Key Findings:

The Democratic presidential primary campaign featured extensive discussions of different health care reform proposals. As Democratic primary voters in early primary states begin casting their ballots to select their nominee, the latest KFF tracking poll finds that a majority of Americans favor a national Medicare-for-all health plan (56%) but a larger share favors a government-administered “public option” (68%). Notably, nearly half of adults (48%) favor both of these proposals. Among the 17% who favor a public option but oppose Medicare-for-all, when asked to explain their reasoning in their own words, the most common responses indicate that they prefer a public option because it allows choice (32% of those who were asked, or 5% of the total public).

Eight in ten Americans think taxes for most people would increase both under a Medicare-for-all plan (83%) or a public option health plan available to all (81%). However, more adults think that all Americans would have health insurance coverage under a Medicare-for-all system (62%) than under a public option (53%).

At the start of this election year, lowering prescription drug costs (22%) and continuing the ACA’s protections for people with pre-existing conditions (19%) lead the public’s health care priorities for Congress. Additionally, eight in ten or more say it is at least very important that Congress work on lowering prescription drug costs (87%), ensuring the ACA’s pre-existing condition protections continue (83%), and protecting people from surprise high out-of-network medical bills (80%) during the next year.

President Trump has an overall negative approval rating among the public when it comes to his handling of various health issues, with his most negative ratings for his handling of the Affordable Care Act (35% approve and 56% disapprove, for a net approval of -21 percentage points) and his handling of the costs of prescription drugs (30% approve, 54% disapprove, net approval -24 percentage points). On the other hand, majorities of Republicans approve of his handling of all the health care issues asked about in this month’s poll, especially his handling of Medicare (+68 percentage points net approval). Among all adults, President Trump’s net approval rating for his handling of Medicare is -10 percentage points.

In a December ruling, the U.S. Court of Appeals for the 5th Circuit in Texas agreed with a lower court judge that the provision of the Affordable Care Act’s individual mandate is unconstitutional since Congress eliminated the tax penalty established to enforce it, and sent the case back to the lower court to decide how much of the ACA should be allowed to stand. A majority of adults say they are worried that they or someone in their family will lose health insurance coverage in the future if the Supreme Court overturns either the ACA’s protections for people with pre-existing conditions (57%) or the entire health care law (58%).

Medicare-for-all and Public Option

This month’s poll finds that majorities favor a national Medicare-for-all health plan (56%) and favor a “public option” (68%) in which a government-administered plan would compete with private health insurance and be available to all Americans.

Though both proposed changes to the nation’s health care system have majority support, a public option that would compete with private health insurance plans continues to garner more support than the more sweeping change presented in a Medicare-for-all plan (Click here to see a side-by-side comparison of the competing proposals). Large majorities of Democrats favor both proposals (77% Medicare-for-all, 85% public option), as do majorities of independents (61% Medicare-for-all, 73% public option). Among Republicans, one in four (24%) support a national Medicare-for-all plan and four in ten (42%) favor a public option.

While both proposals aim to expand the role of the federal government in health care, the two plans are very different – which has been highlighted during the recent Democratic presidential primary debates. Yet, nearly half of adults (48%) favor both of these proposals while 22% oppose both. Few (6%) say they favor Medicare-for-all but oppose a public option while 17% favor a public option, but oppose Medicare-for-all.

When those who favor a public option but oppose Medicare-for-all are asked to explain their reasoning in their own words, the most common responses indicate that people like that a public option is not forced, but instead is an option that allows choice (32% of those who were asked, or 5% of the total public). Thirteen percent of those who were asked (2% of total) mentioned competition among private plans as the reason they support a public option but not Medicare-for-all. Smaller shares mention that it would allow people to keep their current plans, concerns about cost and increased taxes for a Medicare-for-all plan, or concerns about government involvement in health care (each named by 7% of those who were asked, or 1% of the total public).

Most Americans think the two major health care reform proposals being discussed by Democratic presidential candidates, as well as the 2010 Affordable Care Act, are all mostly intended to extend health care coverage to all Americans, rather than mostly intended to lower people’s health care costs. About two-thirds of Americans think Medicare-for-all (68%) is intended mostly to provide health care coverage to all Americans. Fewer, but still majorities, say the Affordable Care Act (59%) and a government-administered public option plan (58%) are intended mostly to provide coverage for all Americans rather than mostly intended to lower health care costs (26% and 29% respectively). For each of these health care reform proposals, majorities across partisans say they are intended mostly to provide coverage to all Americans.

