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Memo to Congress: Here's what Americans really want in health insurance, according to new survey

POSTED: November 20, 2017 8:10 a.m.
Americans would rather have lower insurance deductibles than more health care providers. They’d rather have health insurance for everyone than the right to opt out of coverage. And regardless of their political leanings, they're not enthused about what Republicans in Congress have been trying to give them.

These are among the findings of the American Family Survey released Thursday by the Deseret News and the Center for the Study of Elections and Democracy at Brigham Young University.

As Senate Republicans seek to eliminate the Obamacare individual mandate as part of a proposed tax reform bill, the survey finds Americans deeply divided on priorities for health care policy.

For example, nine out of 10 Hillary Clinton voters say they would prefer making insurance accessible to all over giving people more flexibility to opt out. Just four out of 10 Donald Trump voters agree.

And three-quarters of Clinton voters want to guarantee coverage for pre-existing conditions even if it means higher monthly costs, while fewer than half of Trump voters say the same.

The one thing most Americans agree on — regardless of who they voted for — is that they would trade a wider network of doctors for lower deductibles. But overall, Trump voters champion lower costs, lower taxes and freedom of choice, while Clinton voters want universal access, guaranteed coverage and help for the poor, the report said.

The third annual American Family Survey questioned 3,000 adults on a variety of political and social issues that affect families, such as health insurance, addiction and social media use. This year’s findings are especially relevant as Congress wrangles over what to do with the beleaguered Affordable Care Act even as Americans are enrolling in insurance plans for next year.

And they help to explain why Congress has been unable to enact changes to the health care law despite two attempts this year by Republicans, who campaigned on repealing on replacing Obamacare.

Conducted in July, the American Family Survey reveals that more than half of Americans have an immediate family member with a chronic or serious health condition, and that personal experience with illness impacts what people want from the nation's health care policy.

Illness in America

With an $1,800 monthly premium for health insurance that will go up another $400 in January, the Cashin family, who live in Portola Valley, California, illustrates why the cost of health care, not the options available, matter so much to Americans.

Kimberley Cashin, a stay-at-home mother of two boys, 6 and 7, has a chronic genetic disease called Ehlers Danlos Syndrome, which made it difficult for her to find insurance before the Affordable Care Act took effect. Now, under the current health care law, insurance companies can't discriminate against people like Cashin who have pre-existing conditions.

But as premiums and deductibles have gone up, and some insurers have pulled out of the federal marketplace because their losses were higher than they expected, the family's premiums have become "excruciating," Cashin said. She hasn't yet told her husband that they're climbing again in a few months because she doesn't want him to be stressed.

One striking finding of the American Family Survey is how many families, like the Cashins, are struggling with serious health issues.

"One of the things we asked was whether you or your spouse or your children are dealing with a serious medical condition. Almost 6 in 10 respondents said they are dealing with something serious that requires regular medicine or regular trips to the doctor. That’s a big number. So, I think understanding a little more about how that affects people is key," said Christopher F. Karpowitz, co-director of the Center for the Study of Elections and Democracy at BYU, and a co-author of the report.

Forty-four percent of respondents say they themselves require ongoing treatment or medicine, while 43 percent said a spouse does and 24 percent said a child.

Their responses on other questions suggest that personal experience with chronic or serious health conditions can inform decisions more than partisanship when people consider what they want from a national health care bill.

“For example, people who’ve had a serious medical condition in the family are just a lot more likely, whether they’re Trump voters or Clinton voters, to believe that pre-existing conditions should be covered, or that we should help people who can’t afford insurance to have insurance,” Karpowitz said.

Interestingly, a chronic illness does not seem to determine how much a family spends on health care. The type of insurance they have does.

People on Medicaid report paying the least to have coverage, while people who buy policies on their own, like the Cashins, pay the most.

Before subsidies for Obamacare policies became available in 2013, the percentage of uninsured Americans younger than 65 hit 18.2 percent, according to 2010 data from the Centers for Disease Control and Prevention. The American Family Survey found that just 8 percent of respondents report they have no health coverage this year.

