The Public's Health Care Agenda for the 113th Congress

As the 113th Congress is sworn in, and President Barack Obama begins his second term of office, a comprehensive new Kaiser Family Foundation/Robert Wood Johnson Foundation/Harvard School of Public Health survey queried the public about their priorities for, and views on, a wide range of health and health policy issues. These include issues that will preoccupy federal lawmakers, such as the role of Medicare in the deficit reduction debate, as well as issues currently being debated in the states surrounding the implementation of the Affordable Care Act (ACA), such as establishing insurance exchanges and expanding state Medicaid programs.

State Level Health Policy Priorities in the Era of ACA Implementation

With the implementation of the Affordable Care Act now unfolding at the state level, some of the survey’s most interesting new findings concerned issues being debated in the states. Asked about health policy priorities for their state leadership, Americans put the creation of health insurance exchanges – a key piece of the ACA and one whose implementation has divided states along political lines over the course of the past year – at the top of their priority list. Asked how high a priority it was for their state to create “a health insurance exchange or marketplace where small businesses and people who don’t get coverage through their jobs can shop for insurance and compare prices and benefits,” 55 percent name this as a top priority (including majorities of Democrats and Republicans, 60 and 55 percent respectively, and 49 percent of independents) – the only one of the seven possibilities listed where a majority called it a top priority. The survey did not make a distinction as to whether the exchange was run by the state or the federal government.

Should States Implement Medicaid Expansion? When it comes to another key state decision regarding the implementation of the ACA – whether to adopt the Medicaid expansion built into the ACA – the January survey finds more Americans think their state should undertake the expansion (52 percent) than oppose it (42 percent). Unlike exchanges, which enjoy bipartisan support, these views differ sharply by party identification, with most Republicans saying they prefer to keep their Medicaid program as is (66 percent) and most Democrats (75 percent) supporting their state’s expansion. Independents are evenly divided. In terms of overall state-level priorities, three in ten call the Medicaid expansion a “top priority,” and another 35 percent say it is important but a lower priority.

Arguments suggesting that states would be giving up federal dollars and leaving many low-income people without insurance, or that there would be less money available for state providers, shift about ten percent of the public to be more interested in expanding the federal-state health insurance program. Arguments suggesting that the expansion may require states to spend some more money on Medicaid in the future, even though the federal government would be picking up most of the costs, shift 14 percent of the public toward keeping the Medicaid status quo in their state.

FIGURE 3: SOME MALLEABILITY IN VIEWS ON MEDICAID EXPANSION
As you may know, the health care law expands Medicaid to provide health insurance to more low-income uninsured adults. The federal government will initially pay the entire cost of this expansion, and after several years, states will pay 10 percent and the federal government will pay 90 percent. The Supreme Court ruled that states may choose whether or not to participate in this expansion. What do you think your state should do?	Keep Medicaid as it is today		Expand Medicaid
	42%		52%
After those who said they want to keep Medicaid as it is today heard that…	Keep Medicaid as it is today	Now prefer to expand	Expand Medicaid
…this would mean many low-income people in your state would be left without health insurance, and your state would be giving up additional federal dollars for covering its uninsured residents	27%	12%	52%
…this would mean that your state would be giving up additional revenue for health care providers – such as doctors and hospitals	29%	11%	52%
After those who said they want to expand Medicaid heard that…	Keep Medicaid as it is today		Now prefer to keep as is	Expand Medicaid
…this expansion may require your state to spend some more money on Medicaid in the future, even though thee federal government would be picking up most of the cost	42%		14%	37%

The survey confirmed previous Kaiser findings that the Medicaid program remains important to a majority of Americans on a personal level. Six in ten Americans say Medicaid is important to their own family, with 38 percent calling it “very important.” Democrats are more than twice as likely as Republicans to say the program is “very important” to them (48 percent versus 22 percent). Overall, about half of Americans (including equal shares of Democrats and Republicans), and a slightly higher share of those living in low-income households, say the Medicaid program is working well for people in their state, with about three in ten disagreeing, and two in ten not having enough information to offer an opinion.