Large Majorities Think Taxes would increase under either Medicare-for-all or a Public Option

Overall, the public does not perceive major differences in how a public option or a Medicare-for-all plan would impact taxes and personal health care costs. Eight in ten (81%) think taxes for most people would increase under a public option which is similar to the share who say taxes would increase under a Medicare-for-all plan (83%). In addition, majorities say people would continue to pay deductibles and co-pays when they use health care services under both a public option and a Medicare-for-all plan (68% and 61%, respectively). About half say individuals and employers would continue to pay premiums under both proposals (50% vs. 44%). However, there are some differences in perceptions of how the proposals would impact those with private health insurance coverage. Larger shares say people who buy their own coverage or get their coverage through their employer would be able to keep their current plans under a public option (59% and 60%), than say the same about a national Medicare-for-all plan (48% and 47%).

There has been some shift in the public’s perception of how things would or would not change under Medicare-for-all since the first Democratic presidential debate. Compared to six months ago, larger shares of adults now say that, under Medicare-for-all, people with employer-sponsored insurance would not be able to keep their current coverage (45% vs. 38% in June 2019) and people who purchase their own plans would not be able to keep their current coverage (44% vs. 39%). Additionally, larger shares now say that individuals and employers would not continue to pay health insurance premiums (50% vs. 39%) and that people would not continue to pay deductibles and co-pays when they use health care services (33% vs. 27%).

Democrats, in particular, are now more likely to be familiar with some of the potential impacts of a Medicare-for-all plan than they were in the June 2019 Tracking Poll. With the Democratic presidential primary campaign featuring extensive debates over Medicare-for-all, Democrats are now more likely than they were six months ago to say that under a Medicare-for-all plan individuals and employers would not continue to pay health insurance premiums (53% vs. 31%). Similarly, compared to six months ago, Democrats are now more likely to say that under Medicare-for-all people with employer-sponsored insurance would not be able to keep their current health plans (41% vs. 25% in June 2019), that people who purchase their own insurance would not be able to keep their current plans (40% vs. 24%), and that people would not continue to pay deductibles and co-pays when they use health care services (36% vs. 25%).

Health Care Legislation and Court Actions

When asked about a list of potential health care priorities for Congress to address, majorities say it is at least very important that Congress work on lowering prescription drug costs for as many Americans as possible (87%), making sure the ACA’s protections for people with pre-existing health conditions continue (83%), protecting people with health insurance from surprise high out-of-network medical bills (80%), doing more to address the heroin and opioid addition epidemic (75%) and to work on addressing the rise of vaping and e-cigarette use among teenagers (61%).

When asked to choose their top health care priority, lowering prescription drug costs (22%) and continuing the ACA’s pre-existing condition protections (19%) top the list of most important priorities for Congress to work on. About one-fifth (21%) said none of these health care issues were extremely important for Congress to work on. Notably, lowering prescription drug cost and continuing the ACA’s pre-existing condition protections were also the public’s top health care priorities for Congress one year ago.

Lowering the cost of prescription drugs is the only health care priority that tops the list for Democrats (26%), independents (21%) and Republicans (19%). While making sure the ACA’s pre-existing condition protections continue is among the top priorities for Democrats (31%) and independents (19%), it ranks lower among Republicans (10%). Independents and Republicans are about twice as likely as Democrats to say doing more to address the opioid epidemic is their top priority for Congress of the health care issues presented.

Table 1: Pre-Existing Condition Protections and Prescription Drug Costs Top Public’s Health Care Priorities for Congress Percent who say the following is the top priority for Congress to work on: Democrats Independents Republicans Lowering prescription drug costs for as many Americans as possible 26% 21% 19% Making sure the ACA’s pre-existing condition protections continue 31 19 10 Doing more to address the heroin and opioid addiction epidemic 8 18 19 Protecting people from surprise high out-of-network medical bills 11 11 10 Addressing the rise of vaping and e-cigarette use among teenagers 4 9 7 NOTE: If more than one priority was chosen as “extremely important,” respondent was asked to choose which priority was the “most important.”

