would qualify for the coverage." 60
Oklahoma April
'13
"As you may know, the new health care law expands Medicaid to provide health care coverage to more low-income, uninsured adults. As part of the new law, the federal government has set aside enough money for the state so these people can get coverage through Medicaid. The federal government will pay 100 percent of these costs in the first few years, and 90 percent of the costs after that. Should the state turn the money down or accept the money?" 51
Alabama May
'13
"... the law will expand the existing Medicaid program to cover more low income uninsured adults" 64.2
Georgia " " 61.0
Louisiana " " 62.6
Mississippi " " 58.6
S. Carolina " " 65.2
Ohio May
'13
"...do you favor or oppose expanding Medicaid to provide health insurance to more low-income uninsured adults?" 63.1
Tennessee May
'13
"Recently, Tennessee declined to expand Medicaid to provide health insurance to more low-income uninsured adults, including adults with no children whose incomes are below about $16,000 per year. Do you support or oppose Tennessee's decision not to expand Medicaid?" An alternative, split-sample question wording added detail about the federal funding of the expansion and about how the lack of Medicaid coverage would force some people to go to emergency rooms for their health care. 62%
oppose not entering, on brief item; 58% on elaborate 
item
Wisconsin May
'13
Item not confined to Medicaid, but rather Gov. Walker's larger plan to decline Medicaid expansion, tighten some existing eligibility thresholds, and put childless adults into new health-insurance exchanges. 44 (oppose Walker plan)
Pennsylvania July
'13
"Do you agree or disagree that the state of Pennsylvania should expand Medicaid coverage for low-income individuals, as called for under... [SPLIT WORDING EXPERIMENT: the new health care law known as the Affordable Care Act/ President Obama's new health care law]?" ~57
~52





On the whole, there is remarkable consistency among the results, with majority support (often reaching roughly 60%) for Medicaid expansion emerging in nearly all of the surveyed states. Politically, these states tend to be conservative, Republican-dominated ones, although some (Florida, Michigan, Ohio, Pennsylvania, Wisconsin) have a "divided personality," going Democratic in recent presidential elections but currently having their state governments dominated by the Republicans. Add in the fact that these polls were conducted by different polling outfits, using different question-wordings, and the consistency of results really seems amazing. Some of the question-wordings do seem over-the-top in touting the expected benefits or costs of the program, but many of the wordings seem pretty neutral.  

There were two multi-state survey projects (shown with light-orange backgrounds in the above table). One was from the American Cancer Society in January. According to the project report, these states represented "a geographic mix of states that have been wrestling with the decision to accept federal funds to cover more people through their Medicaid programs. "

Second, amongst the May polls, is a set of results from five southern states that were surveyed simultaneously by the Joint Center for Political and Economic Studies. In these states, support for Medicaid expansion ranged from roughly 58-65 percent. Quoting from the project's report:

...85 percent of African Americans and 53 percent of non-Hispanic whites who live in those five states were in favor of expansion. Among those who identified themselves as liberal, 78 percent favored expansion, versus 47 percent for those who considered themselves conservative.

When respondents were given a bit more detail about the Medicaid expansion—for example, that states eventually will have to cover 10 percent of the costs—support dropped to 54 percent.

Among the polls conducted in a single state, the Pennsylvania results warrant clarification on a number of levels. First, the results appeared to be presented only by subgroups (e.g., men and women; geographic regions of the state; party ID) in the news release. On the assumption that men and women would be at least approximately equally represented, I simply averaged the male and female results to estimate what the results would be for the full sample (the "~" signifies the approximate nature of the figures). Second, the figures I placed in the table are the combined percentages for "strongly agree" and "somewhat agree." Third, the pollsters conducted an experiment within the survey, using two different question-wordings on respective halves of the sample (one that referred to the law as the "Affordable Care Act" and another that specifically mentioned President Obama). I have used color codings in red and blue to signify the results of the two wordings.

One finding among demographic subgroups in Pennsylvania is surprising in one way, but not surprising in another. The oldest respondents (66 and older) are the most supportive of Medicaid expansion (roughly 65 and 62 percent, under the two wordings). One the one hand, this age group is generally the most hostile to Obama nationally. On the other hand, however, one can see where older adults' health concerns might lead this group to react favorably to potential expansions of government health care. Another interesting finding is that explicit mention of Obama causes the youngest subgroup (18-35) to increase its support of Medicaid expansion (from 44% under the ACA terminology to 59% when the law is attributed to Obama).