Priority Placed on State Regulation of Premiums. With large premium increases making news in recent months, the survey also finds that 37 percent overall say that “increasing government regulation of premiums charged by health insurance companies” should be a top priority for their state’s lawmakers, and another 30 percent call this “important,” though a lower priority. Again this is a topic with a partisan split. Democrats are more likely to call premium regulation a top priority: 47 percent do, compared to 27 percent of Republicans.

Should Opponents Stop Their Efforts Against the Affordable Care Act? Currently a narrow majority of Americans report they are willing to see the law’s opponents continue to try to change or stop it. Overall, 52 percent agree that opponents of the law should “continue trying to change or stop it, so it has less impact on taxpayers, employers, and health care providers,” while 40 percent agree that “those opposed to the health care law should accept that it is now the law of the land and stop trying to block [its] implementation.” Reflecting the long standing partisan division on the ACA, most Democrats (67 percent) want to see opponents drop their efforts against the law, while most Republicans (78 percent) support opponents’ continued efforts. By a two to one margin, independents would like to see policymakers continue to try to stop or change the law (59 percent say so, compared to 31 percent that would rather see challenges stop).

Addressing Health Policy Challenges in an Era of Deficit Reduction

At the federal level, lawmakers face a familiar conundrum: the public continues to express a general sense of urgency about addressing the nation’s budget deficit, even as most Americans resist changes to the nation’s largest (and most expensive) entitlement programs and express an unwillingness to make financial sacrifices themselves. In fact, in an open-ended question the public named the following three issues as one of the top priorities for policymakers to address this year: deficit/taxes (named by 45 percent), health care (32 percent) and the economy/jobs (27 percent). At the same time, the deep partisan divides in Washington as to how to address the deficit situation continue to be reflected among Democrats and Republicans across the country.

Sense of Urgency Regarding Deficit. The survey, conducted immediately after the resolution of the early January ‘fiscal cliff’ debate, found that the public thinks the president and the new Congress should act quickly to reduce the deficit, rather than waiting for a stronger economic recovery. Overall, two in three Americans say they want to see policymakers acting in the shorter term—up 11 percentage points from a similar survey fielded at the start of the last Congressional session – and including bipartisan majorities of Republicans (74 percent), independents (71 percent) and Democrats (57 percent), as well as seniors and non-seniors (73 percent and 63 percent, respectively). But when it comes to next steps, bipartisanship is in shorter supply.

But Partisans Disagree on How Best to Address It. Just over half of Americans believe deficit reduction should come through a fairly even combination of spending cuts and tax increases (52 percent say so), compared to 38 percent that believe that most of the reduction should mostly come through spending cuts. Sixty-eight percent of Democrats say there is a role for tax increases along with spending cuts, while 61 percent of Republicans want most of the action to be on the side of cutting spending.

General Resistance to Widespread Sacrifice. Asked about several possible tax increases, raising taxes on wealthier Americans – the plan recently embraced by the president and Congress – topped the list, backed by roughly three in four Americans, including 60 percent of Republicans. Two in three say they would be willing to see taxes raised on corporations, and slightly fewer but still a majority (57 percent) would accept “limiting the dollar amount of deductions some taxpayers can take” (with partisans of different stripes taking different views on both these issues as expected). Raising everyone’s income taxes, however, is as unpopular as one might expect: 72 percent of Americans oppose this idea, including 69 percent of Democrats. Similarly, a majority (55 percent) oppose the idea of increasing the Medicare payroll tax on all Americans.

Few Willing to Cut Major Entitlement Programs. Pressed to specify which programs they would be willing to see impacted by spending cuts, few Americans name the large entitlement programs that budget experts most commonly point to as necessary targets for reduction. The three areas where most Americans say they would not be willing to see any reductions: public education (61 percent), Medicare (58 percent) and Social Security (58 percent), followed by 46 percent that said they would not be able to accept any reductions to the Medicaid program. All of these percentages are roughly unchanged from two years ago, suggesting the past year of debate over the need to make cuts has not greatly altered the general shape of public opinion. Instead, the parts of the budget most commonly named by the public are foreign aid and, up from a similar survey fielded at the start of 2011, funding for the conflict in Afghanistan. For each of these, just over half of Americans say they would support major spending reductions.

