TO: Interested Parties
FROM: Geoff Garin
DATE: September 5, 2017
RE: New Polling on Voters’ Priorities for Healthcare After the Failure of Repeal and Replace
From August 18 to 21, Hart Research Associates completed 1,017 online interviews with a representative national cross section of Americans who voted in the 2016 election. The selfreported presidential vote among the sample is 48% for Hillary Clinton, 45% for Donald Trump, 5% for Gary Johnson, and 2% for Jill Stein. The party identification of the survey respondents is 43% Democrat, 39% Republican, and 18% independent.
Overview
Our recent national survey of 1,017 voters, conducted August 18 to 21, 2017, confirms that the efforts of President Trump and Republicans in Congress to repeal and replace the Affordable Care Act already have put them very far at odds with the public and are a major political vulnerability for them. The poll results also clearly demonstrate that continued efforts by Trump and congressional Republicans to undermine the Affordable Care Act will be deeply unpopular with voters, including many rank-and-file Republican voters. Large majorities of voters recognize that President Trump is trying to make the Affordable Care Act fail and playing politics with people’s healthcare. This behavior is in direct contrast with the priorities of most voters; for example, two-thirds of voters agree that “President Trump and the Republicans in Congress need to put politics aside and take the necessary steps to make sure individuals have access to affordable health insurance under the Affordable Care Act.”
There is widespread disapproval of President Trump’s threats to cut off the funding that helps insurance companies reduce out-of-pocket costs for individuals, and these threats are one of the top sources of concern about Trump’s handling of healthcare. Voters react strongly to the fact that cutting off these funds would increase health insurance premiums for individuals by 19%, as well as to the uncertainty that these threats create for insurers and the resultant possibility that many Americans could be left without affordable healthcare options. If these outcomes occur and there are failures in the Affordable Care Act, voters will blame President Trump and the congressional Republicans who are complicit in his efforts to undermine the ACA. Healthcare stands out as the number-one issue for voters in the 2018 midterm elections, and large majorities say they will be less likely to reelect their senator or congressperson if he/she supports efforts by President Trump to destabilize the health insurance markets and sabotage the Affordable Care Act.
From a political perspective, these poll results underline one clear conclusion: Democrats and progressives should be playing offense on the issue of healthcare, and should keep the issue front and center for voters in the coming weeks and months. This poll and others show that healthcare is a priority voting issue across the electorate, and the threat to healthcare presented by the policies of President Trump and congressional Republicans is a matter of deep personal concern to many voters. There is an obvious high ground in the debate about what should happen next in healthcare policy: voters want a bipartisan effort to keep what works in the Affordable Care Act and make the necessary improvements so it can work better, and they want action to bring more stability to the health insurance markets to keep premiums down and make sure people continue to have affordable healthcare options. If President Trump and congressional Republicans fail on these objectives and outcomes, voters will hold them accountable for that, and Democrats and progressives should be aggressive in shining a spotlight on each and every action by Trump and the Republicans that contributes to higher premiums and greater instability in the healthcare system.
In making these points, Democrats and progressives should:
- Remind voters of Trump’s frequent declarations of his intention to let the Affordable Care Act fail and the ways he has followed through on these threats — including his efforts to limit and subvert enrollment;
- Blame Trump and congressional Republicans for rising premiums and insurer opt-outs in the health insurance marketplaces, as a direct result of policies and actions designed to promote uncertainty and instability;
- Emphasize that Trump is deliberately sabotaging people’s healthcare because of his own egomania, political spitefulness, and personal hostility to the previous administration;
- Hold congressional Republicans accountable for supporting Trump’s efforts to destabilize the health insurance markets and sabotage the Affordable Care Act, and for their lack of independence in standing up to these efforts;
- Never let voters forget that Trump and the Republicans in Congress see the alternative to the Affordable Care Act as a system that weakens protections for pre-existing conditions, imposes an age tax through higher premiums on people over the age of 50, leaves 16 million to 32 million more Americans uninsured, and eviscerates Medicaid at the expense of children, people with serious disabilities, and people in need of nursing home care;
- Remind voters that instead of sabotaging people’s healthcare, the better way is a bipartisan effort to keep what works in the Affordable Care Act and make the necessary improvements so all Americans have access to affordable, quality healthcare.
Discussion of Key Findings
1. The efforts of President Trump and Republicans in Congress to repeal and replace the Affordable Care Act already have put them in a very deep hole with the public on the issue of healthcare.
By 61% to 39%, voters disapprove of the way Donald Trump is handling the issue of healthcare as president — including fully half (50%) who strongly disapprove; only 21% strongly approve. Independent voters disapprove of Trump’s handling of the issue by 40 points (70% to 30%), and one-in-five (20%) Trump voters disapproves as well. Voters volunteer a variety of reasons for disapproving of Trump’s handling of healthcare: Democrats emphasize that Trump just wants to destroy former President Obama’s legacy, while Republicans focus on Trump’s lack of accomplishments on the issue and his failure to come up with a good plan to replace the Affordable Care Act.
