SURVEY BRIEF MARCH 2018 Americans’ 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 Views on Health 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 Insurance at January, about 3.7 percent fewer than the prior year.1 There 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. the End of a To gauge the perspectives of Americans on the marketplaces, Medicaid, and other health insurance issues, the Commonwealth Fund Affordable Care Act Tracking Survey interviewed Turbulent Year 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. Sara R. Collins Vice President HIGHLIGHTS The Commonwealth Fund Adults were asked about: Munira Z. Gunja INSURANCE COVERAGE 14 percent of working age adults were uninsured at the end of 2017, Senior Researcher unchanged from March–June 2017. The Commonwealth Fund WARENESS OF THE MARKETPLACES 35 percent of uninsured adults were not aware of the A marketplaces. Michelle M. Doty Vice President EASONS FOR NOT GETTING COVERED Among uninsured adults who were aware of the R The Commonwealth Fund 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71 percent said they didn’t think they could afford health insurance, while 23 percent thought the ACA was going to be repealed. Herman K. Bhupal Program Assistant ONFIDENCE ABOUT STAYING COVERED About three in 10 people with marketplace C The Commonwealth Fund 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%). HOULD AFFORDABLE HEALTH CARE BE A RIGHT? 92 percent of working-age adults think S 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. Americans’ Views on Health Insurance at the End of a Turbulent Year 2 The uninsured rate among working-age adults held steady at 14 percent. The uninsured rate among working-age adults held steady at 14 percent. Percent of adults ages 19–64 who were uninsured At the end of 2017, 14 percent of adults ages 19 to 64 were 40 uninsured, the same as six months earlier. (See the 33.6 Appendix for a comparison with other recent federal 30 and private survey estimates.) This remains 23.4 22.4 above the lowest rate in 21.2 20.9 2016, although the difference 19.9 20 20.7 <250% FPL is not statistically significant. 14.8 Still, it is well below the 20 13.3 14.0 12.7 percent uninsured rate seen 14.0 All adults just prior to the ACA’s first 10 open enrollment period. 7.2 6.2 5.7 7.7 4.1 4.4 250% FPL Uninsured rates are highest or more among low-income adults, Latinos, the unemployed, 0 July–Sept. 2013 April–June 2014 March–May 2015 Feb.–April 2016 March–June 2017 Nov.–Dec. 2017 employees of small firms, and residents of states that have yet to expand Note: FPL refers to federal poverty level; 250% FPL is about $31,150 for an individual and $61,500 for a family of four. Medicaid. (See Tables 1–3 for Data: The Commonwealth Fund Affordable Care Act Tracking Surveys, July–Sept. 2013, April–June 2014, March–May 2015, Feb.–April 2016, March–June 2017, and Nov.–Dec. 2017. complete data.) Note: FPL refers to federal poverty level; 250% FPL is about $31,150 for an individual and $61,500 for a family of four. Source: 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, Data: The Commonwealth Fund Affordable Care Act Tracking Surveys, July–Sept. 2013, April–June 2014, March–May 2015, Feb.–April 2016, March–June 2017, The Commonwealth Fund, March 2018. and Nov.–Dec. 2017. commonwealthfund.org Survey Brief, March 2018 Americans’ Views on Health Insurance at the End of a Turbulent Year 3 Most adults are aware of the marketplaces, but uninsured adults remain less aware. Most adults are aware of the marketplaces, but uninsured adults remain less aware. Five years after the rollout Are you aware of the marketplaces also known as HealthCare.gov or the marketplace in the marketplaces also known as HealthCare.gov or the marketplace in the health insurance Are you aware of your state? of marketplaces, most of the your state? public is aware that people who don’t have employer Adults ages19–64 who responded “no” coverage can get a plan through the marketplaces. 75 Lack of awareness is higher 68 among uninsured adults, and though there has been some improvement over the 60 50 last year, the change is not 42 40 statistically significant. 40 37 These findings suggest 35 Uninsured that more advertising and unaware 25 outreach could help lower 26 21 Total the uninsured rate. 24 19 21 unaware 0 July–Sept. 2013 April–June 2014 March–May 2015 Feb.–April 2016 March–June 2017 Nov.–Dec. 2017 Data: The Commonwealth Fund Affordable Care Act Tracking Surveys, July–Sept. 2013, April–June 2014, March–May 2015, Feb.–April 2016, March–June 2017, and Nov.–Dec. 2017. Data: The Commonwealth Fund Affordable Care Act Tracking Surveys, July–Sept. 2013, April–June 2014, March–May 2015, Feb.