When it comes to the ACA’s role in deficit reduction, the largest group (40 percent) opposes the idea of reducing tax subsidies scheduled to help people pay for insurance beginning in 2014, with 34 percent supporting minor reductions and 24 percent major reductions. There are, not surprisingly, partisan divisions in these views: Most Democrats (55 percent) say they do not want to see any cuts to spending on the subsidies, whereas eight in ten Republicans (79 percent) would be willing to see at least minor cuts. These partisan differences on where to cut spending are fairly widespread, with Republicans more likely than Democrats to be willing to cut spending in nearly every area, with the one prominent exception being national defense.

FIGURE 5: MAJORITIES AGREE NO CUTS TO MEDICARE AND SOCIAL SECURITY
Percent who say they would support “no reductions” to spending for each of the following programs as a way to reduce the federal deficit:	Democrats	Independents	Republicans
Public education	71%	62%	44%
Medicare	66	56	50
Social Security	66	55	55
Medicaid	59	42	29
Health insurance subsidies	55	36	18
Food stamps	43	24	13
Unemployment insurance	37	20	17
Aid to farmers	34	32	32
Salaries and benefits for federal government workers	23	13	19
National defense	22	30	45
Foreign aid	11	9	2
The conflict in Afghanistan	9	12	14
Note: Some items asked of separate half samples.

Medicare and the Debate over Deficit Reduction

One important question in the debate over deficit reduction is the appropriate role that should be played by the Medicare program, with some policymakers advocating reductions in Medicare spending via a variety of different proposals and others vowing to block any cuts. When it comes to public opinion on the topic, the survey suggests that while the public may be open to some specific proposals to reduce Medicare spending, overall they are quite reluctant to see the program cut significantly or changed.

Medicare Seen as Important, Successful. Medicare is a program that is woven into the fabric of most Americans’ family lives over time, and is seen by most people – and particularly its prime constituency, seniors – as working well. Overall, three in four Americans – including majorities of Democrats, independents and Republicans – say Medicare is at least somewhat important to their own family, with 54 percent overall calling it “very important.” Highlighting the economic security aspect of the program, the share saying the program is “very important” rises to over seven in ten among seniors, those in low income households, African Americans, and those who report not being in good health.

And six in ten Americans – again with majorities across the partisan spectrum – say that the program is working well. Seniors themselves are the most likely to say the program is successful, with eight in ten saying it serves seniors well, by far the highest approval rating across age groups.

Most Don’t See the Need for Medicare Cuts. Perhaps presenting an even higher public opinion hurdle to those who would make changes to the program, there is a widespread view among the public that cuts to Medicare are not really needed—that there are other, ‘better’ ways to reduce the deficit. According to the survey, most Americans (75 percent) currently believe that if the president and Congress made the “right changes,” they could significantly reduce the budget deficit without making major reductions in Medicare spending. Over seven in ten Democrats, independents and Republicans are of this opinion, one of the few areas of bipartisan agreement, and younger Americans are as likely to say so as seniors. And these views are strongly related to willingness to cut the program. Among those who believe the deficit can be reduced without major cuts to Medicare, about a third (36 percent) would be willing to support spending cuts, compared to two in three (67 percent) among those that say major deficit reduction can’t take place without involving Medicare.

FIGURE 8: THOSE WHO BELIEVE THE PRESIDENT AND CONGRESS CAN’T SOLVE DEFICIT PROBLEM WITHOUT MEDICARE MORE WILLING TO SEE PROGRAM CUT
If the president and Congress decide to reduce the deficit by reducing spending on federal programs and services…	Among those who say deficit can be reduced without major cuts in Medicare spending	Among those who say real deficit reduction requires major cuts in Medicare spending
…would support major cuts in Medicare spending	6%	23%
…would support minor cuts	30	44
…would not support any cuts	63	32