Republicans in Congress get poor marks on this issue as well: eight-in-10 (80%) voters disapprove of the way congressional Republicans are handling the issue of healthcare, while only 20% approve. This “disapprove” number includes 91% of Democrats, 81% of independents, and, notably, 68% of Republicans themselves. These marks reflect the public’s dislike for Republicans’ legislative proposals over the course of this year: 60% of voters are unfavorable toward the bills proposed by the Republicans to repeal and replace the ACA, while only 25% are favorable. Among those with a strong opinion, negative attitudes outnumber positive ones by more than seven-to-one (6% very favorable, 43% very unfavorable). Independent voters oppose the GOP bills by a wide margin of 64% to 17%, while more than a third (35%) of Republicans are opposed as well. This represents significant erosion in support since our poll back in May, when voters expressed unfavorable views toward the House version of the Republican healthcare repeal bill (the AHCA) by a much smaller margin, 54% to 40% (with Republicans supportive by 71% to 22%). What’s more, our March poll — conducted at the outset of the healthcare fight — found voters to be essentially split on the issue, with 48% unfavorable and 45% favorable toward the Republicans’ efforts at that point.
2. Large majorities of voters recognize that President Trump is “trying to make the Affordable Care Act fail” and “playing politics with people’s healthcare.” This behavior is in direct contrast with the priorities of most voters.
There is a major disconnect between what voters want President Trump to do now that Congress has failed to repeal and replace the current healthcare law and what they believe he actually is doing, as the following table shows:
Hart Research Associates
On a related set of questions, nearly two-thirds (64%) of voters believe it is true that Donald Trump is “undermining the Affordable Care Act” and three-in-five (61%) voters believe that he is actively “trying to make the Affordable Care Act fail.” Additionally, 64% say that Trump is “playing politics with people’s healthcare,” including one-in-four (24%) of his own voters. Along similar lines, a 57% majority believe that the president is “sacrificing people’s healthcare in order to oppose Barack Obama.” And when provided with a list of phrases describing potential actions Trump could take around healthcare, this idea — that Trump would hurt people purely out of his own personal animus toward his predecessor — scores as the most worrisome for voters, with onethird (32%) choosing it as their number-one concern.
Clear majorities of voters see each of the following statements about Trump’s approach to healthcare as true:
- Trump is undermining the Affordable Care Act (64% true)
- Trump is playing politics with people’s healthcare (64% true)
- Trump is trying to make the Affordable Care Act fail (61% true)
- Trump is sacrificing people’s healthcare in order to oppose Barack Obama (57% true)
3. There is widespread disapproval of President Trump’s threats to cut off the funding that helps insurance companies reduce out-of-pocket costs for individuals, and these threats are one of the top sources of concern about Trump’s handling of healthcare.
When asked to react to a variety of actions President Trump has taken on healthcare, several elicit widespread disapproval from voters.
- He has frequently threatened to cut off the funding that helps insurance companies reduce out-of-pocket costs for individuals, which non-partisan analysis says can raise premiums by 19% (66% disapprove)
- He has frequently threatened to cut off the funding that helps insurance companies reduce out-of-pocket costs for individuals, creating uncertainty for insurance companies when calculating next year’s premiums (66% disapprove)
- He has cut in half the amount of time when people are able to sign up for health insurance under the Affordable Care Act (65% disapprove)
- His budget makes deep cuts in funding for Healthcare.gov — the website people use to sign up for insurance under the Affordable Care Act — knowing that these cuts would make the website less reliable and less easy to use (63% disapprove)
- He has publicly said several times that he will let the Affordable Care Act fail — signaling to insurance companies that they cannot rely on the Trump administration and creating uncertainty about what rules they will be operating under (61% disapprove)
Of these different actions taken by President Trump, many voters highlight his threat to cut off the CSR payments as one of the two items causing them the most concern (selected by 47%). Voters also emphasize Trump’s statements about letting the ACA fail as a top concern (selected by 43%), because these statements signal to insurance companies that they cannot rely on his administration and create uncertainty about the rules they will be operating under.
After hearing about what Trump has said and done on healthcare, voters overwhelmingly are convinced that his actions are destructive and will have negative consequences. For example, 70% of voters say it is true that Trump is “actively trying to undermine the Affordable Care Act and taking actions that are destabilizing health insurance markets,” while 65% say it is true that he is trying to “sabotage” the law. And more than three-in-five (61%) respondents concur with the conclusion that “on healthcare, Donald Trump is putting his ego and dislike for Barack Obama ahead of doing what is necessary to ensure that people have access to affordable health insurance” — exactly the petty, politically motivated approach they tell us bothers them the most.