Of those with insurance, 44 percent have policies provided by their employer, 24 percent have Medicare, 18 percent have Medicaid and 12 percent had purchased a policy themselves.

As for out-of-pocket costs, whether they have employer-provided insurance or buy their own, people pay about the same amount whether they are healthy or sick. Out-of-pocket costs rise for people on Medicare and are the highest for people with no insurance.

Having a chronically ill family member also impacts Americans' opinions on helping the poor get health insurance. The number of Trump and Clinton voters who prioritize helping the poor rises by 10 percentage points when they have illness in their immediate families.

The majority of Trump voters would still prefer lower taxes over helping the poor, but “results nonetheless still provide some evidence for the notion that experiencing an ongoing medical difficulty that requires medical care boosts concern for the plight of the poor in obtaining health insurance,” the report says.

What Americans really want

So far, Congress has failed to act on two replacements for the Affordable Care Act that have been proposed, and the American Family Survey reveals why: Americans generally don't like what the Republicans have proposed, even if they are Republicans themselves.

"Consistent with other surveys, many elements of the Republican plan proved highly unpopular, regardless of income or family medical challenges," the report summary said.

The American Family Survey asked people to assess four components of the Republican plans: eliminating the mandate that people have insurance or face penalties; giving states control over insurance rules; cutting federal funding for Medicaid; and making available a greater variety of plans. Of these, only offering a greater variety of plans had the approval of respondents across the political spectrum.

Ninety percent of Trump voters, 63 percent of Clinton voters and 72 percent of all respondents approved of this component.

The only other overwhelmingly positive response in this category was among Trump voters on the question of removing the insurance mandate: Nearly three-quarters said they want the mandate gone. Just 18 percent of Clinton voters do.

As for the other Republican proposals — cutting Medicaid and giving states more control of what insurance companies cover and charge — fewer than half of respondents expressed support, regardless of their political party, family income, and health status.

"The only exception to this unpopular slate of reforms is allowing for a greater variety of plans," the authors of the summary report wrote.

Matthew Fiedler, a fellow with the Center for Health Policy in Brookings’ Economic Studies Program, said that finding is consistent with other research he has seen, and reflects what he sees as an inconsistency between what some Republicans say they want to do and their beliefs about the role of government in health care.

“When Republicans have talked about their proposal and what they’re trying to achieve, they say they want to keep people covered and they want that coverage to be affordable and they want people with pre-existing conditions to be protected,” he said.

“But the problem is, the set of policies that they’re committed to really won’t do that.”

Where we go from here

Cashin, who leads an online community of mothers dealing with chronic illness, said that although she and her husband initially supported the Affordable Care Act, and they voted for Barack Obama twice, they're hoping a replacement passes that will relieve the staggering premiums that she and others in her Facebook group are having to pay. One woman Cashin knows will be paying $2,700 a month for health insurance for a family of four come January, she said.

But until America finds a way to lower the cost of health care, not just the cost of health insurance, either premiums or deductibles will remain high, Fiedler said.

“A lot of the debate we’ve been having is about how we finance care, how many people have coverage, who pays for that coverage and what does that coverage cost," he said.

“But there’s an underlying question, which is, ‘What the underlying cost of health care?’”

The proposals put forth so far, he said, are largely a Hobson’s choice for consumers: pay more for premiums and less for health care, or pay less for premiums and more for health care.

Debate over health insurance tends to be partisan and ideological, but when the conversation turns to how to reduce the cost of care, there’s room for more bipartisan discussion and work, he said, adding, “This could potentially be a productive place of where the debate could go.”

“The only way we’re going to be able to reduce deductibles for everyone system-wide over the long run is if we find ways to reduce that underlying cost of care.”

For the Cashin family, which leans Democratic (although both spouses voted for President George W. Bush), the issue now goes beyond politics.

“I do think a new bill is necessary. I’m just hoping that the millions of people that are currently covered can maintain their coverage," Cashin said.

“There’s this dichotomy: We have all these people who were essentially uninsurable, and now we’re insured, but at the same time, families are getting hit with these premiums," she said. "It’s not a balanced system. Somehow, some way, we need to fix that, without affecting those who are not insured.”

Lois Collins contributed to this article.
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