Over Half of Nonelderly Adults Support Either a Public Option or Medicare for All, with More Preferring a Public Option

 

Michael Karpman and John Holahan

December 3, 2019

 

At a Glance
  • Among adults ages 18 to 64, more than half (51.6 percent) support either a public option or Medicare for All, with more preferring a public option. Nearly one-quarter are neutral toward both approaches
  • Though Democrats are more likely to prefer a public option to Medicare for All, most support or are neutral toward each approach. Among Republicans, opposition to Medicare for All is much stronger than opposition to a public option.
  • Adults who are young, are Hispanic, have low educational attainment and income, and who do not have private insurance are more likely to prefer Medicare for All than adults without those characteristics. Problems affording care and dissatisfaction with current coverage also increase the likelihood of preferring Medicare for All.

The Affordable Care Act (ACA) expanded health insurance coverage and made health care more affordable for many, but gaps in coverage and affordability remain (Haley, McMorrow, and Kenney 2019; Long et al. 2017). Policymakers and presidential candidates are now debating several options to address these gaps, from incremental reforms to an overhaul of the health insurance system.

 

Two proposals that have received significant attention are the “public option,” which would provide some or all nonelderly people the option to keep their private insurance or buy into a government-run plan, generally with larger premium and cost-sharing subsidies than under current law, and “Medicare for All,” which would enroll everyone in a single government-run plan with comprehensive benefits and no cost-sharing requirements. The question about whether to maintain a role for private insurance in the current health care system has been a central divide among candidates competing for the 2020 Democratic presidential nomination. The findings in this brief are not intended to endorse or oppose any candidate for public office or the proposed platforms or policies of any candidate for public office.

 

Numerous polls have examined attitudes toward the public option and Medicare for All (Collins and Gunja 2019; TCF, NYT, and Chan 2019),1 but few have assessed preferences between these proposals or the characteristics of people who prefer each approach.2 We find that more than half of nonelderly adults support expanding public coverage through one of these proposals. More prefer a public option to Medicare for All, but preferences vary by political party affiliation, demographic and socioeconomic characteristics, type of health insurance coverage, health care experiences, and satisfaction with coverage.

 

What We Did

 

We used data from the September 2019 round of the Health Reform Monitoring Survey (HRMS), a nationally representative survey of adults ages 18 to 64.3 All 9,619 participants in the September 2019 round were asked whether they support or oppose a public option and Medicare for All.4 Respondents could report that they strongly support, somewhat support, neither support nor oppose, somewhat oppose, or strongly oppose each proposal. The inclusion of a neutral category in the response scale captures more ambivalence about each proposal than other surveys that force a choice between support and opposition (Holahan and Karpman 2019).

 

Those who supported both a public option and Medicare for All were asked, “If you had to choose one approach for expanding health insurance coverage, would you prefer Medicare for All with little or no role for private insurance, or the public option with private insurance available for those who want it?” We use these responses to construct the following groups:

  • prefers the public option
  • prefers Medicare for All
  • neutral toward both approaches
  • does not support either approach and opposes one or both5

 

We estimate the share of adults in each of these groups, overall and among those who identify as Democrats or lean Democratic (hereafter referred to collectively as Democrats) and those who identify as Republican or lean Republican (hereafter referred to collectively as Republicans).6 We also assess variation by party affiliation in support of and in opposition to each approach separately (i.e., looking at support for the public option even if the respondent’s first preference was Medicare for All, and vice versa).

 

We then compare preferences for the public option and Medicare for All by age, race or ethnicity, educational attainment, annual family income as a share of the federal poverty level (FPL), and type of health insurance coverage at the time of the survey. We also compare preferences based on two measures of health care affordability—unmet needs for care in the past year because of costs and problems paying family medical bills in the past year—as well as satisfaction with coverage in terms of the range of health care services available, choice of providers, premiums, cost of out-of-network care, and protection against high medical bills.

