Thursday, April 24, 2014

Red state attitudes toward the ACA: like America's, but more so

Update, 4/25:  see next post re the high rate of pre-existing conditions reported by respondents to this poll.

A New York Times/Kaiser Family Foundation poll released yesterday probes perceptions of the Affordable Care Act in four red states, Arkansas, Kentucky, Louisiana and North Carolina. * In all of these states, Obama's approval rating is in the 30s, and the ACA is also deep underwater, with approval/disapproval percentages ranging from 29/62  in Arizona to 38/54 in North Carolina.*

Those overall judgments, stoked by five years of relentless Republican denunciations and a barrage of negative advertising in recent months, are stark.  And yet, the underlying attitudes revealed in the poll's internals are strikingly congruent in key respects to the attitudes toward prospective healthcare reform recorded nationally in a Kaiser poll conducted in December 2008, when approval for a president-elect who had campaigned on a national healthcare overhaul was sky-high. 

In both polls, majorities opposed simply maintaining the pre-ACA status quo -- doing little or nothing to expand coverage in 2008, repealing the ACA today. In both, majorities favored government action to make health insurance available to people who could not get it from their employers. In both, majorities supported expanding Medicaid.  Yet in both, majorities rejected the notion that it was the federal government's responsibility to make affordable healthcare coverage available to all Americans.


In the December 2008 national poll (as I noted earlier this week), only 24% favored leaving the healthcare system more or less untouched; 74% wanted to see a new health plan. But only 48% wanted to see a plan that would make "a major effort to provide health insurance for nearly all uninsured Americans and involve a substantial increase in spending." Another 26% said they favored a more limited plan that would "cover only some new groups but would involve less spending." That is, 52% opposed a drive toward universal coverage.

In the red state poll conducted this month, when asked whether it was the responsibility of the federal government to provide affordable healthcare coverage to all, the yes-no responses were 38-55 in Arkansas, 43-48 in Kentucky, 45-49 in Louisiana, and 45-49 in North Carolina.  When asked whether they wanted the law improved or repealed, however, majorities or pluralities favored keep-and-improve by 48-46 (AR), 52-41 (KY), 52-44 (LA) and 60-35 (NC).

Underlying the unwillingness to go back is apparently a sense that government should plug some if not all the holes left by the country's primary reliance on employer-sponsored insurance. When asked what they thought should be "the government's role inproviding health insurance middle-income people under age 65 who don't get insurance at work," strong majorities in each state said the government should either subsidize private insurance for such people or "provide them with health insurance, as it does for seniors and many poor people." The combined percentages of those favoring either of those options were 55% (AR), 63% (KY), 58% (LA) and 57% (NC).

In each case, moreover, government-provided insurance (i.e., for practical purposes, Medicaid) strongly outpolled the private option -- 34-21 (AR), 38-25 (KY), 37-21 (LA) and 37-24 (NC).  In Arkansas, which obtained a waiver to provide private insurance to those whom the law deemed eligible for Medicaid -- and where 155,000 people have accessed that private option -- respondents, when asked how the government should help low-income people, preferred Medicaid to the private option, 52-23. (But then, only 20% were aware that the state had implemented a private option, versus 35% who thought erroneously that the state had expanded Medicaid.)

Expanding Medicaid to low-income Americans is enduringly popular -- notwithstanding the rooted hostility of red-state elected officials to doing so. In the December 2008 poll, 73% favored "expanding state government programs for low-income people, such a Medicaid of the State Children's Health Insurance Program." In national polling conducted by Kaiser this March, 74% favored it.

Americans want access to affordable health insurance to be extended to their fellow citizens who lack it, but they are wary of full-body system overhauls.  Republicans have relentlessly exploited that wariness, hyping the relatively small number of people for whom the law has raised the cost of health insurance -- that is, mainly, people who a) were buying their own insurance in the individual market prior to 2014, b) ineligible for subsidies (as well under half in these red states would be), and c) had no pre-existing condition, or family member sharing their insurance with such a condition.

On that last front, the red-state poll has an interesting tidbit. Majorities in each state, ranging from 57-60%, reported that someone in their household had a pre-existing condition.  That means that if they were buying insurance in the individual market (as only about 11% reported doing), pre-ACA, they would either be priced out entirely or would pay substantially more than those not deemed to have a pre-existing condition. People with pre-existing conditions who were buying insurance in the pre-ACA individual market have benefited dramatically from the law, even if they don't qualify for subsidies.

And yet, in each state polled, about twice as many people (from 26-29%) said the law had hurt them or their family as said it helped them (13-15%).  Of those who said they were hurt, by far the largest category said the law had increased their healthcare costs (51-61%). Since most respondents get their insurance from employers or public programs, that would appear to suggest that many are blaming the ACA for increased premiums or co-pays or reduced benefits. 

*         *          *

  *Kentucky both accepted the Medicaid expansion and ran its own health insurance exchange. Arkansas accepted the Medicaid expansion on its own terms, winning a waiver to use the federal funding to pay for private insurance for those deemed eligible for Medicaid under the law, while declining to run its own state exchange. Louisiana and North Carolina rejected  the Medicaid expansion and also declined to run their state exchanges.

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