In the big picture, as shown above, this leads to the finding that a majority (58 percent) of Americans say they would not be willing to see any reductions to Medicare as part of deficit reduction discussions. About three in ten would accept minor reductions, and one in ten say they would support major cuts to spending on the program. When thinking about the public’s willingness to accept spending cuts or changes to the Medicare program, it’s worth noting that the context of the arguments they hear could be important to their views. Because the discussion in early 2013 is embedded in a high-profile debate over raising the debt ceiling, sequestration and funding government activities, we have put the questions in that context. But our analysis of previous survey research on Medicare suggests that the public may react more favorably to changes in the program if they are placed in the context of attempts to save and preserve the program itself, rather than presented as ways to reduce the deficit. ¹

The Specifics of Medicare Spending Reduction Proposals. In addition to asking Americans about overall cuts to Medicare spending, a proposal whose non-specific nature might seem more threatening than a more targeted proposal, the survey also queried the public about a list of possible changes to Medicare currently being discussed in the framework of deficit reduction. A number of proposals have been raised as ways to reduce Medicare spending in the context of deficit reduction. Two of the six tested on our survey received majority support: first, requiring drug companies to give the federal government a better deal on medications for low-income people on Medicare, and second, requiring high-income seniors to pay higher Medicare premiums, backed by 85 percent and 59 percent respectively. On the latter proposal, it is notable that the survey also shows that relatively few Americans (roughly two in ten) are aware that wealthier seniors already pay higher premiums for their Medicare coverage.

Meanwhile, Americans tilt negative on the idea of increasing Medicare payroll taxes (43 percent versus 55 percent oppose), and are strongly against the idea of raising premiums for all beneficiaries (85 percent oppose, including 61 percent that strongly oppose), at least when framed as ways to reduce the deficit.

Raising the Age of Eligibility. Two other proposals currently divide the public nearly in half: raising the age of Medicare eligibility (48 percent support, 51 percent oppose), and reducing payments to hospitals and other providers (46 percent versus 51 percent). The survey suggests that public opinion on changing the age of eligibility – a proposal that has received a fair amount of attention in recent months – is still moveable to a degree. When those who favor raising Medicare’s eligibility age were provided a counterargument, that the proposal would increase costs for employers and those people not yet eligible for Medicare and might leave some uninsured, just over half of them (representing 24 percent of the public overall) said they would be more likely to oppose the age change. On the flip side, when those who oppose the idea of increasing the eligibility age were told that the proposal would save the federal government money and help preserve the program, 15 percent of the public now felt more favorable to the proposal.

FIGURE 10: ARGUMENTS CAN SWAY PUBLIC OPINION ON RAISING THE ELIGIBILITY AGE
Would you favor or oppose raising the age of eligibility for Medicare from 65 to 67 for future retirees as a way to reduce the federal deficit?	Favor		Oppose
	48%		51%
After those in favor heard that “this proposal would increase costs for employers and people not yet eligible for Medicare, and may leave those that can’t afford coverage uninsured”	Favor	More likely to oppose	Oppose
	20%	24%	51%
After those opposed heard that “this proposal would save the federal government money and help preserve Medicare for the long term”	Favor		More likely to favor	Oppose
	48%		15%	35%

There is one group of Americans where a clear majority would be willing to see the future Medicare retirement age rise to 67: those who have already safely passed the current eligibility age of 65. Among today’s seniors, most say they favor the idea of increasing the age for future beneficiaries. At the same time, however, seniors are much less likely to favor the idea of cutting Medicare payments to hospitals and other health care providers that are treating them.

FIGURE 11: MOST SENIORS FAVOR INCREASING THE MEDICARE ELIGIBILITY AGE
	18-64	65+
Gradually raising the age of eligibility for Medicare
Favor	43%	64%
Oppose	55	35
Reducing payments to hospitals/other providers for treating Medicare patients
Favor	48%	35%
Oppose	49	59

Views on Public Health Spending Priorities

In addition to questions about the federal government’s insurance programs (Medicare, Medicaid, and the Affordable Care Act), the survey also asked people about their priorities for health spending in 15 additional program areas, given the substantial federal budget deficit. Five of these areas were cited by a majority of the public as being “one of the top priorities” for federal spending: funding for veterans’ health care (60 percent), preparing for and responding to health problems or injuries resulting from natural disasters or terrorist attacks (59 percent), increasing research to find new cures and treatments for major disease threats (58 percent), preventing the spread of infectious diseases, including providing vaccinations (52 percent), and preventing chronic illnesses, such as heart disease, cancer, and diabetes (51 percent). When asked if federal spending on improving health and preventing illness saves the nation money in the long run, two-thirds of the public (67 percent) says it does. Not surprisingly, those who hold this belief are significantly more likely to prioritize spending on things like vaccinations and screening tests, as well as providing funds to state public health departments and hospitals that treat the uninsured.