 

This analysis has several limitations. The sample does not include adults ages 65 and older, nearly all of whom are covered by Medicare. Some polls have found that the opinions of these adults are similar to those of nonelderly adults,7 but others suggest older adults are more likely to oppose Medicare for All.8 The survey also does not assess respondents’ understanding of the public option or Medicare for All. The Kaiser Family Foundation’s Health Tracking Poll has found that attitudes toward Medicare for All vary substantially based on whether respondents receive information on potential advantages or disadvantages of this approach.9

 

What We Found

 

Among adults ages 18 to 64, more than half (51.6 percent) support either a public option or Medicare for All, with more preferring a public option. Nearly one-quarter are neutral toward both approaches.

 

More than half of nonelderly adults prefer either a public option (30.1 percent) or Medicare for All (21.4 percent; figure 1).10 Another 23.8 percent were neutral toward both approaches. A similar share, 23.5 percent, did not support either approach and opposed one or both.

 

Nearly two-thirds of Democrats support either a public option or Medicare for All, with a slightly higher share preferring a public option to Medicare for All (35.2 percent versus 30.1 percent; figure 1). About one-quarter (24.7 percent) of Democrats were neutral toward both, and 9.1 percent do not support either approach and oppose one or both.

 

More than one-third of Republicans support either a public option or Medicare for All, including 24.5 percent who prefer a public option and 9.4 percent who prefer Medicare for All (figure 1). About one in five Republicans are neutral toward both, and 44.6 percent do not support either approach and oppose one or both.

 

Among those who prefer a public option (Democrats, Republicans, and independent, third party, and unaffiliated individuals combined), about 38 percent oppose Medicare for All and 42 percent would support Medicare for All as a second choice (data not shown). In contrast, among those who prefer Medicare for All, only 10 percent oppose a public option and 64 percent would support a public option even though it is not their preferred approach.

 

 

Though Democrats are more likely to prefer a public option to Medicare for All, most support or are neutral toward each approach. Among Republicans, opposition to Medicare for All is much stronger than opposition to a public option.

 

Figure 2 highlights adults’ support for each approach separately, even if the approach was not their first preference. Overall, support for the public option is greater than opposition (43.8 percent versus 17.1 percent). The shares supporting and opposing Medicare for All are about the same (34.2 percent versus 33.6 percent).

 

Differences in support and opposition toward these approaches are driven by party affiliation. Support among Democrats is substantially greater than opposition for both the public option (55.0 percent versus 8.3 percent) and Medicare for All (48.0 percent versus 17.2 percent). Just over one-third of Democrats are neutral toward each approach.

 

Republicans were equally likely to support or oppose a public option (29.7 percent versus 29.9 percent). But only 15.4 percent support Medicare for All, compared with 58.3 percent who oppose. Of Republicans who oppose Medicare for All, nearly three-quarters strongly oppose that approach (data not shown).

 

 

Adults who are young, are Hispanic, have low educational attainment and income, and who do not have private insurance are more likely to prefer Medicare for All than adults without those characteristics. Problems affording care and dissatisfaction with current coverage also increase the likelihood of preferring Medicare for All.

 

Table 1 shows preferences for Medicare for All and the public option by selected demographic and socioeconomic characteristics. Young adults ages 18 to 34 are about equally likely to prefer a public option as they are to prefer Medicare for All. Older adults ages 50 to 64 are about twice as likely to prefer a public option as they are to prefer Medicare for All (34.4 percent versus 17.3 percent).

 

Among Hispanic adults, roughly equal shares prefer Medicare for All and a public option. But other racial and ethnic groups prefer a public option to Medicare for All by a margin of 8 to 11 percentage points. In addition, those who did not complete high school are more likely to prefer Medicare for All to a public option (28.8 percent versus 20.8 percent), whereas higher levels of educational attainment are associated with an increased likelihood of preferring a public option. Those with a college degree or more prefer a public option by a margin of 36.5 percent to 22.1 percent.

 

Twenty-five percent of adults with incomes below the ACA’s Medicaid eligibility threshold of 138 percent of the FPL in states that expanded Medicaid prefer Medicare for All, and the same share prefers a public option. Adults in higher income groups (between 139 and 399 percent of the FPL or 400 percent or more of the FPL) were more likely to prefer a public option than Medicare for All.

