What Percentage of Americans Purchase Health Insurance Only Because of Individual Mandate?

With U.S. Senate Republicans leaning toward including a repeal of the Affordable Care Act's individual mandate in their upcoming tax bill, the question once again emerges of how much the mandate affects people's decisions whether or not to obtain health insurance. Should the mandate to have health insurance be repealed, some people who currently have insurance likely would drop it. Decisions of some individuals (presumably in good health) to drop coverage could well have implications beyond those individuals themselves. The fewer the healthy people in the insurance pool, after all, the less money available for insurers to pay the relatively expensive claims of less-healthy people.

But how many people actually would drop coverage if the mandate were to be repealed? According to a 2013 essay from conservative-libertarian group Freedom Works, "Forcing many of our citizens to buy expensive, unneeded and unwanted coverage, which, in turn, impairs every person's freedom to choose how they spend and use their money – [is] a total violation of our civil rights." One can only imagine health-insurance subscribers heading to the exits in droves to discontinue their coverage!

Well, as I learned this morning from a New York Times article on the ACA mandate-repeal aspect of the GOP tax plan, an October poll from the Kaiser Family Foundation examined this issue and the answer is... 7 percent. Quoting from the Times, "the nonpartisan Kaiser Family Foundation found that just 7 percent of people who buy insurance on the individual market said they would go without coverage if the mandate were no longer enforced." The direct link to the Kaiser report is here; Figure 10 is where to look.

All the usual cautions about interpreting polls apply here. One in particular is that, whereas the full poll sample of roughly 2,500 has a narrow margin of error of +/- 2%, the subgroups of respondents for whom the question about dropping coverage is most relevant (i.e., those who bought their coverage via the ACA marketplaces or through all types of non-group-employer plans) have margins of error of +/- 9 and +/- 7, respectively (Kaiser methodology report).

The proportion of Americans who buy their health insurance on the ACA exchanges and who would drop this coverage if the individual mandate were lifted may thus actually be higher than 7%. It will still be a small minority of ACA customers.

Ezra Klein's "Why Obamacare Survived" Cites Public-Opinion Surveys

With Republican efforts to repeal and replace the Affordable Care Act stymied once again (for the short term, at least), Ezra Klein analyzes "Why Obamacare Survived" at Vox. The article cites and links to public-opinion surveys on consumers' satisfaction with the different types of health-care coverage they receive, and also provides several statistics on the costs of the ACA. All in all, Klein's article is a handy one to have, for analyzing health-insurance policy.

Blendon and Benson Article in New England Journal of Medicine

Robert Blendon and John Benson have a new piece in the New England Journal of Medicine, entitled "Public Opinion About the Future of the Affordable Care Act." Focusing on the aftermath of late July's failure of the U.S. Senate to pass an ACA "repeal and replace" bill, Blendon and Benson set out the following agenda in their article:

Our analysis of 27 national opinion polls by 12 survey organizations provides background on four critical issues relevant to the previous House and recent Senate health care decisions: the public favorability of the current law, the public values underlying the debate about the future, support for various health policy changes in the proposed Republican legislation, and support for the overall Republican proposals debated in the House and Senate.

Vox's Sarah Kliff writes about the Harvard study, focusing on the substantial rise in the percentage of Americans who believe the federal government has a duty to ensure that everyone has basic health insurance.

Another noteworthy finding I noticed is that the individual mandate, long the most unpopular feature of Obamacare, no longer appears to be so toxic. B&B note that: "...48% favored removing this requirement, whereas 50% were opposed" (from a March 2017 CNN/ORC poll).

A large amount of attention during this year's House and Senate debates focused on how the various Republican bills would treat people with pre-existing conditions. The House-passed bill featured the McArthur-Meadows amendment, which would allow states to opt out of some of the Obamacare coverage standards (including those protecting people with pre-existing conditions), as long as those states operated high-risk pools for this purpose. The Senate process included a proposed amendment by Ted Cruz, which would have allowed insurance companies to offer relatively cheap plans that did not comply with Obamacare standards, as long as they also offered plans that did.

