Americans' Values And Beliefs About National Health Insurance Reform

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AMERICANS’ VALUESAND BELIEFS ABOUTNATIONAL HEALTHINSURANCE REFORMOctober 20190

THE COMMONWEALTH FUNDTHE NEW YORK TIMESHARVARD T.H. CHAN SCHOOL OF PUBLIC HEALTHAMERICANS’ VALUES AND BELIEFS ABOUTNATIONAL HEALTH INSURANCE REFORMReforming the U.S. health insurance system has become a major issue in the upcomingpresidential election, both in primaries and likely in the general election. There are anumber of different health care reform proposals that have been put forth by candidatesand parties, but prior studies show that voters in the general public are often not aware ofthe details of these plans. This suggests that the differentiation voters make between oneplan and another is likely based on underlying values, beliefs, and life experiences. Thisreport addresses specifically adults’ views in these three areas, as they relate to healthinsurance reform proposals supported by the public.One of the issues that has emerged in recent polling on health insurance reform is thatpeople often report they support more than one type of plan, even though these plans areoften very different from each other from a policy perspective. This poll seeks to examinethis issue by asking people who are interviewed to choose the plan that they most favoramong the three major plans that are being debated currently: (1) Medicare-for-all, (2)improving the existing Affordable Care Act (Obamacare), or (3) replacing the AffordableCare Act with a new law that would give taxpayer funding to states to design their ownhealth insurance systems with fewer federal rules. These preferences can change overtime.The report consists of findings about Americans’ values and beliefs on national healthinsurance reform in seven sections:1. The preferred role of government generally in the U.S.2. The preferred role for government in health care3. Attitudes towards the current U.S. health care system4. Views on equal treatment in the U.S. health care system5. Personal experiences with health care and health issues6. Views on the future desired direction of health insurance reform in the U.S.7. Public trust in groups trying to improve the U.S. health care systemIn addition, this report includes an additional section on how these issues are likely to beseen in the Democratic primary and the general election in 2020.1

About the Survey SampleThis survey was conducted for The Commonwealth Fund, The New York Times, andHarvard T.H. Chan School of Public Health by SSRS, an independent research company.Respondents were asked to choose the plan that they most favor among the three majorplans that are being debated currently: (1) Medicare-for-all, (2) improving the existingAffordable Care Act (ACA), or (3) replacing the ACA with state health plans. See TableA below details on Americans’ broad preferences for the type of health insurance systemthe U.S. should have in the future. Notably, none of the three policies received a majorityof Americans’ support as their most-favored plan.Table A. Americans’ preferences for future health insurance system plans (inpercent)Total adultsPreferred policyMedicare-for-allChanging our health care system so that all Americans would get healthinsurance from Medicare, which is now mainly for people age 65 orover and is paid for by taxpayers. This plan is often called Medicare forAll.Improving the existing ACAKeeping the existing Affordable Care Act, also known as Obamacare,and passing additional legislation to improve how it works.Replacing the ACA with state health plansReplacing the Affordable Care Act, also known as Obamacare, with anew law that would give taxpayer funding to states to design their ownhealth insurance systems with fewer federal rules.100322829Source: The Commonwealth Fund/The New York Times/Harvard T.H. Chan School of Public Health,Americans’ Values and Beliefs about National Health Insurance Reform. July 10 – August 11, 2019.N 2,005 U.S. adults.Interviews were conducted in English and Spanish, July 10 – August 11, 2019, with anationally representative, probability-based sample of 2,005 randomly selected adults,ages 18 and older, via telephone (including cell phones and landlines). The data wereweighted to reflect the demographics of the national adult population as described by theU.S. Census. Additional methodology is available at the end of the report.2