 

Nearly one-third (32.7 percent) of adults with private health insurance prefer a public option, compared with 20.0 percent who prefer Medicare for All. But preferences are more evenly divided among adults who are publicly insured or uninsured. These patterns are generally the same within each party affiliation (data not shown).

 

Adults who had health care affordability problems in the past year, including unmet needs for care because of costs and problems paying family medical bills, are significantly more likely to prefer Medicare for All than those who did not have these problems, but they are just as likely to prefer a public option as Medicare for All. Similarly, preferences for Medicare for All are higher among insured adults who are dissatisfied with one or more aspects of their coverage, compared with those who are not dissatisfied. But even among those who are dissatisfied, a larger share prefer a public option to Medicare for All (33.0 percent versus 26.9 percent). Also notable is that nearly one in five adults who are not dissatisfied with any aspects of their own coverage still prefer Medicare for All (though a larger share, 29.5 percent, would prefer a public option) and that nearly one-quarter of those who are dissatisfied with at least one aspect of their coverage do not support either reform and oppose one or both.

 

Adults who are ages 50 to 64, are non-Hispanic white, have incomes at or above 400 percent of the FPL, have private insurance, have not had health care affordability problems, and who are satisfied with their coverage are more likely to oppose one or both approaches than to prefer Medicare for All. But across all the characteristics we examined in this analysis, no more than 30 percent of adults in each group reported that they did not support either approach and opposed one or both.

 

Table 1. Preferences toward a Public Option and Medicare for All among Adults Ages 18 to 64, by Demographic and Socioeconomic Characteristics, Health Care Experiences, and Satisfaction with Coverage, September 2019

  Share that prefers Medicare for All Share that prefers public option Share that is neutral toward both Share that does not support either approach and opposes one or both Sample size
Age          
18–34~ 25.5% 26.7% 25.8% 20.2%^^^ 2,222
35–49 20.9%*** 29.6%**^^^ 26.3%^^^ 22.1% 2,979
50–64 17.3%*** 34.4%***^^^ 19.1%*** 28.6%***^^^ 4,418
Race and ethnicity          
White, non-Hispanic~ 19.2% 30.5%^^^ 20.4% 29.1%^^^ 6,570
Black, non-Hispanic 21.0% 29.2%^^^ 35.3%***^^^ 12.8%***^^^ 868
Other race or more than one race, non-Hispanic 21.1% 30.6%^^^ 28.2%***^ 18.2%*** 692
Hispanic 29.2%*** 29.3% 24.9%*** 15.3***^^^ 1,489
Educational attainment          
Less than high school~ 28.8% 20.8%^^^ 36.0% 13.2%^^^ 630
High school graduate 19.9%*** 25.7%**^^^ 31.6%^^^ 21.1%*** 2,181
Some college 19.5%*** 30.2%***^^^ 22.4%***^ 26.6%***^^^ 2,693
College graduate or higher 22.1%*** 36.5%***^^^ 14.8%***^^^ 25.9%***^ 4,115
Family income          
At or below 138% FPL~ 25.2% 25.2% 32.7%^^^ 15.3%^^^ 1,859
139–399% FPL 22.2%* 27.9%^^^ 24.7%*** 23.8%*** 3,422
400% FPL or more 18.3%*** 35.2%***^^^ 17.3%*** 28.4%***^^^ 4,338
Health insurance at time of survey          
Private coverage~ 20.0% 32.7%^^^ 20.0% 26.4%^^^ 7,211
Public coverage 26.5%*** 24.0%*** 31.7%***^ 16.3%***^^^ 1,398
Uninsured 24.2%*** 26.5%*** 31.4%***^^^ 16.5%***^^ 811
Health care affordability in past year          
Unmet needs for care because of cost~ 27.7% 29.4% 23.3%^^^ 18.5%^^^ 2,857
Did not report unmet needs for care because of cost 18.5%*** 30.4%^^^ 24.0%^^^ 25.9%***^^^ 6,762
Problems paying family medical bills~ 29.8% 29.3% 21.2%^^^ 18.6%^^^ 1,600
Did not report problems paying family medical bills 19.6%*** 30.3%^^^ 24.3%**^^^ 24.6%***^^ 8,019
Satisfaction with coverage, if insured          
Dissatified with any aspect of coverage~ 26.9 33.0^^^ 14.9^^^ 24.3 2,892
Not dissatisfied with any aspect of coverage 18.4%*** 29.5%**^^^ 26.4%***^^^ 24.5%^^^ 5,916
Source: Health Reform Monitoring Survey, quarter 3 2019.
Notes: FPL is federal poverty level. Unmet needs for care include medical care, general doctor care, specialist care, prescription drugs, dental care, mental health care and counseling, and tests, treatment, or follow-up care. Satisfaction with coverage includes the range of health care services available, choice of doctors and other providers, premiums, out-of-network costs, and protection against high medical bills.
**/**/*** Estimate differs significantly from reference group (~) at the 0.10/0.05/0.01 levels, using two-tailed tests.
^/^^/^^^ Estimate differs significantly from share that prefers Medicare for All at the 0.10/0.05/0.01 levels, using two-tailed tests.

