Affordable, quality health care. For everyone.

Americans’ Views on Health Insurance at the End of a Turbulent Year

The Affordable Care Act’s 2018 open enrollment period came at the end of a turbulent year in health care. The Trump administration took several steps to weaken the ACA’s insurance marketplaces. Meanwhile, congressional Republicans engaged in a nine-month effort to repeal and replace the law’s coverage expansions and roll back Medicaid.

Nevertheless, 11.8 million people had selected plans through the marketplaces by the end of January, about 3.7 percent fewer than the prior year.1There was an overall increase in enrollment this year in states that run their own marketplaces and a decrease in those states that rely on the federal marketplace.

To gauge the perspectives of Americans on the marketplaces, Medicaid, and other health insurance issues, the Commonwealth Fund Affordable Care Act Tracking Survey interviewed a random, nationally representative sample of 2,410 adults ages 19 to 64 between November 2 and December 27, 2017, including 541 people who have marketplace or Medicaid coverage. The findings are compared to prior ACA tracking surveys, the most recent of which was fielded between March and June 2017. The survey research firm SSRS conducted the survey, which has an overall margin of error is +/– 2.7 percentage points at the 95 percent confidence level. See How We Conducted This Study to learn more about the survey methods.

HIGHLIGHTS

Adults were asked about:

  • INSURANCE COVERAGE 14 percent of working age adults were uninsured at the end of 2017, unchanged from March–June 2017.
  • AWARENESS OF THE MARKETPLACES 35 percent of uninsured adults were not aware of the marketplaces.
  • REASONS FOR NOT GETTING COVERED Among uninsured adults who were aware of the marketplaces but did not plan to visit them, 71 percent said they didn’t think they could afford health insurance, while 23 percent thought the ACA was going to be repealed.
  • CONFIDENCE ABOUT STAYING COVERED About three in 10 people with marketplace coverage or Medicaid said they were not confident they would be able to keep their coverage in the future. Of those, 47 percent said they felt this way because either the Trump administration would not carry out the law (32%) or Congress would repeal it (15%).
  • SHOULD AFFORDABLE HEALTH CARE BE A RIGHT? 92 percent of working-age adults think that all Americans should have the right to affordable health care, including 99 percent of Democrats, 82 percent of Republicans, and 92 percent of independents.

At the end of 2017, 14 percent of adults ages 19 to 64 were uninsured, the same as six months earlier. (See the Appendix for a comparison with other recent federal and private survey estimates.) This remains above the lowest rate in 2016, although the difference is not statistically significant. Still, it is well below the 20 percent uninsured rate seen just prior to the ACA’s first open enrollment period.

Uninsured rates are highest among low-income adults, Latinos, the unemployed, employees of small firms, and residents of states that have yet to expand Medicaid. (See Table 1, Table 2, and Table 3 for complete data.)

Five years after the rollout of the health insurance marketplaces, most of the public is aware that people who don’t have employer coverage can get a plan through the marketplaces. Lack of awareness is higher among uninsured adults, and though there has been some improvement over the last year, the change is not statistically significant.

These findings suggest that more advertising and outreach could help lower the uninsured rate.

About half (47%) of uninsured adults were aware of the marketplaces but said they did not intend to visit them last fall to buy health insurance. When asked what the reasons were, 71 percent said they didn’t think they could afford coverage. About one-third said they didn’t think they would be eligible, while a similar share said they didn’t think they needed health insurance.

Last year’s debate over the ACA likely affected some uninsured adults’ decisions not to shop for marketplace coverage: 23 percent said they thought the law was going to be repealed, and 16 percent said they thought the government no longer required them to have health insurance.

People with marketplace plans or Medicaid are significantly less likely than those with employer benefits to be confident that they will be able to keep their health insurance in the future. About one-third of marketplace enrollees and one-quarter of Medicaid beneficiaries were not confident they could keep their plans in the future; just 9 percent of those with employer plans were not confident. (See Table 4 for complete data.)

When asked why they weren’t confident they could keep their health insurance in the future, 32 percent of marketplace and Medicaid enrollees said they didn’t think the Trump administration would carry out the ACA, while 15 percent expected Congress to repeal the law. About one in five didn’t think they would be able to afford their insurance, and 12 percent thought insurers might not offer it where they live.