1. The preferred role of government generally in the U.S.People who prefer each of the three different approaches to national health insurancereform are divided in their views about the preferred role of government in general.Adults who favor replacing the ACA with state health plans hold the most negative viewsof government, as 69% say things run by the federal government are not run too well ornot well at all, while 31% say things run by the federal government are run very orsomewhat well. Those who favor Medicare-for-all and improving the existing ACA aremore evenly split in their views. A slight majority of adults who favor Medicare-for-all(52%) think when something is run by the federal government, it is generally run very orsomewhat well, while 46% think it is not run too well or not well at all (Table 1). Half ofadults who favor improving the existing ACA (50%) think things run by the federalgovernment are run very or somewhat well, while 48% think things run by thegovernment are not run too well or not well at all.Table 1. Americans’ views on their preferred role of government (in percent)Preferreplacing theTotalACA withstate healthplansWhen something is run by the federal government, it is generally run Very/somewhat well43525031Not too well/not well at all56464869Government regulation of businesses and corporations Is necessary to protect the61707644publicUsually does more harm34252154than goodImage of capitalismPositive57415373Negative35484122Image of icarefor-allPreferimprovingthe existingACASource: The Commonwealth Fund/The New York Times/Harvard T.H. Chan School of Public Health,Americans’ Values and Beliefs about National Health Insurance Reform. July 10 – August 11, 2019.N 2,005 U.S. adults. Don’t know/refused responses are included in the total but are not shown.3

Americans who prefer different health plans are also divided in their beliefs aboutwhether government regulation of business does more harm than good. When askedwhich comes closer to their own view, more than three-quarters of adults favoringimproving the existing ACA (76%) say government regulation of businesses andcorporations is necessary to protect the public, while 21% say government regulation ofbusinesses and corporations usually does more harm than good. Medicare-for-allproponents expressed similar views, with 70% saying government regulation is necessaryto protect the public and 25% saying government regulation usually does more harm thangood. However, among adults who favor replacing the ACA with state health plans, aslight majority (54%) say government regulation usually does more harm than good,while 44% say government regulation is necessary to protect the public.In addition, there are dramatic differences in views about capitalism and socialism, byAmericans’ preferred approach to national health reform. On capitalism, more than sevenin ten adults who favor replacing the ACA with state health plans (73%) say they have apositive image of capitalism, compared to only four in ten adults who favor Medicarefor-all (41%). Adults who favor improving the existing ACA are more split, as a slightmajority (53%) say they have a positive image of capitalism. On socialism, a majority ofadults who favor Medicare-for-all (56%) have a positive image of socialism, comparedjust 13% of adults who favor replacing the ACA with state health plans. Adults whofavor improving the existing ACA are more divided, as four in ten (40%) say they have apositive image of socialism.4

2. The preferred role for government in health careRegardless of their preferences for health insurance reform, a majority of the publicbelieves all Americans have a right to health care regardless of their ability to pay.However, the public is split on whether it is the federal government’s role to solve theseproblems (Table 2).Most adults favoring Medicare-for-all (94%) and improving the existing ACA (91%)think all Americans should have a right to health care regardless of their ability to pay,while six in ten adults who favor replacing the ACA with state health plans (60%) saythis. However, when it comes to government involvement, while majorities of adultsfavoring Medicare-for-all (85%) and improving the existing ACA (73%) say they think itis the responsibility of the government to make sure all Americans have health insurancecoverage, only one in five adults favoring replacing the ACA with state health plans(20%) say this.When asked about the future role of the federal government in health care, about twothirds of adults favoring Medicare-for-all (67%) say the federal government should bemore involved, while 14% say it should be less involved, and 16% say it should be aboutas involved as it is now. By contrast, about two-thirds of adults who favor replacing theACA with state health plans (65%) say the federal government should be less involved inhealth care, while only 17% say it should be more involved, and 16% say it should beabout as involved as it is now. A slight majority of adults who favor improving theexisting ACA (54%) say the federal government should be more involved in health care,while 15% say it should be less involved, and 28% say it should be about as involved asit is now.When it comes to providing health insurance in the U.S., about three-quarters of adultswho favor Medicare-for-all (73%) and a majority of adults who favor improving theexisting ACA (55%) say they prefer a health insurance system run mostly by thegovernment over a system based mostly on private health insurance. By contrast, mostadults who favor replacing the ACA with state health plans (84%) say they prefer ahealth insurance system based mostly on private insurance over one run mostly by thegovernment.5