FIGURE 12: PUBLIC HEALTH SPENDING PRIORITIES
Given the national budget deficit, what should be a priority for federal spending this year?	One of the Top Priorities
Funding for veterans’ health care	60%
Preparing for – and responding to – health problems or injuries resulting from natural disasters or terrorist attacks	59
Increasing research to find new cures and treatments for major disease threats	58
Preventing the spread of infectious diseases, including providing vaccinations	52
Preventing chronic illnesses, such as heart disease, cancer and diabetes	51
Ensuring the safety and effectiveness of prescription drugs	47
Providing screening tests for major health problems	40
Detecting and preventing foodborne illnesses	36
Preventing the spread of HIV/AIDS	36
Funding support to hospitals so they can provide free or subsidized care to people without health insurance	34
Ensuring workplace safety	33
Funding to state public health departments	31
Reducing smoking and tobacco use	26
Reducing obesity by promoting healthy lifestyles	26
Preventing injuries, such as burns, poisoning and falls	17

The Government’s Role in Health Care Policy: The Big Picture

Asked to say in their own words what they thought the federal government should focus on to improve the American health care system, the public was fairly divided, focusing on three familiar themes in the ongoing public debate: making health care more affordable (25 percent), making it more accessible (21 percent), and staying out of the way (19 percent).

FIGURE 13: IN THEIR OWN WORDS… “If the federal government could do one thing to improve the nation’s health care system in the next few years, what do you think it should be?”
Make health care more affordable, lower costs	25%
“Facilitate lower health care costs”
“Make it more affordable for people to get health care”
“Reduce hospital costs”
“Make sure every patient is able to afford their needed medication”
“Make insurance more affordable”
“Make it affordable for people who don’t have that much”
“The cost needs to go down”
Make health care more accessible, available to more people	21%
“I feel that there should be a mandate that everyone participate in national health insurance”
“Universal health care”
“Health care for everybody regardless of age and pre-existing conditions”
“That everyone in the United States should have health care”
“To get more health care for people”
“Having a broader spectrum of health coverage”
“More health care for the elderly”
Less federal government intervention	19%
“Get their nose out of health care and just open up competition amongst the health care providers”
“Get out of the way and let people who are involved in the industry do their job”
“Get out of the health care business”
“Let people take care of themselves financially including health insurance. I just don’t think the government should be telling people what to do”
“Get rid of ObamaCare”
“The federal government should stay out of it. Leave it up to local government”
“Start with repealing the Affordable Care Act”
Note: Only responses of 5 percent or more shown. Other, Don’t know/Refused answers not shown.

What Role Should the Federal and State Governments Play in Improving the Health Care System? Underlying the partisan divisions on specific aspects of health care policy and government spending lie real differences of opinion about the role of the federal and state governments in making the American health care system work well. Most Democrats say the federal government should play a “major role” in this arena (67 percent), and only slightly fewer say the same about state governments (58 percent). But while most Republicans do see some role for the federal and state governments in improving health care access and quality, the plurality see that role as a “minor” one. Independents are even more divided when it comes to how involved government should be.

Cancer and Heart Disease of Most Concern to Americans. Asked about the diseases or health conditions that pose the greatest threats to the American public, the public’s top concerns are cancer (56 percent) and heart disease (35 percent), as was the case when the same question was asked in a 2007 Robert Wood Johnson Foundation/Harvard School of Public Health poll. That same six-year period saw a substantial increase in the proportion of the public that saw diabetes (30 percent in 2013, compared to 14 percent in 2007) and obesity (26 percent in 2013, compared to 6 percent in 2007) as posing one of the two greatest threats.