Efforts to fully or partially repeal the Affordable Care Act (ACA), most recently through tax reform legislation—along with new administration policies that could undermine the risk pools for ACA-compliant nongroup and small group health plans—have revealed fundamentally different visions for the US health care system. Policymakers are divided over how much people should be responsible for paying for their own health care and whether healthy and wealthy people should subsidize coverage for sicker and poorer people.
The repeal debate has provoked broader discussion about the values underlying policy choices about health insurance. In a May 8 interview with Senator Bill Cassidy, late-night talk show host Jimmy Kimmel suggested that these policies should be evaluated based on a principle of shared responsibility that “no family should be denied medical care, emergency or otherwise, because they can’t afford it.” The “Jimmy Kimmel test” became a widely referenced standard for assessing ACA repeal legislation and framed health care as a right people owe each other as opposed to solely being an individual responsibility. In a recent New Yorker article, Atul Gawande interviewed people from his hometown in Ohio and found mixed views on whether health care is a “right,” given that “a right makes no distinction between the deserving and the undeserving.”
In this blog post, we provide data about whether Americans think there is a shared responsibility to provide health care to people who cannot afford it or whether health care is an individual responsibility, recognizing that these beliefs are not mutually exclusive. We also describe the characteristics of adults who agree or disagree with each notion to understand who is most likely to be receptive toward the risk pooling arrangements and transfer of resources established by the ACA and other major US health care programs.
Most Americans view health care as a shared responsibility
Using a split sample experiment from the September 2017 Health Reform Monitoring Survey, we asked nonelderly adults whether they agreed or disagreed with two statements that framed health care as a shared responsibility versus health care as an individual responsibility. Half of adults in the sample were randomly asked if they agreed or disagreed that “No one should be denied medical care because they can’t afford it,” and the other half were randomly asked if they agreed or disagreed that “Uninsured people should only get medical care if they can pay for it.” Though these questions do not capture the nuances in how Americans think about health care, the responses provide insight into where their attitudes fall in terms of viewing health care through the lens of individual versus collective obligations.
Seventy-nine percent of nonelderly adults agreed with the statement “No one should be denied medical care because they can’t afford it,” which suggests strong support for a shared responsibility to provide health care to those who need it. Consistent with that finding, only 19.1 percent of nonelderly adults agreed with the statement that implies an individual responsibility for health care: “Uninsured people should only get medical care if they can pay for it.”
Few disagreed with health care as a shared responsibility (6.1 percent), and more than half disagreed with health care as an individual responsibility (54.0 percent). The share of adults who neither agreed nor disagreed with the first statement was 14.4 percent, and the share who neither agreed nor disagreed with the second statement was 26.4 percent, suggesting more ambivalence about individual responsibility.
These results suggest strong support for a societal obligation to provide health care, as well as some support and ambivalence toward health care as an individual responsibility. These are not necessarily mutually exclusive views. Americans may believe there is a societal obligation to provide health care while also expecting people to shoulder some of the costs of their own care when they can. Or, in the words of one of Gawande’s interviewees, “Everybody has a right to access health care, but they should be contributing to the cost.”
Who doesn’t view health care as a shared responsibility?
Strong majorities of adults of every age, gender, race or ethnicity, income level, educational level, and health status agreed that health care is a shared responsibility (i.e., that no one should be denied medical care because they can’t afford it), and about half or more adults in each group disagreed that health care is an individual responsibility (i.e., that uninsured people should only get medical care if they can pay for it).
Adults who disagreed with the idea of health care as a shared responsibility were disproportionately non-Hispanic white, men, higher income, healthy, and highly educated. There were fewer differences in the characteristics of people who agreed that uninsured people should only get medical care if they can afford it. Agreement was higher among men than among women and was higher among adults without a chronic condition or disability.
These differences suggest that healthy and affluent adults, particularly men, will be less receptive to policies that spread the risk of health care costs across the population.
Although opinions were correlated with political party affiliation, with strong Republicans less likely than strong Democrats to agree that no one should be denied medical care because they can’t afford it, most adults of each party affiliation viewed health care as a shared responsibility.
Strong Republicans were also more likely than strong Democrats to agree that uninsured people should only get medical care if they can afford it, but most Democrats and Republicans either disagreed with this statement or were neutral. At least one in five adults of each affiliation neither agreed nor disagreed, suggesting that ambivalence toward health care as an individual responsibility crosses party lines.
Rolling back the ACA will not achieve the health care goals shared by most Americans
Although other surveys show that Americans are divided over the ACA and the federal government’s role in guaranteeing health insurance coverage, they generally share a common belief that people should not be denied medical care because they can’t afford it.
The ACA made significant progress toward this goal, as the share of adults reporting they didn’t get health care in the previous year because they couldn’t afford it declined 17.1 percent between September 2013 and March 2017. Several recent studies have attributed improvements in health care affordability to the ACA’s coverage expansion.
Recent actions in Washington have created new uncertainty for people who obtain health insurance through the nongroup and small group markets, including
- efforts to repeal the individual mandate through tax reform legislation,
- the elimination of cost-sharing reduction payments to insurers,
- an executive order to weaken regulation of association health plans and short-term plans, and
- cuts to Marketplace outreach and enrollment assistance funding.
These policies are expected to raise premiums for ACA-compliant coverage by drawing healthy people out of the risk pools and causing insurers to compensate for the loss of expected cost-sharing payments. Though premium tax credits will rise to offset the increase in premiums for many Marketplace enrollees, coverage may become too expensive for people ineligible for subsidies or who cannot obtain subsidized coverage if no insurers are willing to sell Marketplace plans in their area, and the resulting loss of coverage will diminish their ability to get medical care.
Efforts to scale back access to health insurance coverage stand in opposition to views held by most Americans that health care is a shared responsibility. Though both Republican and Democratic policymakers subscribe to the goal of making health care more affordable and accessible by providing “insurance for everybody,” their proposals for doing so must be judged based on evidence, and the evidence suggests that rolling back the ACA will lead to significant losses in coverage among people who can least afford to pay for their care.
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The Urban Institute podcast, Evidence in Action, inspires changemakers to lead with evidence and act with equity. Co-hosted by Urban President Sarah Rosen Wartell and Executive Vice President Kimberlyn Leary, every episode features in-depth discussions with experts and leaders on topics ranging from how to advance equity, to designing innovative solutions that achieve community impact, to what it means to practice evidence-based leadership.