Table 2. Americans’ preferred role for federal government involvement in healthcare (in he existingACAPreferreplacing theACA withstate healthplansViews on health care as a rightAll Americans should have aright to health care regardless of799491their ability to payAll Americans should not havea right to health care regardless1856of their ability to payGovernment responsibility for health insurance coverageIt is the responsibility of thegovernment to make sure all568573Americans have healthinsurance coverageIt is not the responsibility of thegovernment to make sure all411323Americans have healthinsurance coverageIn the future, the federal government should be in health careMore involved436754Less involved351415About as involved as it is now191628Preferred approach for providing health insurance in the United StatesHealth insurance system run447355mostly by the governmentHealth insurance system basedmostly on private health492036insurance603520761765161484Source: The Commonwealth Fund/The New York Times/Harvard T.H. Chan School of Public Health,Americans’ Values and Beliefs about National Health Insurance Reform. July 10 – August 11, 2019.N 2,005 U.S. adults. Don’t know/refused responses are included in the total but are not shown.6

3. Attitudes towards the current U.S. health care systemAmericans are split in their attitudes toward the current U.S. health care system, by theirpreferences for health reform (Table 3). While divisions exist on how the U.S. health caresystem compares to other countries and public opinion on the Affordable Care Act,regardless of their preferences for health insurance reform, a majority of the public holdsfavorable views of current public and private health insurance options.On comparing the U.S. health care system with other countries, a majority of adults whofavor replacing the ACA with state health plans (55%) say the U.S. has the best healthcare system in the world (Table 3). By contrast, only about three in ten (29%) adultsfavoring improving the existing ACA and 21% of adults favoring Medicare-for-all saythis, as majorities of adults favoring these policies say there are other countries withbetter health care systems than the U.S.Table 3. Americans’ attitudes towards the U.S. health care system (in he existingACAComparing the U.S. health care system with other countries The U.S. has the best health362129care system in the worldThere are other countries withbetter health care systems than486955the U.S.Public opinion about the Affordable Care ActFavorable536783Unfavorable412413Rating the U.S. health care systemExcellent/good352433Fair/poor647567Public opinion about Medicare*Very/somewhat favorable808683Very/somewhat unfavorable151112Public opinion about Medicaid**Very/somewhat favorable708177Very/somewhat unfavorable231218Public opinion about private health insurance provided by employersVery/somewhat favorable685168Very/somewhat unfavorable2641277Preferreplacing theACA withstate healthplans553021754949771960328414

Views on Medicaid work requirementsLow-income adults who areable to work should be required5637to do so in order to receiveMedicaid coverageLow-income adults who areable to work should be able toreceive Medicaid coverage,4059regardless of whether or notthey are workingViews on health insurance coverage for illegal immigrantsGovernment health careprograms should cover anyoneliving in the U.S., including3758those who have entered the U.S.illegallyGovernment health careprograms should only cover6039legal residents of the U.S.Views on abortionShould be legal in all/most cases 6172Should be illegal in all/most3422cases497947194913468676391757Source: The Commonwealth Fund/The New York Times/Harvard T.H. Chan School of Public Health,Americans’ Values and Beliefs about National Health Insurance Reform. July 10 – August 11, 2019.N 2,005 U.S. adults. Don’t know/refused responses are included in the total but are not shown. *Medicaredescribed as the government health insurance program for seniors and for younger adults with long-termdisabilities. **Medicaid described as the federal and state government health insurance program for lowincome adults and children.More than eight in ten Americans who favor improving the existing ACA (83%) say theygenerally have a favorable opinion of the ACA, while about two-thirds of Americans whofavor Medicare-for-all have a favorable opinion of the ACA (67%). Meanwhile, onlyabout one in five Americans who favor replacing the ACA with state health plans (21%)say they have a favorable opinion of the ACA.When it comes to rating the U.S. health care system, a majority of adults favoringMedicare-for-all (75%) rate the U.S. health care system negatively as fair or poor, whileonly 24% rate it as excellent or good. Two-thirds of adults favoring improving theexisting ACA (67%) also rate the U.S. health care system negatively as fair or poor,while one-third (33%) rate it as excellent or good. Adults who favor replacing the ACAwith state health plans are more split in their ratings of the U.S. health care system, withabout half (49%) rating it as excellent or good and about half (49%) rating it as fair orpoor.8