 

What It Means

 

Just over half of nonelderly adults support either a public option or Medicare for All, with more preferring a public option. Attitudes vary by party affiliation. Democrats are somewhat evenly divided in their preferences and are more likely to prefer a public option than Medicare for All by a small margin. But few Democrats oppose either approach. Among Republicans, support for Medicare for All is much weaker and opposition much stronger relative to support for and opposition to a public option. A majority of Republicans oppose Medicare for All and few support it, compared with about 30 percent who oppose a public option and 30 percent who support it.

 

Compared with adults who prefer a public option, those who prefer Medicare for All tend to be more disadvantaged based on their characteristics: they are disproportionately younger, have lower incomes and educational attainment, and are more likely to have Medicaid or other public coverage or to be uninsured (though nearly two-thirds have private insurance). Adults who prefer Medicare for All are more likely than others to have had problems affording care in the past year and are less likely to be satisfied with their coverage. These adults may therefore see more to gain from Medicare for All.

 

In contrast, those who prefer a public option to Medicare for All tend to be in more socioeconomically advantaged groups (older, non-Hispanic white, higher incomes and educational attainment, privately insured), are generally more satisfied with their coverage, and may be reluctant to risk giving up private insurance. Those who do not support either approach and oppose one or both share many of these characteristics.

 

Compared with the roughly half of adults who support the public option or Medicare for All, less than one-quarter of adults do not support either proposal and oppose one or both. These results indicate that most nonelderly adults are either receptive or neutral toward expanding public health insurance to close remaining gaps in coverage and health care affordability.

 

References

 

Collins, Sara R., and Munira Z. Gunja. 2019. “What Do Americans Think about Their Health Coverage ahead of the 2020 Election?” New York: The Commonwealth Fund.

 

Haley, Jennifer M., Stacey McMorrow, and Genevieve M. Kenney. 2019. “Despite Recent Improvement, One in Six Children Lived in a Family with Problems Paying Medical Bills in 2017.” Washington, DC: Urban Institute.

 

Holahan, John, and Michael Karpman. 2019. “What Explains Support for or Opposition to Medicare for All?” Washington, DC: Urban Institute.

 

Long, Sharon K., Lea Bart, Michael Karpman, Adele Shartzer, and Stephen Zuckerman. 2017. “Sustained Gains in Coverage, Access, and Affordability under the ACA: 2017 Update.” Health Affairs 36 (9): 1656–62. https://doi.org/10.1377/hlthaff.2017.0798.

 

TCF, NYT, and Chan (The Commonwealth Fund, the New York Times, and the Harvard T. H. Chan School of Public Health). 2019. Americans’ Values and Beliefs about National Health Insurance Reform. New York: TCF, NYT; Boston: Chan.

 

About the Series

 

This brief is part of a series drawing on the HRMS, a survey of the nonelderly population that explores the value of cutting-edge internet-based survey methods to monitor the Affordable Care Act before data from federal government surveys are available. Funding for the core HRMS is provided by the Robert Wood Johnson Foundation and the Urban Institute. For more information on the HRMS and for other briefs in this series, visit www.urban.org/hrms.