–April 2016, March–June 2017, and Nov.–Dec. 2017. Source: 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. commonwealthfund.org Survey Brief, March 2018 Americans’ Views on Health Insurance at the End of a Turbulent Year 4 Uninsured adults most often cite concerns about affordability as the reason why they didn’t plan to shop for marketplace coverage. Uninsured adults most often not concerns aboutthe marketplace to shop for health You said that you do cite intend to visit affordability as the reason why they About half (47%) of didn’t plan to shop for marketplace coverage. insurance this fall. What are the reasons you do not plan to visit the uninsured adults were You said that you doit because...? marketplace? Is not intend to visit the marketplace to shop for health insurance this aware of the marketplaces fall. What are the reasons you do not plan to visit the marketplace? Is it because...? but said they did not intend to visit them last fall to buy Percent of uninsured adults ages 19–64 who were aware of the marketplaces health insurance. When but did not intend to visit asked what the reasons were, 71 percent said they didn’t think they could 71 afford coverage. About one- third said they didn’t think they would be eligible, while a similar share said they 38 37 didn’t think they needed 29 26 23 health insurance. 16 Last year’s debate over the You don’t think You don’t think You don’t think You are going to go You heard the You don’t think Some other ACA likely affected some you can afford you will be eligible you need health someplace else Affordable Care the government reason uninsured adults’ decisions health insurance for health insurance insurance to look for health Act is going requires you to have insurance coverage to be repealed health insurance not to shop for marketplace any longer coverage: 23 percent said they thought the law was going to be repealed, and 16 Data: The Commonwealth Fund Affordable Care Act Tracking Survey, Nov.–Dec. 2017. percent said they thought the government no longer Source: 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. required them to have Data: The Commonwealth Fund Affordable Care Act Tracking Survey, Nov.–Dec. 2017. health insurance. commonwealthfund.org Survey Brief, March 2018 Americans’ Views on Health Insurance at the End of a Turbulent Year 5 Adults with marketplace plans or Medicaid express the least confidence in being able to keep their coverage in the future. Adults with marketplace plans or Medicaid express the least confidence in being able to keep their coverage in the future. You said you currently have health insurance. How confident are you that People with marketplace You said you currently have health insurance. How confident are you that you will be able you will be able to keep this health care coverage in the future? to keep this health care coverage in the future? plans or Medicaid are significantly less likely Percent of insured adults ages 19–64 than those with employer who were not too or not at all confident Not too confident Not at all confident benefits to be confident that they will be able to keep their health insurance in the All adults 10 6 15 future. About one-third of marketplace enrollees and one-quarter of Medicaid Employer 6 3 9 beneficiaries were not confident they could keep Medicaid 18 9 27 their plans in the future; Marketplace 19 17 36 just 9 percent of those with employer plans were not confident. (See Table 4 for Income below 250% FPL 16 7 22 complete data.) Income at or above 250% FPL 5 5 10 Notes: Segments may not sum to indicated total because of rounding. FPL refers to federal poverty level; 250% FPL is about $31,150 for an individual and $61,500 for a family of four. Data: The Commonwealth Fund Affordable Care Act Tracking Survey, Nov.–Dec. 2017. Source: 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. Notes: Segments may not sum to indicated total because of rounding. FPL refers to federal poverty level; 250% FPL is about $31,150 for an individual and $61,500 for a family of four. Data: The Commonwealth Fund Affordable Care Act Tracking Survey, Nov.