When asked about Medicare, described as the government health insurance program forseniors and for younger adults with long-term disabilities, 86% of adults who favorMedicare-for-all, 83% of adults who favor improving the existing ACA, and 77% ofadults who favor replacing the ACA with state health plans say they generally have afavorable view of Medicare. When asked about Medicaid, described as the federal andstate government health insurance program for low-income adults and children, 81% ofadults who favor Medicare-for-all, 77% of adults who favor improving the existing ACA,and 60% of adults who favor replacing the ACA with state health plans say theygenerally have a favorable view of Medicaid. When asked about private health insuranceprovided by employers, 84% of adults who favor replacing the ACA with state healthplans, 68% of adults who favor improving the existing ACA, and 51% of adults whofavor Medicare-for-all say they generally have a favorable view of private healthinsurance.Recently, a number of states have proposed work requirements in Medicaid as acondition of eligibility. When asked whether low-income adults who are able to workshould be required to do so in order to receive Medicaid coverage, about eight in tenadults who favor replacing the ACA with state health plans (79%) say they should berequired to work, while 19% say they should be able to receive Medicaid coverageregardless of whether or not they are working. Meanwhile, only 37% of adults who favorMedicare-for-all say low-income adults who are able to work should be required to do so,and 59% say low-income adults who are able to work should be able to receive Medicaidcoverage regardless of whether or not they are working. Adults who favor improving theexisting ACA are split, with 49% saying low-income adults who are able to work shouldbe required to do so in order to receive Medicaid coverage, and 47% saying they shouldbe able to receive Medicaid coverage regardless of whether or not they are working.In addition, a majority of adults who favor Medicare-for-all (58%) think governmenthealth care programs should cover anyone living in the U.S., including those who haveentered the country illegally, while 39% of Medicare-for-all proponents thinkgovernment health care programs should only cover legal U.S. residents. By contrast,only 13% of adults who favor replacing the ACA with state health plans thinkgovernment health care programs should cover anyone living in the U.S. (includingillegal immigrants), while 86% think government health care programs should only coverlegal U.S. residents. Adults who favor improving the existing ACA are about evenlysplit, where 49% think government health care programs should cover anyone living inthe U.S. (including illegal immigrants), and 46% think government health care programsshould only cover legal U.S. residents.When asked whether abortion should be legal or illegal, more than seven in ten adultswho favor replacing the existing ACA (76%) and Medicare-for-all (72%) think abortionshould be legal in all or most cases, while the majority of adults who favor replacing theACA with state health plans (57%) think abortion should be illegal in all or most cases.9

4. Views on equal treatment in the U.S. health care systemWhen it comes to equal treatment in U.S. health care, large majorities of adults favoringall three plans share views that while equal treatment is not a current reality, it is animportant goal. When it comes to health care people receive, about nine in ten adults whofavor Medicare-for-all (89%) and improving the existing ACA (89%), as well as 69% ofadults who favor replacing the ACA with state health plans, say some Americans are nottreated as well as others (Table 4).Table 4. Americans’ views on equal treatment (in he existingACAPreferreplacing theACA withstate healthplansViews on equal treatment in U.S. health careAll Americans are treated1691026equallySome Americans are not81898969treated as well as othersImportance of equal treatment in health care for all AmericansVery important77898762Somewhat important1681126Not too/not at all important63210Importance of poor American families receiving same quality of health care asrich American familiesVery important79918664Somewhat important1671226Not too/not at all important5227Importance of African Americans receiving same quality of health care as WhiteAmericansVery important88949580Somewhat important85412Not too/not at all important21 1%2Source: The Commonwealth Fund/The New York Times/Harvard T.H. Chan School of Public Health,Americans’ Values and Beliefs about National Health Insurance Reform. July 10 – August 11, 2019.N 2,005 U.S. adults. Don’t know/refused responses are included in the total but are not shown.10