 

About the Authors and Acknowledgments

 

Michael Karpman is a senior research associate in the Health Policy Center at the Urban Institute. John Holahan is an Institute fellow in the Health Policy Center. This brief was funded by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders. Funders do not determine research findings or the insights and recommendations of Urban experts. Further information on the Urban Institute’s funding principles is available at urban.org/fundingprinciples. The authors gratefully acknowledge helpful comments from Linda Blumberg.

 

Notes


1 See also Lunna Lopes, Liz Hamel, Audrey Kearney, and Mollyann Brodie, “KFF Health Tracking Poll–October 2019: Health Care in the Democratic Debates, Congress, and the Courts,” Henry J. Kaiser Family Foundation, October 15, 2019, https://www.kff.org/health-reform/poll-finding/kff-health-tracking-poll-october-2019/; Julia Manchester, “70 Percent of Americans Support ‘Medicare for All’ Proposal,” The Hill, October 22, 2018, https://thehill.com/hilltv/what-americas-thinking/412545-70-percent-of-americans-support-medicare-for-all-health-care; “NPR/PBS NewsHour/Marist Poll Results,” Marist Poll, July 22, 2019, http://maristpoll.marist.edu/npr-pbs-newshour-marist-poll-results-7/#sthash.jhc5HNKy.dpbs. ^

 

2 Polls that compare preferences between Medicare for All and improving on the ACA include the Kaiser Family Foundation Health Tracking Poll (Ashley Kirzinger, Cailey Muñana, and Mollyann Brodie, “KFF Health Tracking Poll–January 2019: The Public on Next Steps for the ACA and Proposals to Expand Coverage,” Henry J. Kaiser Family Foundation, January 23, 2019, https://www.kff.org/health-reform/poll-finding/kff-health-tracking-poll-january-2019/) and a poll conducted by The Commonwealth Fund, the New York Times, and the Harvard T. H. Chan School of Public Health (TCF, NYT, and Chan 2019). ^

 

3 For more information about the design of the HRMS, visit the FAQ page. ^

 

4 Respondents were asked the following questions:

The next few questions focus on proposals for expanding health insurance coverage. One approach would give some or all Americans the option of enrolling in a government-run health insurance plan that would be similar to Medicare. Medicare is a federal health insurance program for people 65 and older and for people with certain disabilities. This strategy for expanding health insurance coverage is sometimes called a “public option.” This new government-run plan would not replace the other health insurance options that are currently available, but would instead be an additional option. People would pay a premium based on their income to buy into the government-run plan. The government-run plan would have lower premiums and out-of-pocket costs than most private health insurance plans. Would you support or oppose a public option?

Another approach to expand health insurance coverage would enroll all Americans in a single government-run health insurance plan that would be similar to Medicare. This would be done as part of a new national health insurance program. This strategy is sometimes called “Medicare for All.” This new program would replace the current health insurance system with a single government-run plan, with little or no role for private insurance. Instead of paying premiums, taxpayers would cover the costs of this national health insurance program. Would you support or oppose Medicare for All? ^

 

5 The analysis excludes the 1.1 percent of adults who did not express support for either approach and did not report whether they supported one or both approaches, and it excludes 0.1 percent of adults who supported both approaches but did not report their preference. ^

 

6 We do not provide separate estimates for the 4.6 percent of adults whose party affiliation was undecided, independent, or other or for the 5.9 percent of adults who did not report party affiliation. ^

 

7 Kirzinger, Muñana, and Brodie, “KFF Health Tracking Poll.” ^

 

8 Matthew Sheffield, “Poll: Supporting ‘Medicare for All’ Helps Presidential Candidates,” The Hill, February 4, 2019, https://thehill.com/hilltv/what-americas-thinking/428332-poll-most-americans-say-theyd-be-more-likely-to-support. ^

 

9 Kirzinger, Muñana, and Brodie, “KFF Health Tracking Poll.” ^

 

10 About 0.1 percent of adults support both approaches but do not report a preference. ^

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