–Dec. 2017. commonwealthfund.org Survey Brief, March 2018 Americans’ Views on Health Insurance at the End of a Turbulent Year 6 Among Medicaid or marketplace enrollees who lacked confidence about keeping their plans, nearly half said the Trump administration wouldn’t carry out the ACA or Congress would repeal it. Among Medicaid or marketplace enrollees who lacked confidence about keeping their plans, nearly half said the Trump administration wouldn’t carry out the ACA or Congress would repeal it. When asked why they What is the main reason youyou are not confident will be able to keep this coverage in What is the main reason are not confident you you will be able to keep this weren’t confident they the future? in the future? coverage could keep their health insurance in the future, 32 percent of marketplace and The Trump administration will not carry out the law 32 Medicaid enrollees said You won't be able to afford this coverage they didn’t think the Trump 19 administration would Congress will repeal the law carry out the ACA, while 15 15 percent expected Congress Insurers won't provide this coverage where you live to repeal the law. About 12 one in five didn’t think they Will not longer qualify for it would be able to afford their 8 insurance, and 12 percent Some other reason 11 thought insurers might not offer it where they live. Don't know 4 Adults ages 19–64 with marketplace or Medicaid coverage who were not confident they would be able to keep health care coverage in the future Note: Categories may not sum to 100 percent because of rounding. Data: The Commonwealth Fund Affordable Care Act Tracking Survey, Nov.–Dec. 2017. Note: Categories may not sum to 100 percent because of rounding. Data: The Commonwealth Fund Affordable Care M. Z.Tracking M. Doty, and H. K. Bhupal, Americans’ Views on Health Insurance at the End of a Turbulent Year, Source: S. R. Collins, Act Gunja, M. Survey, Nov.–Dec. 2017. The Commonwealth Fund, March 2018. commonwealthfund.org Survey Brief, March 2018 Americans’ Views on Health Insurance at the End of a Turbulent Year 7 Most people think all Americans should have the right to affordable health care. Most people think all Americans should have the right to affordable health care. Nearly all U.S. adults, Do you think all Americans should have the right to affordable health care? regardless of political Do you think all Americans should have the right to affordable health care? affiliation or income, think all Americans should have What if everyone had to contribute the right to affordable financially over their lifetime in health care. This includes order to have the right to affordable 99 percent of Democrats, 82 health care? Under those circumstances would you consider percent of Republicans, and affordable health care to be a right? 92 percent of independents. (See Table 5 for complete Yes data.) No 29% Of the 8 percent of adults Yes 92% Adults ages 7% who either don’t think 19–64 No Americans should have Don't know/Refused 1% 58% the right to affordable health care, or didn’t know Don't know/Refused or refused to respond, 29 13% percent said they would Adults who don't think Americans consider health care a right should have the right to affordable if people had to contribute health care or responded "don't know”/refused to respond financially over their lifetime. Data: The Commonwealth Fund Affordable Care Act Tracking Survey, Nov.–Dec. 2017. Source: 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. Data: The Commonwealth Fund Affordable Care Act Tracking Survey, Nov.–Dec. 2017. commonwealthfund.org Survey Brief, March 2018 Americans’ Views on Health Insurance at the End of a Turbulent Year 8 Most think paying into Medicare over a lifetime is a fair way to ensure everyone hink paying into Medicare over a lifetime is a fair way to ensure everyone has s to care at age 65.to care at age 65. has access Most people contribute financially to Medicare over their lifetime through payroll taxes. Do you think thispeople contribute financially toeveryone over access to Medicare when they requires lifetime Most is a fair way to help ensure Medicare has their lifetime through Medicare become eligible attaxes.65, or not? this is a fair way to help ensure everyone has payroll age Do you think financial contributions. access to Medicare when they become eligible at age 65, or not? 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 No Democrats, 84 percent of Adults 9% Republicans, and 87 percent Yes of independents. (See Table 6 ages 19–64 87% Don't know/Refused for complete data.) 4% monwealth Fund Affordable Care Act Tracking Survey, Nov.–Dec. 2017. Data: The Commonwealth Fund Affordable Care Act Tracking Survey, Nov.