Many have contended that high-risk pools typically are not funded well enough to help everyone with expensive illnesses and chronic conditions to treat, and that the Cruz plan would likely make things difficult for those with pre-existing conditions  because the ACA-compliant plans would become very expensive. Two pertinent findings from the Harvard authors were that:

• "Approximately one third of the public (35%) believed that insurers should be allowed to offer health plans that cover fewer benefits than currently required"
• " less than one fourth of the public believed that insurers should be allowed to charge more for people with preexisting conditions (24%)."

Kliff writes that "Blendon attributes the change in attitudes to Americans thinking through the consequences of repealing the Affordable Care Act, resulting in millions losing coverage." That seems as good as explanation as any.

"The Most Unpopular Bill in Three Decades"

This is from about two weeks ago. Axios reported an analysis showing how public support for the Republicans' health care legislation compared to support for other controversial bills (including, but not limited, to health care) over the past 30 years (via Vox).

Medicaid Patients' Quality Ratings of Their Care

Medicaid patients appear to rate the health care they receive very favorably, according to this Huffington Post report. The article also contains statistics on doctors' willingness to take Medicaid patients.

Looking at Americans' Pro/Con Views of ACA to Anticipate How People Will Feel About Republicans' (Potential) Replacement

Over at FiveThirtyEight, Dan Hopkins attempts to connect reasons cited by respondents in the past for supporting or opposing the Affordable Care Act (aka Obamacare) to Americans' future attitudes toward a Republican replacement bill (should one pass). For example, the most commonly cited reason for supporting the ACA, endorsed by roughly 17% of respondents, was "increased access." Hopkins then invokes "initial analyses suggest[ing] that the proposed changes probably won’t cut out-of-pocket spending" and concludes, "if the reform reduces access to health insurance, it’s hard to envision the bill becoming more popular than the law it seeks to replace."

Single-Payer Proposal in California

The Los Angeles Times reports polling results from the Public Policy Institute of California, under the headline "Single-payer healthcare is popular with Californians — unless it raises their taxes."

Polls on American Health Care Act (AHCA) After House Passage

HuffPollster reports on four polls that have gauged public opinion toward the American Health Care Act (ACHA), Speaker Paul Ryan's (R-WI) repeal-and-replacement bill for the Affordable Care Act (ACA; also known as Obamacare), since the bill passed the U.S. House on May 4. Note that some of the survey questions generating the following results alluded to the ACHA having passed, whereas others described the legislation as a proposal. Support for the AHCA comes in at:

• 31% in a May 6 HuffPost/YouGov poll; this poll also found that, "Americans are more likely to be intensely opposed than even modestly supportive. Just 8 percent say they favor the bill strongly, with 34 percent strongly opposed."
• 31% in a May 6-9 Economist/YouGov poll (strongly 11%, somewhat 20%). 
• 38% in a May 4-6 Morning Consult/Politico poll (strongly 13%, somewhat 25%). This poll also found that, "...55 percent of voters said they support bas[ing tax] credits on people’s income and location — which is how Obamacare’s subsidies are calculated. In contrast, 18 percent of voters supported basing credits on age, as proposed in the GOP alternative." (The apparent rationale for age-based credits is that tax-based subsidies can be used to attract younger people to purchase health insurance.)
• 21% in a May 4-9 Quinnipiac poll (strongly 9%, somewhat 12%). The Q-Poll also found that, "Voters say 75-21 percent, including 59-34 percent among Republicans, that it's a 'bad idea' to give states the ability to allow health insurance companies to raise rates on people with pre-existing conditions."

Overall, then, neither the AHCA as a whole, nor some of its specific policy changes to Obamacare, seem particularly popular at this time. The bill is now in the Senate's hands and, while most observers expect the Senate to make modifications, the extent of these is anybody's guess.

UPDATE (5/14/17): Via Political Wire, there's a new NBC/Wall Street Journal poll in which "just 23% call the legislation a good idea, including 18% who 'strongly' say that."