On the importance of equal treatment, 89% of adults favoring Medicare-for-all, 87% ofthose favoring improving the existing ACA, and 62% of those favoring replacing theACA with state health plans say it is very important to them that all Americans be treatedequally in terms of the health care they receive. When asked about the importance tothem that poor American families receive the same quality of health care as richAmerican families, 91% of adults favoring Medicare-for-all, 86% of those favoringimproving the existing ACA, and 64% of those favoring replacing the ACA with statehealth plans say it is very important. And when asked about the importance to them thatAfrican Americans receive the same quality of health care as White Americans, 94% ofadults favoring Medicare-for-all, 95% of those favoring improving the existing ACA, and80% of those favoring replacing the ACA with state health plans say it is very important.11

5. Personal experiences with health care and health issuesWhen it comes to personal experiences with health care and health issues, there arerelatively small differences between Americans by their preferred approach to healthinsurance reform. The largest difference is reported satisfaction with the way things aregoing in the nation today, where adults who favor replacing the ACA with state-run plansare largely satisfied, while those favoring Medicare-for-all and improving the existingACA are not. In addition, a greater share of adults who favor Medicare-for-all expressconcerns about health care costs and their ability to pay future medical bills compared tothose who prefer replacing the ACA with state health plans. However, large majorities ofadults preferring all three plans say they are satisfied with their current health insurancecoverage.Two-thirds of adults who favor replacing the ACA (67%) say they are very or somewhatsatisfied with the way things are going in the nation today (Table 5). By contrast, onlyabout one in three adults who favor improving the existing ACA (32%) and about one infour adults favoring Medicare-for-all (26%) say they are satisfied with how things aregoing in the nation today.On health care costs (Table 5), a majority (56%) of adults who favor Medicare-for-all,44% of adults who favor improving the existing ACA, and 45% of adults who favorreplacing the ACA with state health plans say they have been dissatisfied with the cost oftheir health care in the past few years.On health care access, about one-third of adults who favor Medicare-for-all (34%), 18%of adults who favor improving the existing ACA, and 19% of adults who favor replacingthe ACA with state health plans report being dissatisfied with their ability to get healthcare when they needed it in the last few years.On health care quality, about one-quarter of adults who favor Medicare-for-all (24%),15% of adults who favor improving the existing ACA, and 18% of adults who favorreplacing the ACA with state health plans report being dissatisfied with the quality oftheir healthcare in the last few years.When it comes to concerns about future medical bills, the majority of adults who favorMedicare-for-all (63%) and about half of adults who favor improving the existing ACA(51%) say they are worried about not being able to pay their medical bills if they get sickin the next year. By contrast, only one-third of adults who favor replacing the ACA withstate health plans (33%) say they are worried about this.12

Table 5. Americans’ personal experiences with health care and health issues (inpercent)PreferPrefer replacingimprovingthe ACA withTotalthe existingstate healthACAplansSatisfaction with the way things are going in the nation todayVery/somewhat satisfied42263267Very/somewhat dissatisfied55736631Satisfaction with the cost of your health careVery/somewhat satisfied49425453Very/somewhat dissatisfied49564445Satisfaction with your ability to get health care when you need itVery/somewhat satisfied74648280Very/somewhat dissatisfied24341819Satisfaction with the quality of your health careVery/somewhat satisfied79758481Very/somewhat dissatisfied20241518Concerns about ability to pay your medical bills if you get sick in the next yearVery/somewhat worried47635133Not too/not at all worried52374967Satisfaction with your current health insurance coverage (among those withhealth insurance)Very/somewhat satisfied84799085Very/somewhat dissatisfied1620915Health statusExcellent/very good/good78727783Only fair/poor22282317Have a disability21252317Have a chronic illness45474941PreferMedicarefor-allSource: The Commonwealth Fund/The New York Times/Harvard T.H. Chan School of Public Health,Americans’ Values and Beliefs about National Health Insurance Reform. July 10 – August 11, 2019.N 2,005 U.S. adults. Don’t know/refused responses are included in the total but are not shown.Despite these concerns, vast majorities of insured adults favoring all three major healthreform proposals—90% of adults who favor improving the existing ACA, 85% of adultswho favor replacing the ACA with state health plans, and 79% of adults who favorMedicare-for-all—say they are satisfied with their current health insurance coverage.When it comes to health status and experiencing health issues, more than one in fouradults who favor Medicare-for-all (28%) say they are in only fair or poor health,compared to less than one in five (17%) of those who favor replacing the ACA with statehealth plans. Adults are similar across groups when it comes to having a disability orchronic illness (see Table 5).13