–Dec. 2017. Source: 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, commonwealthfund.org The Commonwealth Fund, March 2018. Survey Brief, March 2018 Americans’ Views on Health Insurance at the End of a Turbulent Year 9 POLICY IMPLICATIONS This survey, along with other recent federal and private surveys, The absence of such signals from Washington may fuel an emerging indicate that gains in coverage post-ACA have leveled out, and debate over how best to insure that all Americans have coverage that uninsured rates may even be ticking up slightly. As our findings provides them with access to affordable health care. Some proposals suggest, policy changes could increase coverage, including greater call for building on the ACA to achieve this goal. Others would allow outreach and advertising in all states and reforms to improve plan people to buy in to Medicare or Medicaid. Still others would replace affordability. the ACA with a Medicare for all approach, while others would Analysts Christine Eibner and Jodi Liu modeled six options to provide funds to states to design their own systems. This survey’s increase affordability of marketplace coverage, including extending finding that strong majorities of U.S. adults, regardless of party tax credits to people who are above the income eligibility threshold affiliation, believe that all Americans should have a right to affordable and instituting a federal reinsurance program.2 Medicaid expansion, health care suggests there may be popular support for a discussion however, remains the most obvious means for expanding coverage over our preferred path. 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. commonwealthfund.org Survey Brief, March 2018 Americans’ Views on Health Insurance at the End of a Turbulent Year 10 HOW WE CONDUCTED THIS STUDY The most recent Commonwealth Fund Affordable households reached through their omnibus survey of respondents who had gained coverage under the ACA. Care Act Tracking Survey was conducted by SSRS from adults between November 5, 2014, and February 1, 2015, Interviews in wave 6 were obtained through two sources: November 2 to December 27, 2017. The survey consisted who were uninsured, had individual coverage, had a 1) stratified RDD sample, using the same methodology of telephone interviews in English or Spanish and was marketplace plan, or had public insurance. The survey had as in waves 1–5; and 2) households reached through conducted among a random, nationally representative an overall margin of sampling error of +/– 2.1 percentage the SSRS Omnibus, where interviews were previously sample of 2,410 adults, ages 19 to 64, living in the United points at the 95 percent confidence level. completed with respondents ages 19 to 64 who were States. Overall, 122 interviews were conducted on landline The fourth survey in the series was conducted by SSRS uninsured, had individual coverage, had a marketplace telephones and 2,288 interviews on cell phones. from February 2 to April 5, 2016, by telephone among a plan, or had public insurance. This survey is the sixth in a series of Commonwealth random, nationally representative U.S. sample of 4,802 As in all waves of the survey, SSRS oversampled adults Fund surveys to track the implementation and impact of adults, ages 19 to 64. The February–April 2016 sample with incomes under 250 percent of the federal poverty the ACA. The first was conducted by SSRS from July 15 was also designed to increase the likelihood of surveying level to further increase the likelihood of surveying to September 8, 2013, by telephone among a random, respondents who had gained coverage under the ACA. respondents eligible for the coverage options as well as nationally representative U.S. sample of 6,132 adults ages Interviews in wave 4 were obtained through two sources: to allow separate analyses of responses from low-income 19 to 64. The survey had an overall margin of sampling 1) stratified RDD sample, using the same methodology households. error of +/– 1.8 percent at the 95 percent confidence level. as in waves 1–3; and 2) households reached through The data were weighted to correct for oversampling The second survey in the series was conducted by the SSRS Omnibus, where interviews were previously uninsured and direct purchase respondents, the stratified SSRS from April 9 to June 2, 2014, by telephone among completed with respondents ages 19 to 64 who were sample design, the overlapping landline and cell phone a random, nationally representative U.S. sample of uninsured, had individual coverage, had a marketplace sample frames, and disproportionate nonresponse that 4,425 adults ages 19 to 64. The survey had an overall plan, or had public insurance. The survey had an overall might bias results. New to this wave’s sample design, the margin of sampling error of +/– 2.1 percent at the 95 margin of sampling error of +/– 2.0 percentage points at weights also corrected for oversampling respondents with percent confidence level. The sample for the April–June the 95 percent confidence level. a prepaid cell phone. The data are weighted to the U.S. 2014 survey was designed to increase the likelihood of The fifth survey in the series was conducted by SSRS from 19-to-64 adult population by age by state, gender by state, surveying respondents who were most likely eligible