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, as analogous to, 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
"... 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
"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
(Hill Res.)
"Changing the rules for Michigan Medicaid to allow more people to qualify for coverage under Medicaid " 49
Michigan (EPIC-MRA) April
Respondents "heard a brief description of eligibility requirements and the number of working adults who would qualify for the coverage." 60
Oklahoma April
"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
"... 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
" you favor or oppose expanding Medicaid to provide health insurance to more low-income uninsured adults?" 63.1
Tennessee May
"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 
Wisconsin May
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
"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

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."