Most Are Unaware The House Passed Legislation To Address Prescription Drug Costs

In December 2019, the U.S. House of Representatives passed a bill that would require the government to negotiate the prices of a minimum of 25 Medicare Part D drugs annually and would cap out-of-pocket drug costs for Medicare beneficiaries. The House bill aimed at addressing drug costs would also provide dental, vision, and hearing benefits to older adults on Medicare. Two in ten adults are aware that the House has passed legislation to address the cost of prescription drugs and that the House passed legislation to address these additional benefits (21% each).

Though there was an effort by House Democrats to pass legislation to address surprise medical bills, ultimately, the House did not pass legislation to address this issue last year. A majority of the public (56%) are aware that the House had not passed legislation to address surprise medical bills while 14% say the House has indeed passed a bill and 29% say they “don’t know.”

Majorities Disapprove Of President Trump’s Handling Of The ACA, Prescription Drug Costs

The latest KFF poll finds about four in ten adults (42%) approve of the way President Trump is handling his job as president, while a slight majority (56%) disapprove.

The President’s net overall job approval (measured as the share who approve minus the share who disapprove) among adults stands at -14 percentage points, and his net approval is also negative when it comes to handling various health care programs and issues. Among health issues, President Trump receives his lowest net approval ratings on his handling of the cost of prescription drugs (-24 percentage points) and on his handling of the Affordable Care Act (-21 percentage points), whereas his net approval on his handling of Medicare is somewhat higher at -10 percentage points. While President Trump receives his lowest net approval rating on his handling of prescription drug costs, KFF’s November 2019 tracking poll found that one-fourth of adults (26%) – including just one in four Democrats and independents and just three in ten Republicans – think it is likely that legislation to lower the costs of prescription drugs will pass this year.

There are stark partisan differences in President Trump’s approval ratings on various health care programs and issues. Democrats and independents give the President negative net approval ratings on all the health care issues asked. However, the President’s position with his base appears strong when it comes to his handling of health care issues, as Republicans give the President positive net approval ratings on each of the health care programs and issues included in the poll.

Table 2: Republicans Give Positive Ratings On Health Issues to the President While Democrats and Independents Give President Trump Negative Net Approval Ratings Net approval for President Trump’s handling of: Total Democrats Independents Republicans His job as president -14 -85 -24 +85 Medicare -10 -64 -25 +68 Medicaid -16 -70 -29 +60 HIV/AIDS -13 -59 -25 +48 Protections for people with pre-existing conditions -16 -70 -32 +63 The heroin and opioid addition epidemic -11 -57 -23 +57 The Affordable Care Act -21 -74 -36 +56 The cost of prescription drugs -24 -68 -35 +44

The Affordable Care Act And The Courts

Overall opinions of the Affordable Care Act (ACA) have continued relatively unchanged for the past two years since the Republican efforts to repeal the 2010 health care law. Half of the public (53%) this month hold favorable opinions of the ACA while 37% hold a negative opinion of the law. Partisans remain divided on the ACA as eight in ten Democrats (84%) have a favorable view of the ACA compared to a slight majority of independents (55%) and about one in five Republicans (19%).

In December 2019, the U.S. Court of Appeals for the 5th Circuit in Texas issued a ruling siding with a lower court judge’s decision that the Affordable Care Act’s individual mandate is unconstitutional since Congress zeroed out the penalty for not having health insurance. The case was sent back to the lower court to decide how much of the ACA should be allowed to stand and many expect it to make its way to the U.S. Supreme Court. While about two-thirds (64%) of the public say they have heard at least “a little” about this ongoing case, just one in ten (9%) say they have heard “a lot.”

Recent KFF polling has found that a majority of the public do not want to see the Supreme Court overturn the ACA’s pre-existing condition protections; however, they are more divided on whether they want the Supreme Court to overturn the entire law. The January 2020 poll finds that a majority of adults say they are “very” or “somewhat” worried that they or someone in their family will lose health insurance coverage in the future if the Supreme Court eventually overturns either the ACA’s protections for people with pre-existing conditions (57%) or the entire health care law (58%). There are some notable differences across partisans with majorities of Democrats and independents saying they are at least somewhat worried that they or someone in their family will lose coverage if the Supreme Court overturns the ACA’s protections for people with pre-existing conditions (77% and 59% respectively) or the entire health care law (84% and 58% respectively), while majorities of Republicans say they are “not too worried” or “not at all worried” about the loss of coverage if the ACA’s protections pre-existing conditions (63%) or the entire health care law are overturned (70%).