Nearly all U.S. adults, regardless of political affiliation or income, think all Americans should have the right to affordable health care. This includes 99 percent of Democrats, 82 percent of Republicans, and 92 percent of independents. (See Table 5 for complete data.)

Of the 8 percent of adults who either don’t think Americans should have the right to affordable health care, or didn’t know or refused to respond, 29 percent said they would consider health care a right if people had to contribute financially over their lifetime.

Medicare requires lifetime financial contributions. Workers pay into Medicare through payroll taxes. When people were asked whether they thought this was a fair way to ensure everyone has access to Medicare when they turn 65, 87 percent of respondents said yes. This included 92 percent of Democrats, 84 percent of Republicans, and 87 percent of independents. (See Table 6 for complete data.)

POLICY IMPLICATIONS

This survey, along with other recent federal and private surveys, indicate that gains in coverage post-ACA have leveled out, and uninsured rates may even be ticking up slightly. As our findings suggest, policy changes could increase coverage, including greater outreach and advertising in all states and reforms to improve plan affordability.

Analysts Christine Eibner and Jodi Liu modeled six options to increase affordability of marketplace coverage, including extending tax credits to people who are above the income eligibility threshold and instituting a federal reinsurance program.2 Medicaid expansion, however, remains the most obvious means for expanding coverage nationwide: this and other surveys show that uninsured rates in the 19 states that have not expanded Medicaid are higher than in expansion states.3

Among survey respondents who were extremely pessimistic about their ability to maintain their marketplace or Medicaid coverage going forward, nearly half pointed to actions by the Trump administration and Congress as the main source of their unease. It seems clear that signals of support for this coverage from both branches of government would reassure consumers about their access to health care. Such a shift also would provide a more stable regulatory environment for insurers participating in both the marketplaces and Medicaid.

The absence of such signals from Washington may fuel an emerging debate over how best to insure that all Americans have coverage that provides them with access to affordable health care. Some proposals call for building on the ACA to achieve this goal. Others would allow people to buy in to Medicare or Medicaid. Still others would replace the ACA with a Medicare for all approach, while others would provide funds to states to design their own systems. This survey’s finding that strong majorities of U.S. adults, regardless of party affiliation, believe that all Americans should have a right to affordable health care suggests there may be popular support for a discussion over our preferred path.



How We Conducted This Study

The most recent Commonwealth Fund Affordable Care Act Tracking Survey was conducted by SSRS from November 2 to December 27, 2017. The survey consisted of telephone interviews in English or Spanish and was conducted among a random, nationally representative sample of 2,410 adults, ages 19 to 64, living in the United States. Overall, 122 interviews were conducted on landline telephones and 2,288 interviews on cell phones.

This survey is the sixth in a series of Commonwealth Fund surveys to track the implementation and impact of the ACA. The first was conducted by SSRS from July 15 to September 8, 2013, by telephone among a random, nationally representative U.S. sample of 6,132 adults ages 19 to 64. The survey had an overall margin of sampling error of +/– 1.8 percent at the 95 percent confidence level.

The second survey in the series was conducted by SSRS from April 9 to June 2, 2014, by telephone among a random, nationally representative U.S. sample of 4,425 adults ages 19 to 64. The survey had an overall margin of sampling error of +/– 2.1 percent at the 95 percent confidence level. The sample for the April–June 2014 survey was designed to increase the likelihood of surveying respondents who were most likely eligible for new coverage options under the ACA. As such, respondents in the July–September 2013 survey who said they were uninsured or had individual coverage were asked if they could be recontacted for the April–June 2014 survey. SSRS also recontacted households reached through their omnibus survey of adults who were uninsured or had individual coverage prior to the first open enrollment period for 2014 marketplace coverage.

The third survey in the series was conducted by SSRS from March 9 to May 3, 2015, by telephone among a random, nationally representative U.S. sample of 4,881 adults, ages 19 to 64. The March–May 2015 sample was also designed to increase the likelihood of surveying respondents who had gained coverage under the ACA. SSRS recontacted households reached through their omnibus survey of adults between November 5, 2014, and February 1, 2015, who were uninsured, had individual coverage, had a marketplace plan, or had public insurance. The survey had an overall margin of sampling error of +/– 2.1 percentage points at the 95 percent confidence level.