March 28 to June 20, 2017, by telephone among a random, race/ethnicity by state, education by state, household size, for new coverage options under the ACA. As such, nationally representative U.S. sample of 4,813 adults, ages geographic division, and population density using the U.S. respondents in the July–September 2013 survey who 19 to 64. The March–June 2017 sample was also designed Census Bureau’s 2015 American Community Survey. Data said they were uninsured or had individual coverage to increase the likelihood of surveying respondents who were weighted to household telephone use parameters were asked if they could be recontacted for the April– had gained coverage under the ACA. Interviews in wave based on the CDC’s 2016 National Health Interview Survey June 2014 survey. SSRS also recontacted households 5 were obtained through two sources: 1) stratified RDD (NHIS). reached through their omnibus survey of adults who were sample, using the same methodology as in waves 1–4; and The resulting weighted sample is representative of the uninsured or had individual coverage prior to the first open 2) households reached through the SSRS Omnibus where approximately 190 million U.S. adults ages 19 to 64. Data enrollment period for 2014 marketplace coverage. interviews were previously completed with respondents for income, and subsequently for federal poverty level, The third survey in the series was conducted by SSRS from ages 19 to 64 who were uninsured, had individual were imputed for cases with missing data, utilizing a March 9 to May 3, 2015, by telephone among a random, coverage, had a marketplace plan, or had public insurance. standard general linear model procedure. The survey has nationally representative U.S. sample of 4,881 adults, ages The survey had an overall margin of sampling error of +/– an overall margin of sampling error of +/– 2.7 percentage 19 to 64. The March–May 2015 sample was also designed 1.8 percentage points at the 95 percent confidence level. points at the 95 percent confidence level. The overall to increase the likelihood of surveying respondents who The November–December 2017 sample was also response rate, including the prescreened sample, was had gained coverage under the ACA. SSRS recontacted designed to increase the likelihood of surveying 7.0 percent. commonwealthfund.org Survey Brief, March 2018 Americans’ Views on Health Insurance at the End of a Turbulent Year 11 Table 1. Demographics of Overall Sample, Uninsured Adults, and Adults by Coverage Source Total adults Uninsured Total current marketplace Enrolled in a private health Enrolled in Enrolled in employer- (ages 19–64) adults and Medicaid enrollees plan through the marketplace Medicaid sponsored insurance Percent distribution 100% 14% 19% 7% 12% 54% Age 19–34 33 40 30 24 33 35 19–25 15 17 12 13 12 15 26–34 18 23 18 10 22 19 35–49 32 33 31 31 31 34 50–64 33 27 36 43 33 30 Race/Ethnicity Non-Hispanic White 61 44 54 64 49 68 Black 13 10 17 13 19 12 Latino 18 36 21 15 24 13 U.S.-born Latino 9 11 11 9 11 8 Foreign-born Latino 9 25 10 5 13 5 Asian/Pacific Islander 4 5 4 4 3 4 Other/Mixed 3 3 4 3 4 2 Poverty status Below 250% poverty 48 72 76 54 88 29 250% poverty or more 52 28 24 46 12 71 NOTES Health status Fair/Poor health status, or any * The following states 50 47 62 53 67 43 expanded their Medicaid chronic condition or disability^ No health problem 50 53 38 47 33 57 program and began Political affiliation enrolling individuals by the Democrat 29 19 34 33 35 31 time of the survey: AK, AR, Republican 19 18 13 20 9 21 AZ, CA, CO, CT, DE, HI, IA, Independent 26 26 26 27 25 25 IN, IL, KY, LA, MA, MD, MI, Something else 17 18 18 15 19 17 MN, MT, ND, NH, NJ, NM, State Medicaid expansion decision* NV, NY, OH, OR, PA, RI, VT, Expanded Medicaid 61 49 72 59 79 60 WA, WV, and the District of Did not expand Medicaid 38 51 28 41 21 39 Columbia. All other states Region were considered to have Northeast 17 12 18 14 20 18 not expanded. Midwest 20 18 20 20 20 20 ^ At least one of the South 38 47 30 38 25 38 following chronic West 25 23 33 28 35 23 conditions: hypertension Adult work status or high blood pressure; Full-time 56 40 28 47 18 75 heart disease; diabetes; Part-time 14 18 22 22 23 9 asthma, emphysema, Not working 29 40 50 31 59 15 or lung disease; or high Employer size^^ cholesterol. 1–24 employees 28 57 46 60 34 16 25–99 employees 13 17 14 18 11 11 ^^ Base: full- and part-time 100–499 employees 12 5 4 3 5 15 employed adults ages 500 or more employees 44 15 28 17 38 55 19–64. Education level Data: The Commonwealth High school or less 37 52 46 30 54 30 Fund Affordable Care Act Some college/technical school 31 33 36 40 34 27 Tracking Survey, Nov.