The voices of Urban Institute's researchers and staff
June 14, 2017

Both winners and losers under AHCA oppose repealing core ACA provisions

Public opinion polls exploring general attitudes toward the Affordable Care Act (ACA) and the repeal bill making its way through Congress may conceal the broad level of support for the ACA’s specific consumer protection and financial assistance provisions.  

A new survey shows widespread support for seven of eight key provisions of the ACA, both among people who stand to lose most from the law’s repeal and those who could see their premiums decline under the repeal legislation known as the American Health Care Act (AHCA).

Who stands to win and lose from repealing the ACA?

People with Medicaid and nongroup health insurance have the most at stake as the AHCA is taken up by the Senate. Under the AHCA, Medicaid beneficiaries could lose their coverage or see reduced benefits because of the rollback of the ACA’s Medicaid expansion and the shift to per-capita-capped federal funding to states.

Among people with nongroup coverage, the AHCA would produce both winners and losers. Most low-income enrollees would face higher costs if the ACA’s income-based premium subsidies are replaced by the AHCA’s age-based tax credits. Although older adults would receive the largest credits, many would face higher net premiums because premiums would vary by age at a ratio of at least five to one, while tax credits would vary by age at a ratio of two to one.

In states that receive waivers from the ACA’s essential health benefits and community rating requirements, people with preexisting conditions would likely have trouble buying coverage to meet their needs.

But some adults with nongroup coverage—particularly those who are younger, healthier, and have higher income, including many who buy coverage outside the ACA Marketplaces—could pay lower premiums under the AHCA.

Those most at risk express greatest support for ACA provisions

Recent polls show increasing support for the ACA and widespread opposition to the AHCA. Given its large sample size and capacity to collect extensive information from respondents, the Urban Institute’s Health Reform Monitoring Survey (HRMS) provides a deeper look at public opinion toward ACA repeal. In the March 2017 HRMS, we asked more than 9,500 adults ages 18 to 64 which of eight core ACA provisions they would like to see retained and which they would like to see repealed.

We found high levels of support for retaining seven of the eight provisions:

  • Guaranteed issue
  • Community rating
  • Essential health benefits
  • Age rating limits
  • Premium subsidies
  • Medicaid expansion
  • Dependent coverage provision

Only the individual mandate failed to get majority support.

Over 80 percent of adults wanted to keep the three provisions designed to protect adults with preexisting conditions (guaranteed issue, community rating, and essential health benefits). Nearly 80 percent support the Medicaid expansion and the provision allowing dependents to stay on a parent’s health plan until age 26, and more than two-thirds support the ACA’s premium subsidies and its limits on how much premiums can vary by age.

support for each ACA provision

For several of the core ACA provisions, the strongest support came from adults with Medicaid and Marketplace coverage, who would be most likely to face higher costs or loss of coverage under the AHCA. Adults with Medicaid or nongroup coverage who were older, low income, and less healthy typically expressed the greatest support for ACA coverage provisions.

broad support for ACA provisions

Support for ACA provisions isn’t only driven by self-interest

Attitudes toward these provisions among survey respondents were not solely determined by self-interest. Majorities of adults who obtained nongroup coverage outside the Marketplaces also supported seven of the eight provisions—all except the individual mandate.

Support was also high among those who were younger, higher income, and healthier—and who therefore subsidize older, lower income, and sicker adults under the ACA’s approach to spreading risk across the population. For instance, 77 percent of people ages 50 to 64 with Medicaid or nongroup coverage support the ACA’s limits on how much premiums can vary by age, but so do 72 percent of people ages 18 to 34.

More than 80 percent of adults with a chronic condition support guaranteed issue, community rating, and essential health benefits, and over 75 percent without a chronic condition do as well Response patterns were similar among Medicaid or nongroup enrollees with and without chronic conditions. These findings suggest that many value the ACA’s consumer protections even if they do not benefit from them in the short term.

support for aca provisions not driven by self interest

Download more detailed data here.

Support for ACA provisions crosses party lines

For some adults, attitudes toward the ACA may be rooted in ideology rather than self-interest. Overall opinions toward the ACA have long differed by party affiliation, and Republicans are more likely than Democrats to have a favorable view of the AHCA, but support for specific ACA provisions crosses the partisan divide.

Majorities of both parties supported every ACA provision except the individual mandate. Support for the ACA insurance regulations and financial assistance provisions is also high across different racial and ethnic groups, education levels, and geographic regions.

both parties support aca provisions

Download more detailed data here.

Though unpopular, the individual mandate is likely keeping healthy adults in the nongroup market

Although consistent majorities supported seven of the eight ACA provisions in the survey, no groups gave majority support to the individual mandate, despite its importance to the functioning of the nongroup market.

Nearly one-third of adults with Marketplace coverage and 16 percent of adults with nongroup coverage outside the Marketplaces—primarily those who are young and healthy—said they would be likely to drop their coverage if the mandate is repealed. If this occurred, premium growth would accelerate for those remaining in the market, suggesting the individual mandate remains an essential element of the health insurance system by sharing risk across those who have health problems now and those likely to have health problems in the future.

The March 2017 HRMS data provide a new level of insight on public opinion toward the ACA among adults who would be most affected, positively or negatively, by its repeal. These results suggest there is little appetite for repealing the ACA’s core provisions, even among the AHCA’s intended beneficiaries and the ACA’s detractors. 

Peter Yanez, who is insured under a policy from the Affordable Care Act, has blood drawn by Linda Williams, a medical assistant, as he gets a blood test at a Planned Parenthood health center on May 12, 2017 in Miami, Florida. Photo by Joe Raedle/Getty Images.

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