Newly Released Kaiser and CBS/NY Times Polls

Two polls -- Kaiser Foundation and CBS/New York Times -- dealing (in whole or in part) with health-insurance issues were released in recent days. Two points grabbed my attention.

First, the two polls showed virtually identical numbers on Americans' preferences for retaining, retooling, or repealing the Affordable Care Act. In the Kaiser poll, 8% want Congress to "Keep the law as it is," whereas another 48% want it to "Keep the law in place and work to improve it." Combined, these two categories suggest that 56% of Americans want the essential features of the ACA retained. Twelve percent want the law repealed and replaced "with a Republican-sponsored alternative" and another 19% want Congress to "repeal the law and not replace it." 

The CBS/NYT poll asked respondents: "Which comes closest to your view about the 2010 health care law? The law is working well and should be kept in place as is. There are some good things in the law, but some changes are needed to make it work better. OR, The law has so much wrong with it that it needs to be repealed entirely." Again, a combined 56% of respondents fell into one of the two categories favorable to retention of the ACA, although the component percentages were slightly different (6% keep as is, 50% make changes to improve). Forty-two percent called for repeal.

***

Second, although the retention numbers seem pretty good for Obamacare, basic "favorable/unfavorable" numbers do not. They were 35% and 47%, respectively, in the February Kaiser poll. Opposition seems to have really exploded among the uninsured, who might be expected to embrace the law. As shown in this Kaiser trend diagram, favorable responses to the ACA tended to exceed or match unfavorable ones among the uninsured for nearly four years of monthly polling. In the most recent Kaiser poll, however, unfavorable dominates favorable 56% to 22%.

As acknowledged by Kaiser (and highlighted by HuffPost/Pollster), it may not be opinions shifting so much as the composition of the uninsured. Those who were uninsured before the October 1, 2013 launching of the online exchanges presumably fell into at least two groups: those who were embracing the opportunity to sign-up for free or reduced-cost health insurance (and ultimately did so); and those who, for ideological (or other) reasons, were opposed to participating in Obamacare (and who decided not to).

As roughly 10 million Americans have now signed up for coverage, philosophical opponents of the ACA will comprise an ever-growing share of the uninsured. (As I discussed in another context, the uninsured include some well-off people who choose to pay directly for their medical treatment.) Kaiser summarizes the situation thusly: "As more Americans gain coverage under the law, we can expect the group who remain uninsured to change over time, and some changes in opinion may be attributable to changes in who remains uninsured, rather than a shift in opinion among individuals."

Also, because the uninsured comprise a relatively small share of the U.S. population (around 16%, according to Gallup research), their numbers among Kaiser's overall 1501-person sample would likely be small, thus increasing the margin of error for the uninsured-specific findings. In fact, Kaiser provides a nice methodology report, which states that 137 uninsured individuals were present in the "unweighted" sample (i.e., before statistical adjustments for any under- or over-representation of demographic subgroups to match their percentages of the nation's population). Associated with this subsample size, the margin of error for analyses focusing on the uninsured is plus/minus 9 percentage points (much larger than the typical +/- 3 for samples of around 1,000).

Gallup Shows Decline in % of Uninsured Americans

HuffPost/Pollster provides a round-up of expert opinion on Gallup's latest finding of a reduction in the percent of Americans reporting themselves to lack health insurance.

Hurt by Health Care Reform?

Some of the major polling outfits ask questions in their health care surveys on whether respondents feel the Affordable Care Act has helped or hurt them personally. Variations on this question might ask about the respondent and his/her family collectively, or even whether respondents feel the ACA has hurt Americans at large. There are some interesting things to notice in Gallup's most recent poll (which uses the "you and your family" wording).

As Greg Sargent discusses, of the 19% of Gallup respondents claiming they or their family have been harmed by Obamacare, "Sixty percent of those who say the law has hurt them or their families are Republicans or GOP-leaning independents. Only 23 percent are Dems or Dem-leaning independents, and another 15 percent are non-leaning independents."

Sargent adds that, "It’s always possible Republicans and conservatives are disproportionately impacted by the law, but it’s also possible that some who already dislike Obamacare are more likely to tell pollsters they’ve been negatively impacted by it, perhaps because they’re inclined to blame problems they’re experiencing with the health system in general on the law. Of course, this could work the other way around: Dems and Dem-leaners could be less inclined to say they are being hurt by it."

Another aspect of this issue that jumps out at me is how stable the trend lines for "help" and "hurt" appear to be in Gallup's historical polling on the matter. In February 2012, when relatively few Obamacare provisions had gone into effect, 16% said they or their family had been hurt by the law and 12% said they or their family had been helped. Unfortunately, Gallup went a long time without polling on this question, but its three most recent percentages for "hurt" have been 19, 19, and 19 (from polls taken November 23-24, 2013; January 3-4, 2014; and January 31-February 1, 2014). The respective percentages for "helped" were 9, 10, and 13 in these polls.

Considering the turmoil with the malfunctioning federal-exchange website from its debut on October 1 until the re-launch on December 1, and the controversy over many individual-market plans being cancelled (which was heavily in the news from late October into November), it seems remarkable that the percentages of respondents claiming harm to themselves or their families rose only modestly from the 16% in Feb. 2012 to 19% in late 2013 and early 2014.

Two hypotheses come to mind (although additional plausible ones could probably be generated). One is that a fairly sizable share (greater than the 3% aggregate increment) of Americans who had not felt harm in Feb. 2012 did so in late 2013/early 2014, but that others who were claiming harm in Feb. 2012 (or would have, had they been polled) were no longer feeling this way by late 2013, thus limiting the net increase in felt harm to the aforementioned 3%. The other hypothesis (a la Sargent) is that the help/harm survey questions are being answered heavily through an ideological lens, with little basis in how people really are tangibly affected. This latter explanation is cynical, to be sure, but would seem to explain the consistency of the results from early 2012 to late 2013 and beyond.

Health Status of ACA Enrollees by Sign-Up Month

Using their daily-tracking surveys since October 1, 2013, the operators of the Reuters/Ipsos Poll have been able to characterize trends in health status of people who have been signing up for insurance through the Affordable Care Act/Obamacare exchanges (hat tip to HuffPollster). In October, 69% of ACA enrollees who participated in the Reuters/Ipsos surveys claimed to have some significant health issue, whereas 31% reported none. The trend began shifting in November, however, with 55% of that month's enrollees claiming a health issue and 45% not. For January (which is less than half over), the numbers have reversed: 60% of this month's enrollees now report no major health issue, and 40% do. This development is important because, in order for insurance companies to cover the treatment of the sickest of its policyholders, they need a large volume of healthy subscribers to pay into the system without needing as much treatment.

Two Brief Items

The Republican-associated polling firm Public Opinion Strategies offers "Five Observations from Four Years of Polling Data on Obamacare" (via HuffPollster).  

The Washington Post's "Wonk Blog" notes that public interest in Obamacare seems to be declining, for the moment at least, as indicated by less Google activity and press coverage lately than during the fall (via Daily Kos). One possibly discussed by Wonk Blog is that enrollment under the Affordable Care Act is going relatively smoothly and good news is considered less newsworthy than bad news.

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.

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.