–Dec. College graduate or higher 32 12 18 30 12 43 2017. commonwealthfund.org Survey Brief, March 2018 Americans’ Views on Health Insurance at the End of a Turbulent Year 12 Table 2. Uninsured Rates Among Adults, 2013–2017 July–Sept. 2013 April–June 2014 March–May 2015 Feb.–April 2016 March–June 2017 Nov.–Dec. 2017 Percent distribution 19.9% 14.8% 13.3% 12.7% 14.0% 14.0% Age 19–34 28 18 19 18 16 17 19–25 31 19 16 17 14 15 26–34 26 18 23 19 18 18 35–49 18 15 13 11 15 15 50–64 14 11 8 9 10 11 Race/Ethnicity Non-Hispanic White 16 12 9 9 10 10 Black 21 20 18 13 17 10 Latino 36 23 26 29 30 28 U.S.-born Latino 24 * * 14 17 18 Foreign-born Latino 47 * * 43 42 38 Asian/Pacific Islander 18 10 8 9 5 * Other/Mixed 23 12 14 11 13 — Poverty status Below 250% poverty 34 23 21 21 22 21 250% poverty or more 7 6 4 4 6 8 NOTES Health status * Not applicable. Fair/Poor health status, or any chronic 16 14 13 13 13 20 condition or disability^ — Sample size limitations. No health problem 20 14 13 12 15 15 Political affiliation ** We categorize states Democrat 18 13 10 10 10 9 as expansion states if Republican 11 11 8 8 10 13 their state expanded their Independent 19 14 15 12 15 14 Medicaid program and Something else 28 19 17 16 17 15 were enrolling people by State Medicaid expansion decision** the time of the survey. Expanded Medicaid 18 12 10 10 11 11 ^ At least one of the Did not expand Medicaid 23 19 18 16 19 18 following chronic Region conditions: hypertension Northeast 13 12 8 10 9 10 or high blood pressure; Midwest 17 13 8 8 9 13 heart disease; diabetes; South 24 19 18 16 19 17 asthma, emphysema, West 21 12 13 13 14 13 or lung disease; or high Adult work status cholesterol. Full-time 14 12 10 9 11 10 Part-time 29 19 14 17 20 18 ^^ Base: full- and part-time Not working 25 17 18 17 17 19 employed adults ages Employer size^^ 19–64. 1–24 employees 32 25 21 24 25 23 Data: The Commonwealth 25–99 employees 20 17 17 14 13 16 Fund Affordable Care Act 100–499 employees 13 8 9 6 8 5 Tracking Surveys, July– 500 or more employees 7 6 4 3 5 4 Sept. 2013, April–June Education level 2014, March–May 2015, High school or less 28 23 22 22 23 20 Feb.–April 2016, March– Some college/technical school 19 14 11 11 11 15 June 2017, and Nov.–Dec. College graduate or higher 10 5 5 3 6 5 2017. commonwealthfund.org Survey Brief, March 2018 Americans’ Views on Health Insurance at the End of a Turbulent Year 13 Table 3. Demographics of Total Adults and Uninsured Adults, July–Sept. 2013 and Nov.–Dec. 2017 Total adults (ages 19–64) Uninsured adults (ages 19–64) July–Sept. 2013 Nov.–Dec. 2017 July–Sept. 2013 Nov.–Dec. 2017 Percent distribution 100% 100% 100% 100% Age 19–34 32 33 46 40 19–25 15 15 23 17 26–34 18 18 23 23 35–49 32 32 29 33 50–64 33 33 23 27 Race/Ethnicity Non-Hispanic White 63 61 50 44 Black 12 13 13 10 Latino 16 18 29 36 U.S.-born Latino 7 9 9 11 Foreign-born Latino 9 9 20 25 Asian/Pacific Islander 4 4 3 5 Other/Mixed 2 3 3 3 Poverty status Below 250% poverty 48 48 81 72 250% poverty or more 52 52 19 28 Health status Fair/Poor health status, or any chronic condition or disability^ 47 50 47 47 No health problem 53 50 53 53 Political affiliation Democrat 30 29 28 19 Republican 20 19 11 18 NOTES Independent 24 26 22 26 * We categorize states as Something else 16 17 22 18 expansion states if their State Medicaid expansion decision* state expanded their Expanded Medicaid 59 61 53 49 Medicaid program and Did not expand Medicaid 41 38 46 51 were enrolling people by Region the time of the survey. Northeast 17 17 12 12 Midwest 22 20 18 18 ^ At least one of the South 38 38 46 47 following chronic West 23 25 25 23 conditions: hypertension Adult work status or high blood pressure; Full-time 53 56 39 40 heart disease; diabetes; Part-time 12 14 18 18 asthma, emphysema, or lung disease; or high Not working 33 29 42 40 cholesterol. Employer size^^ 1–24 employees 26 28 48 57 ^^ Base: full- and part-time 25–99 employees 17 13 19 17 employed adults ages 100–499 employees 15 12 11 5 19–64. 500 or more employees 41 44 17 15 Data: The Commonwealth Education level Fund Affordable Care Act High school or less 39 37 56 52 Tracking Surveys, July– Some college/technical school 30 31 29 33 Sept. 2013 and Nov.