Obamacare's Popularity Keeps Rising

Sarah Kliff at Vox writes on how "Obamacare is Getting More Popular By the Day."

Republican Support Grows for Specific Obamacare Provisions (Economist/YouGov)

Kathy Frankovic reviews new poll findings showing that self-identified Republicans now express greater support for many Obamacare provisions than they did in 2010, the year of the bill's passage (via HuffPollster).

Five-Thirty-Eight Presents Three Excellent Articles on ACA/AHCA Public Opinion

Five-Thirty-Eight, which covers politics, sports, and culture through a statistical/analytic lens, has published three articles in recent days on public opinion toward the American Health Care Act (AHCA)*, Republican House Speaker Paul Ryan's alternative to former President Obama's Affordable Care Act (ACA).

• Harry Enten writes about how, "The AHCA is much more disliked than the ACA and [Bill and Hillary] Clinton’s health care reform bill [in 1993-94] were when they were first introduced" and "may haunt the GOP" in future elections.
• Perry Bacon, Jr., argues that the fervor over Obamacare and its possible repeal/replacement by the Republicans is "disproportionate" to the substantive effects of such a policy change, as "less than a tenth of all Americans" receive health care coverage through the ACA. Rather, as Bacon contends, "the Obamacare debate is really about much more than health care. In many ways, the two parties... are also debating fundamental questions about the role of government, work, income redistribution, race, class and Barack Obama."
• Nate Silver estimates support for the AHCA in each of the nation's 435 congressional districts and concludes that "there are about 80 districts... where supporters of the bill are in the plurality [i.e., supporters outnumber opponents, but supporters don't necessarily reach 51%]. But I estimate that there are only three of them — Alabama’s 4th, Kentucky’s 5th and Texas’s 13th — where supporters of the bill constitute an outright majority."

In addition, Slate discusses a Quinnipiac poll showing only a microscopic 13% of women support the AHCA (with men not much higher at 22%).

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*I've started pronouncing the AHCA acronym as "Ock-ah." You may wish to follow suit.

GOP/Ryan Insurance Bill Faring Poorly in the Polls

The Huffington Post summarizes recent public-opinion polling on Republican health-insurance legislation introduced by Speaker Paul Ryan, as part of the GOP's effort to "repeal and replace" the Affordable Care Act (aka Obamacare). This article focuses entirely on public attitudes toward the Ryan plan, whereas a separate article discusses the Speaker's legislation among other topics. In a nutshell, the GOP/Ryan plan is not very popular.

Readers of this blog may recall the extensive discussion of opposition from the left to Obamacare, as some liberals seemed to be holding out for a Canadian-style single-payer plan or other system that did not rely so heavily on private insurance companies. In converse fashion, Fox News looked at opposition to the GOP/Ryan plan from the right on the grounds that it doesn't go far enough in undoing Obamacare. In particular, some of the most conservative members of the U.S. House have taken issue with the GOP/Ryan plan's retention of what are known as refundable tax credits.

How much is opposition from the right driving the overall opposition to the GOP/Ryan plan? Somewhat, but not as the predominant factor. According to the second of the two HuffPost articles linked above:

A Fox News poll published Wednesday night finds that just 34 percent of registered voters support the GOP’s health care plan, with 54 percent in opposition ― 36 percent oppose because it makes too many changes to the Affordable Care Act, also known as Obamacare, and 11 percent because it makes too few.

History of Polling on Government Health Insurance

The Roper Center's Kathleen Weldon briefly reviews the history of public opinion polling on government health-insurance programs, with a focus on the passage of Medicare.

Confusion over "Obamacare" Nickname for Affordable Care Act

According to this report:

Roughly one-third of Americans don't know that Obamacare and the Affordable Care Act are the same thing, according to a recent poll. 

The poll, conducted by Morning Consult and published by the New York Times, found that 35% of Americans either believe that Obamacare and the ACA are different policies (17%) or didn't know if they were (18%).

This is not the first time Morning Consult has delved into the matter of "what's in a name?" In 2014, it polled on attitudes toward Medicaid expansion, with and without mentioning that is was part of the Affordable Care Act.

