Executive Summary

The American Action Forum collaborated with OnMessage to conduct health care policy polling recently. There are three key findings:

• A single-payer system is unpopular and unlikely. It is unpopular in that 51 percent of respondents opposed, while 41 percent favored. It is unlikely because swing voters and those in battleground areas oppose single-payer even more heavily.
• How one tries to stabilize the individual market matters. Cost-sharing reductions make the politics worse among Republicans, while reinsurance does the opposite – while still appealing to Democrats and Independents.
• The above findings are two sides of the same coin. American voters dislike a single-payer system, but across the country that is exactly what many Affordable Care Act exchanges have become. It is unsurprising that voters favor a reinsurance system that could reverse the trend toward no choice on the ACA exchanges, eliminate the de facto single-payer there, and lower premiums.

 

Discussion

Two main arguments have dominated recent health policy discussions. Many on the left are advocating for the desirability and feasibility of moving past the Affordable Care Act (ACA) to a full-blown single-payer system. Meanwhile, on the right some are contending for the need to stabilize the ACA’s individual marketplaces and what combinations of cost-sharing reduction (CSR, or government subsidies to cover the out-of-pocket costs of low-income insurance purchasers) monies and reinsurance funds would be sufficient for that end. These are issues that the American Action Forum (AAF) health policy team has investigated extensively.

At times, however, it is useful to move past what policy experts conclude and ask the actual customer – American voters – their policy preferences. With that in mind, AAF collaborated with OnMessage to conduct a poll of 1,100 likely voters. OnMessage stratified the sample by state to reflect historic mid-term turnout. In addition, OnMessage identified five senatorial battleground states – NV, AZ, WV, IN and MO – and polled an oversample of 100 interviewees in those states. A memo summarizing the key findings is here and the full results here.

I found three important insights. First, a single-payer system – a government-established monopoly insurer – is unpopular and unlikely. It is unpopular in that 51 percent of respondents opposed it, while 41 percent favored it, and 8 percent were undecided. Granted, this is a somewhat partisan finding as 66 percent of Democrats favored a single-payer, while 78 percent of Republicans opposed it. But it is also politically unlikely because the key swing group – Independents – opposed it 55 percent to 39 percent. In addition, single-payer has problems in battleground states, where 53 percent opposed it. Finally, all of these numbers become much more anti-single-payer when respondents learn of the price tag ($3.4 to $4.4 trillion annually) or the fact that private insurance (employer or union coverage) would be illegal and taken away under a single-payer.

The unpopularity of a government-run, single-payer system may reflect the fact that the public thinks that the private sector does a better job with health care quality (49 percent to 27 percent) and affordable health care (42 percent to 39 percent). Interestingly, the public believes these things even though the image of health insurers is in the tank – the favorable versus unfavorable ratings are 30 percent versus 51 percent.

The second major finding is that how one tries to stabilize the individual market matters. Both CSRs (58 percent to 33 percent) and reinsurance (57 percent to 33 percent) have those who favored them outweighing those who opposed them. In both cases, the topline is driven by strong favorability among Democrats, with firm disapproval among Republicans. But Republicans were unmoved or reacted negatively to information about the price tag for CSRs and simply do not believe that providing CSR funding would lower premiums. In contrast, while not wild about the cost of reinsurance, Republicans – along with Democrats and Independents – reacted strongly positively to the notion that reinsurance would stop the loss of insurance companies, provide more choices, and lower premiums. Reinsurance is good policy that is also good politics.

The third observation is that these findings are two sides of the same coin. Americans dislike single-payer health care. But across the country that is exactly what many ACA exchanges have become. It is unsurprising that they favor a reinsurance system that could reverse the trend to no choice, eliminate the de facto single-payer, and lower premiums.