–Dec. College graduate or higher 29 32 14 12 2017. commonwealthfund.org Survey Brief, March 2018 Americans’ Views on Health Insurance at the End of a Turbulent Year 14 Table 4. You said you currently have health insurance. How confident are you that you will be able to keep this health care coverage in the future? Base: Insured adults ages 19–64 Very Somewhat Very or somewhat Not too Not at all Not too or not confident confident confident confident confident at all confident Percent distribution 57% 25% 83% 10% 6% 15% Age 19–34 57 26 83 11 5 16 35–49 59 24 84 10 5 15 50–64 56 26 82 8 6 15 Gender Men 63 22 85 6 7 13 Women 53 28 81 13 5 18 Race/Ethnicity White 61 25 85 7 6 13 Black 56 28 83 10 6 15 Hispanic 44 27 71 22 5 27 Income Below 250% poverty 47 29 76 16 7 22 250% poverty or more 66 23 89 5 5 10 Insurance status Employer 67 22 90 6 3 9 Medicaid 34 36 70 18 9 27 Medicare 44 26 71 13 8 22 Marketplace 32 31 63 19 17 36 Region Northeast 56 25 81 12 6 18 Midwest 60 25 86 9 4 13 South 63 22 85 8 6 13 West 49 30 79 12 6 18 Political affiliation Democrat 57 26 83 11 5 16 Republican 65 20 85 7 8 15 Independent 56 28 84 9 5 14 Voter registration status Not registered 62 22 84 9 5 14 Registered 58 27 85 8 6 14 Notes: Segments may not sum to indicated total because of rounding. “Very or somewhat confident” and “Not too or not at all confident” categories may not sum to 100 percent because of “Don’t know” responses or refusal to respond. Data: The Commonwealth Fund Affordable Care Act Tracking Survey, Nov.–Dec. 2017. commonwealthfund.org Survey Brief, March 2018 Americans’ Views on Health Insurance at the End of a Turbulent Year 15 Table 5. Do you think all Americans should have the right to Table 6. Most people contribute financially to Medicare over affordable health care? their lifetime through payroll taxes. Do you think this is a fair Base: Adults ages 19–64 way to help ensure everyone has access to Medicare when they become eligible at age 65, or not? Base: Adults ages 19–64 Yes No Yes No Percent distribution 92% 7% Percent distribution 87% 9% Age Age 19–34 94 4 19–34 87 9 35–49 91 8 35–49 84 12 50–64 91 8 50–64 89 7 Gender Gender Men 89 9 Men 85 10 Women 95 4 Women 89 8 Race/Ethnicity Race/Ethnicity White 90 9 White 87 9 Black 97 2 Black 85 12 Hispanic 97 2 Hispanic 91 7 Income Income Below 250% poverty 96 2 Below 250% poverty 87 10 250% poverty or more 88 11 250% poverty or more 87 9 Insurance status Insurance status Uninsured 91 7 Uninsured 84 11 Employer 91 8 Employer 88 9 Medicaid 98 1 Medicaid 86 9 Medicare 96 1 Medicare 87 10 Marketplace 93 7 Marketplace 93 5 Region Region Northeast 93 5 Northeast 85 10 Midwest 91 8 Midwest 86 12 South 91 7 South 89 8 West 92 6 West 87 9 Political affiliation Political affiliation Democrat 99 1 Democrat 92 6 Republican 82 17 Republican 84 13 Independent 92 6 Independent 87 10 Voter registration status Voter registration status Not registered 95 4 Not registered 82 12 Registered 91 8 Registered 88 9 Data: The Commonwealth Fund Affordable Care Act Tracking Survey, Nov.–Dec. 2017. Data: The Commonwealth Fund Affordable Care Act Tracking Survey, Nov.–Dec. 2017. commonwealthfund.org Survey Brief, March 2018 Americans’ Views on Health Insurance at the End of a Turbulent Year 16 NOTES ACKNOWLEDGMENTS National Academy for State Health Policy, Individual Marketplace 1 The authors thank Robyn Rapoport, Sarah Glancey, Erin Czyzewicz, Enrollment Remains Stable in the Face of National Uncertainty Rob Manley, and Arina Goyle of SSRS; and David Blumenthal, Eric (NASHP, Feb. 7, 2018), https://nashp.org/individual-marketplace- Schneider, Chris Hollander, Paul Frame, Jen Wilson, Shanoor Seervai, enrollment-remains-stable-in-the-face-of-national-uncertainty/. and Arnav Shah of the Commonwealth Fund. C. Eibner and J. Liu, Options to Expand Health Insurance Enrollment 2 in the Individual Market (The Commonwealth Fund, Oct. 2017), http://www.commonwealthfund.org/publications/fund- reports/2017/oct/expand-insurance-enrollment-individual-market. S. L. Hayes, S. R. Collins, D. C. Radley, and D. McCarthy, What’s 3 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. commonwealthfund.org Survey Brief, March 2018 Americans’ Views on Health Insurance at the End of a Turbulent Year 17 ABOUT THE AUTHORS Sara R. Collins, Ph.D., is vice president for Health Care Coverage and Access Herman K. Bhupal is program assistant in the Health Care Coverage and at the Commonwealth Fund. An economist, Dr. Collins joined the Fund in Access program at the Commonwealth Fund, joining the staff in June 2017. She 2002 and has led the Fund’s national program on health insurance since is responsible for providing daily support for the program, with responsibilities 2005. Since joining the Fund, she has led several national surveys on health ranging from daily administrative and grants management tasks to writing insurance and authored numerous reports, issue briefs, and journal articles and research. Prior to joining the Fund, Ms. Bhupal was an associate at PwC on health insurance coverage and policy. She has provided invited testimony Strategy&, where she served several health care clients in a strategy consulting before several Congressional committees and subcommittees. Prior to joining role. She