The fourth survey in the series was conducted by SSRS from February 2 to April 5, 2016, by telephone among a random, nationally representative U.S. sample of 4,802 adults, ages 19 to 64. The February–April 2016 sample was also designed to increase the likelihood of surveying respondents who had gained coverage under the ACA. Interviews in wave 4 were obtained through two sources: 1) stratified RDD sample, using the same methodology as in waves 1–3; and 2) households reached through the SSRS Omnibus, where interviews were previously completed with respondents ages 19 to 64 who were uninsured, had individual coverage, had a marketplace plan, or had public insurance. The survey had an overall margin of sampling error of +/– 2.0 percentage points at the 95 percent confidence level.

The fifth survey in the series was conducted by SSRS from March 28 to June 20, 2017, by telephone among a random, nationally representative U.S. sample of 4,813 adults, ages 19 to 64. The March–June 2017 sample was also designed to increase the likelihood of surveying respondents who had gained coverage under the ACA. Interviews in wave 5 were obtained through two sources: 1) stratified RDD sample, using the same methodology as in waves 1–4; and 2) households reached through the SSRS Omnibus where interviews were previously completed with respondents ages 19 to 64 who were uninsured, had individual coverage, had a marketplace plan, or had public insurance. The survey had an overall margin of sampling error of +/– 1.8 percentage points at the 95 percent confidence level.

The November–December 2017 sample was also designed to increase the likelihood of surveying respondents who had gained coverage under the ACA. Interviews in wave 6 were obtained through two sources: 1) stratified RDD sample, using the same methodology as in waves 1–5; and 2) households reached through the SSRS Omnibus, where interviews were previously completed with respondents ages 19 to 64 who were uninsured, had individual coverage, had a marketplace plan, or had public insurance.

As in all waves of the survey, SSRS oversampled adults with incomes under 250 percent of the federal poverty level to further increase the likelihood of surveying respondents eligible for the coverage options as well as to allow separate analyses of responses from low-income households.

The data were weighted to correct for oversampling uninsured and direct purchase respondents, the stratified sample design, the overlapping landline and cell phone sample frames, and disproportionate nonresponse that might bias results. New to this wave’s sample design, the weights also corrected for oversampling respondents with a prepaid cell phone. The data are weighted to the U.S. 19-to-64 adult population by age by state, gender by state, race/ethnicity by state, education by state, household size, geographic division, and population density using the U.S. Census Bureau’s 2015 American Community Survey. Data were weighted to household telephone use parameters based on the CDC’s 2016 National Health Interview Survey (NHIS).

The resulting weighted sample is representative of the approximately 190 million U.S. adults ages 19 to 64. Data for income, and subsequently for federal poverty level, were imputed for cases with missing data, utilizing a standard general linear model procedure. The survey has an overall margin of sampling error of +/– 2.7 percentage points at the 95 percent confidence level. The overall response rate, including the prescreened sample, was 7.0 percent.

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Notes

1 National Academy for State Health Policy, Individual Marketplace Enrollment Remains Stable in the Face of National Uncertainty (NASHP, Feb. 7, 2018), https://nashp.org/individual-marketplace-enrollment-remains-stable-in-the-face-of-national-uncertainty/.

2 C. Eibner and J. Liu, Options to Expand Health Insurance Enrollment in the Individual Market (The Commonwealth Fund, Oct. 2017), http://www.commonwealthfund.org/publications/fund-reports/2017/oct/expand-insurance-enrollment-individual-market.

3 S. L. Hayes, S. R. Collins, D. C. Radley, and D. McCarthy, What’s at Stake: States’ Progress on Health Coverage and Access to Care, 2013–2016 (The Commonwealth Fund, Dec. 2017), http://www.commonwealthfund.org/publications/issue-briefs/2017/dec/states-progress-health-coverage-and-access.




Acknowledgments

The authors thank Robyn Rapoport, Sarah Glancey, Erin Czyzewicz, Rob Manley, and Arina Goyle of SSRS; and David Blumenthal, Eric Schneider, Chris Hollander, Paul Frame, Jen Wilson, Shanoor Seervai, and Arnav Shah of the Commonwealth Fund.

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Publication Details

Publication Date: March 1, 2018
Contact: Sara R. Collins, Vice President, Health Care Coverage and Access, Programs, The Commonwealth Fund
Email: src@cmwf.org
Citation: S. R. Collins, M. Z. Gunja, M. M. Doty, and H. K. Bhupal, Americans’ Views on Health Insurance at the End of a Turbulent Year, The Commonwealth Fund, March 2018.