6. Views on the future desired direction of health insurance reform in the U.S.When asked about government requiring everyone to have health insurance, without anymention of a fine or tax, more two-thirds of adults who favor improving the existingACA (71%) and Medicare-for-all (69%) say they favor government requirements foreveryone to have health insurance. By contrast, only about one in four adults who favorreplacing the ACA with state health plans (24%) favor government requirements foreveryone to have health insurance, with 75% saying they oppose this (Table 6).On pre-existing conditions, proponents of all three plans share similar views aboutgovernment requirements for health insurance companies (Table 6). More than nine inten proponents of improving the existing ACA (91%) favor the government continuing torequire insurance companies to provide health insurance for Americans with pre-existingconditions, even though this has led to increased insurance costs for some healthy people.More than eight in ten adults who favor Medicare-for-all (84%) also share this view, asdo nearly three-quarters of adults who favor replacing the ACA with state health plans(73%).When asked whether government should require that all health insurance plans have atleast a minimum set of health benefits, or whether individuals and businesses should beallowed to make their own choices of different types of health insurance benefits, amajority of adults who favor Medicare-for-all (56%) and slight majority of adults whofavor improving the existing ACA (54%) prefer requirements for a minimum set ofhealth benefits. However, among adults who favor replacing the ACA with state healthplans, more than three-quarters (78%) prefer that individuals and businesses are allowedto make their own choices of different types of health insurance benefits.14

Table 6. Americans’ views on the future desired direction of health insurancereform in the U.S. (in percent)PreferPreferPreferimproving replacing theTotal MedicaretheACA withfor-allexistingstate healthACAplansViews on government requiring everyone to have health insuranceFavor52697124Oppose47292675Views on government continuing to require health insurance coverage forAmericans with pre-existing conditionsFavor82849173Oppose1411523Views on government requirements for basic health insurance benefitsGovernment should require all healthinsurance plans to have at least a41565420minimum set of health benefitsIndividuals and businesses should beallowed to make their own choices of55404178different types of health insurancebenefitsWould personally be willing to pay more taxes so everyone can have ws on increasing taxes on higher income people so everyone can have ces for higher taxes/premiums vs. out-of-pocket medical billsWould rather pay higher taxes orpremiums and never pay out-of47695128pocket medical billsWould rather pay lower taxes or48274269premiums and some health care feesPreferences for most hospitals in the U.S. to be operated by Non-profit organizations45444843For-profit organizations122821Government agencies919102It doesn’t matter29302930Source: The Commonwealth Fund/The New York Times/Harvard T.H. Chan School of Public Health,Americans’ Values and Beliefs about National Health Insurance Reform. July 10 – August 11, 2019.N 2,005 U.S. adults. Don’t know/refused responses are included in the total but are not shown.15

On the topic of increasing taxes to pay for health insurance, more than three-quarters ofadults favoring Medicare-for-all (79%) and two-thirds of adults favoring improving theexisting ACA (67%) say they would personally be willing to pay more in taxes so thateveryone can have health insurance in the U.S. However, fewer than one in four adultsfavoring replacing the ACA with state health plans (23%) say they would personally bewilling to pay more in taxes so that everyone can have health insurance in the U.S.Americans share similar views when it comes to taxing higher income Americans. Whenasked if they favor or oppose increasing taxes on higher income people so everyone canhave health insuran

Replacing the ACA with state health plans Replacing the Affordable Care Act, also known as Obamacare, with a new law that would give taxpayer funding to states to design their own health insurance systems with fewer federal rules. 29 Source: The Commonwealth Fund/The New York Times/Harvard T.H. Chan School of Public Health, .

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