I suppose one can conclude that attitudes on an issue are fairly robust when support for a position doesn't vary much, depending on whether or not labels for the policy are varied. Conversely, if support does vary considerably as a function of labels, then people are likely responding more to the entity mentioned in the label (e.g., the president who supported the legislation) than to the specific policy itself.

Health-Insurance Issues Reviewed in HuffPollster Round-Up

Today's Huffington Post polling round-up reports on continuing support for the ACA, worry over many Americans' possibly losing coverage, and low support for repealing the law without a replacement ready.

Obamacare's Favorability Rises as its Champion Leaves Office and Nation Transitions to Trump

With the Republicans now holding the presidency, House, and Senate, the Affordable Care Act (ACA; aka Obamacare) will almost certainly be repealed. With the nature of a GOP-led replacement plan (if the party can ever coalesce around one) unclear, the percentage of uninsured Americans will likely rise, perhaps dramatically. Yet, even as opponents of former President Barack Obama's signature domestic achievement continue blasting the law, headlines such as the following have been popping up lately.

"CNN/ORC Poll Shows Last-Minute Love for Obamacare"

"As GOP Pushes Repeal, Obamacare Has Never Been More Popular" (NBC/Wall Street Journal)

For most of the ACA's history, it has been "underwater" in the public-opinion realm. Higher percentages of Americans have opposed the law than supported it, the only question being whether by a relatively large or relatively small margin.* Now, however, as shown in the following graphic, four mid-January polls by major news organizations have each shown the ACA to be viewed (slightly) more favorably than not.

The polls' sponsors (with article links), dates in the field, question-wordings, and results are as follows:

• CNN/ORC (Jan. 12-15) "generally favor" (49%) vs. "generally oppose" (47%).
• NBC/WSJ (Jan. 12-15) "good idea" (45%) vs. "bad idea" (41%).
• CBS News (Jan. 13-16) approve (48%, "strongly" plus "somewhat") vs. disapprove (47%, "strongly" plus "somewhat").
• FOX News (Jan. 15-18) "generally favorable (50%) or unfavorable (46%)" (also asks whether respondents "strongly" or "somewhat" hold their views).

Even when the ACA, overall, was unpopular, the percentage of Americans wanting to repeal it in full and not replace it (i.e., going back to pre-2010 health care in the U.S.) was small. Now, it is really small. According to the article accompanying the FOX News poll, "The number of voters who want Obamacare completely repealed is at a new low..." (23%). And, as the now-retired Harry Reid (D-NV) pointed out in his farewell speech on the Senate floor, "support for repeal without a replacement is in the basement."

Why the late rise in the ACA's popularity?

One possibility is that, as the departing Obama himself has risen in his job-approval ratings, his popularity could be rubbing off on policies associated with him.

A second possibility involves deeper views about the role of government. In recent years, the Pew Research Center has asked, "Is it the responsibility of the federal government to make sure that all Americans have health care coverage?" (Gallup has also asked this question in the past.) When Pew queried respondents earlier this month, 60% said yes. According to Pew, "The share saying it is the government’s responsibility has increased from 51% last year and now stands at its highest point in nearly a decade."

Whether belief in government as guarantor of a health safety net is driving attitudes toward the ACA, or attitudes toward the government's role and toward the ACA are both manifestations of some deeper dynamic, is unknown. For example, national Republicans' strong desire (now with a clear opportunity) to repeal the ACA, along with the widely publicized claim that repeal (without a replacement) could throw nearly 20 million Americans off health insurance, could be leading the public to take another look at Obamacare. Regardless of the exact causal mechanisms, public acceptance of a government role in health insurance, in general, and of the ACA, in particular, appear to be on the upswing.

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*Complicating the issue a bit is the phenomenon of opposition from the left, which this blog has addressed many times. The general idea is that liberals, who might be expected to favor government efforts to expand health-insurance coverage and regulation of insurers (which the ACA included), nevertheless would tell pollsters they opposed the ACA, because it did not implement a Canadian-style single-payer plan (or other systems popular on the left).