In Ohio, on the other hand, the youngest age group (18-29) evidenced the highest support (75.5%) for expanding Medicaid. The older subgroups (30-45, 46-64, and 65+) all were around 60% support. The Ohio poll also reported findings by income level. Not surprisingly, those currently receiving or who could receive Medicaid under the proposed expansion were highly favorable to the idea of the expansion (83.7% of those below 100% of the poverty line favored it, as did 72.3% of those between 100-138 percent of poverty). However, even respondents above 138% of poverty registered strong support (60.1%).

Iowa (in the February survey) evidences a fairly substantial gender gap. Whereas Medicaid expansion garners the support of 52% of women in the Hawkeye State, it receives the support of only 42% of their male counterparts.

All of the polls in the above table sampled Democrats, Republicans, and Independents, in whatever proportions these groups existed in the various states. An Arizona poll I found, however, looked only at respondents described as GOP primary voters. An article describes the results as follows: "In a live-caller poll of 500 likely GOP primary voters conducted in late May by Public Opinion Strategies... 53 percent of respondents said they supported Gov. Jan Brewer’s plan to expand Medicaid coverage in Arizona. Only 40 percent of respondents said they opposed the plan." This result suggests perhaps that endorsement of Medicaid expansion by a Republican governor can bring along rank-and-file members of the party.

The reported percentage supporting Medicaid expansion among Arizona Republicans  is much higher than that for GOP subsamples in Ohio (36.6%) Pennsylvania (34%), and especially Iowa (16% in the February poll). All three of these states have Republican governors, but they differed somewhat in their approach to expansion: Ohio's John Kasich has been relatively out-front in supporting expansion, Pennsylvania's Tom Corbett has refused it, and Iowa's Terry Branstad, after opposing expansion, signed on to a compromise measure.

Harry Enten, in a March 1, 2013 article, pinpointed the dilemma facing some Republican governors. Medicaid expansion is popular among the general citizenry of many states, but typically not among the GOP "base," the members of which could support a primary challenge to the incumbent (particularly in "deep red" states). Clearly, GOP governors are taking a variety of approaches to Medicaid expansion, the consequences of which we'll see in November 2014.

---

*Some sources report this figure as 138% of the federal poverty level (FPL). According to the Kaiser Foundation, "The threshold is 133% FPL, but 5% of an individual’s income is disregarded, effectively raising the limit to 138% FPL."

Monday, June 24, 2013

Kaiser Poll Results for Young Adults, the Uninsured, and Households with a Pre-Existing Condition

Via Huffington Post/Pollster.com, the Kaiser Family Foundation's monthly health care poll finds support for the Affordable Care Act (ACA) among young adults. This quote from the Kaiser report captures the essence of the findings:

Even among younger adults – a group that many have speculated may be resistant to getting coverage under the ACA – more than seven in ten rate having health insurance as “very important,” and similar shares feel it is something they need and that it is worth the money. Overall, just a quarter of those ages 18-30 feel they are healthy enough to go without insurance.

The young were not the only ones surveyed in this poll, however. Uninsured individuals, and individuals who personally had a pre-existing condition or a household member with one, ranging from 18-64 years old, were also interviewed (at 65, Medicare becomes available). Perhaps unsurprisingly, those currently uninsured have favorable views about health insurance. Households having a member with a pre-existing condition apparently are widespread: "The June survey finds that roughly half (49 percent) of adults under age 65 say they or someone in their household has a pre-existing condition..."

Kaiser also reported on its usual monthly measures among a full, nationally representative sample. On general feelings toward health care reform, more Americans report unfavorable (43%) than favorable (35%) views, as has usually been the case. Interestingly, even though the ACA has been law for more than three years -- and received heightened public attention during 2012 due to the Supreme Court challenge of the law and the presidential election -- the percent saying "don't know" (or refusing to answer) on the favorability/unfavorability item has been higher during 2013 than at any time during 2010-2012.

The survey also included an experimental component, comparing responses to the policy when interviewers referred to it either as the "Health Reform Law" or "Obamacare."

Finally, a combined 22% of Americans claim to have heard "some" or "a lot" about the upcoming health care exchanges in their states. 

Thursday, May 16, 2013

Mellman on State of Obamacare Public Opinion

Via HuffPost/Pollster, Democratic pollster Mark Mellman offers his overview of where public opinion currently stands on the Affordable Care Act (aka Obamacare). Mellman cites figures of roughly 30% (Fox News poll) and 33% (CBS/New York Times poll) of Americans favoring full repeal of the ACA. These percentages, though far from a majority, are higher than the 25% of U.S. voters who favored repealing "all of it" in the 2012 exit polls.