graduated with a B.A. in economics with honors from Harvard the Fund, Dr. Collins was associate director/senior research associate at the University in May 2016. New York Academy of Medicine. Earlier in her career, she was an associate editor at U.S. News & World Report, a senior economist at Health Economics Research, and a senior health policy analyst in the New York City Office of Editorial support was provided by Christopher Hollander. the Public Advocate. Dr. Collins holds a Ph.D. in economics from George Washington University. For more information about this brief, please contact: Munira Z. Gunja, M.P.H., is senior researcher in the Health Care Coverage and Sara R. Collins, Ph.D. Access program at the Commonwealth Fund. Ms. Gunja joined the Fund from Vice President, Health Care Coverage and Access the U.S. Department of Health and Human Services in the office of the Assistant The Commonwealth Fund Secretary for Planning and Evaluation (ASPE), Division of Health Care Access srccmwf.org and Coverage, where she received the Secretary’s Award for Distinguished Service. Before joining ASPE, Ms. Gunja worked for the National Cancer About the Commonwealth Fund Institute where she conducted data analysis for numerous studies featured in The mission of the Commonwealth Fund is to promote a high performance scientific journals. She graduated from Tulane University with a B.S. in public health care system. The Fund carries out this mandate by supporting health and international development and an M.P.H. in epidemiology. independent research on health care issues and making grants to improve health care practice and policy. Support for this research was provided by the Michelle McEvoy Doty, Ph.D., is vice president of survey research and Commonwealth Fund. The views presented here are those of the authors and not evaluation for the Commonwealth Fund. She has authored numerous necessarily those of the Commonwealth Fund or its directors, officers, or staff. publications on cross-national comparisons of health system performance, access to quality health care among vulnerable populations, and the extent to which lack of health insurance contributes to inequities in quality of care. Dr. Doty holds an M.P.H. and a Ph.D. in public health from the University of California, Los Angeles. commonwealthfund.org Survey Brief, March 2018 Americans’ Views on Health Insurance at the End of a Turbulent Year 18 APPENDIX Survey Estimates of Changes in U.S. Uninsured Rates Since 2013 Pre-implementation uninsured rate (%) Current uninsured rate (%) Survey [95% CI] [95% CI] Millions of uninsured The Commonwealth Fund 19.9% 14.0% — Affordable Care Act Tracking Survey1 [18.5%–21.4%] [12.3%–15.8%] 20.4% 12.5% National Health Interview Survey2 24.7 million [19.7%–21.1%] [11.7%–13.3%] Gallup-Sharecare Well-Being Index3 20.7% 14.8% — Notes: Confidence intervals are shown where they were reported out by the organization. Percent estimates were not reported. 1 The Commonwealth Fund Affordable Care Act Tracking Survey, Nov.–Dec. 2017. 2 E . P. Zammitti, R. A. Cohen, and M. E. Martinez, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, Jan.–June 2017 (National Center for Health Statistics, Nov. 2017), https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201711.pdf. 3 Z . Auter, “U.S. Uninsured Rate Steady at 12.2% in Fourth Quarter of 2017,” Gallup-Sharecare Well-Being Index, Jan. 16, 2018, http://news.gallup.com/poll/225383/uninsured-rate-steady-fourth-quarter-2017.aspx. Methodological Differences Between Surveys Survey Population Time frame Sample frame Response rate The Commonwealth Fund July–Sept. 2013 to Dual-frame, RDD 2013: 20.1% U.S. adults ages 19–64 Affordable Care Act Tracking Survey1 Nov.–Dec. 2017 telephone survey 2017: 7% Multistage area probability National Health Interview Survey2,3 U.S. adults ages 18–64 2013 to Jan.–June 2017 80% design Dual-frame, RDD Gallup-Sharecare Well-Being Index4 U.S. adults ages 18–64 2013 to Oct.–Dec. 2017 7%–9% telephone survey 1 The Commonwealth Fund Affordable Care Act Tracking Survey, Nov.–Dec. 2017. 2 E . P. Zammitti, R. A. Cohen, M. E. Martinez, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, Jan.–June 2017 (National Center for Health Statistics, Nov. 2017), https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201711.pdf. 3 National Center for Health Statistics, About the National Health Interview Survey (NCHS, July 2017), https://www.cdc.gov/nchs/nhis/about_nhis.htm. 4 Z. Auter, “U.S. Uninsured Rate Steady at 12.2% in Fourth Quarter of 2017,” Gallup-Sharecare Well-Being Index, Jan. 16, 2018, http://news.gallup.com/poll/225383/uninsured-rate-steady-fourth-quarter-2017.aspx. commonwealthfund.org Survey Brief, March 2018