4. After hearing the pros and cons of the issue, voters say by two to one that payments of the cost sharing reductions should continue — notwithstanding the GOP charge that these payments are bailouts of the insurance industry.
In total, we tested eight different arguments in favor of continuing and guaranteeing costsharing reduction payments for the next several years, all of which garnered majorities saying they were convincing — including three that were rated as convincing by 60% or more of voters. On the other side of the coin, we tested three arguments in support of cutting off these payments. Only one of these arguments — that these funds are used to bail out insurance companies so they can make a profit, and taxpayers should not subsidize insurance companies — was rated as convincing by a majority of voters. Fiftyseven percent (57%) of voters felt this was a convincing argument; while 43% said it was just somewhat or not convincing, including a third (32%) of Republicans.
Of the pro-CSR arguments we tested, the statement that “if these funds are cut off, more health insurance companies will decide not to offer health insurance to individuals and many Americans could be left without affordable healthcare options” tested strongly, with 64% saying this is a convincing argument in favor of continuing these payments, including 41% who say it is “very” convincing. Essentially tied was the argument that if these funds are cut off, non-partisan analysts say that premiums for individuals would be 19% higher each year; 63% of voters, including 66% of independent voters, rated this as convincing.
After hearing both sides, voters told us by 68% to 32% that they believe these payments should be continued, not cut off. Nearly all (94%) Democrats want to see these payments continued, as do 69% of independents and 38% of Republicans. Sixty-four percent (64%) of white non-college educated women and 41% of non-college educated Trump voters want to see these payments continue, as they are essential to keeping down healthcare costs for everyday people and ensuring access to affordable care.
Furthermore, when informed, nearly half (48%) of voters say that the idea that Trump is “sabotaging people’s healthcare” is one of their top concerns about what he would be doing if he cuts off these payments, and only one-in-five (21%) say that the idea of “sabotage” is not really believable to them as a way of describing what Trump would be doing. (Before learning about the effects of cutting off CSR payments, voters were more likely to see Trump as just playing politics with healthcare — but the additional information makes the idea of “sabotage” both highly concerning and broadly credible.)
5. Continued efforts by Trump and congressional Republicans to undermine the Affordable Care Act will be deeply unpopular with voters, and it is clear that voters will blame Trump and the Republicans for future premium increases and disruptions in the health insurance markets.
In terms of the path forward, 78% of voters agree (seven-to-10 ratings on a zero-to-10 scale) with the statement that “President Trump and the Republicans in Congress should take the necessary steps to make sure the health insurance markets are stable, in order to prevent large increases in insurance premiums,” including three-fourths (75%) of Republicans. Another 68% of voters agree that “President Trump and the Republicans in Congress need to put politics aside and take the necessary steps to make sure individuals have access to affordable health insurance under the Affordable Care Act.” Even in spite of its mentioning the ACA, nearly half (45%) of both Republicans and Trump voters agree with this statement as well.
Encouragingly, the poll indicates that — even if there is not universal agreement that the ACA is working well currently — there is a strong sense of optimism that it can work well with the proper support. In fact, 13% of all voters describe themselves as unfavorable toward the ACA, BUT say they believe it the law has the potential to work well in the future. This important target group is three-fifths female (61%) and is made up largely of Trump voters (69%), 70% of whom do not have a college degree.
Going forward, if there are still problems occurring a year from now in terms of premium increases and insurance companies no longer offering plans under the Affordable Care Act, 83% of voters tell us that Republicans in Congress will bear the responsibility, including 48% who say they will have “a lot” of the responsibility. And 71% believe that President Trump will be responsible, compared with only 51% who say the same about President Obama — suggesting that, despite being known as “Obamacare,” the onus to make the law work is now on the current occupant of the White House and leaders in Congress.
6. Healthcare stands out as the number one issue for voters in the 2018 midterm elections, and large majorities say they will be less likely to reelect their senator or congressperson if he/she supports efforts by President Trump to destabilize the health insurance markets and sabotage the Affordable Care Act.
Nearly six-in-10 (57%) voters chose healthcare as one of their top two most important issues heading into the 2018 elections, far and away the top choice (25 percentage points higher than any other issue) out of a list that spanned topics from the economy and taxes, to education, to immigration, to terrorism and national defense. Healthcare was the number-one choice among self-identified Democrats (71%), independents (58%), and Republicans (42%) alike. The issue is pertinent among key voting blocks, such as white non-college educated women, 53% of whom point to healthcare as one of their top issues, and voters across the 10 states Trump carried in 2016 but in which Democratic senators are defending seats next year (57% of voters in these states picked healthcare, compared to only 32% who picked the economy, their number-two choice).
Finally, this poll suggests that there are indeed electoral consequences to Republicans’ actions (or lack thereof) when it comes to improving the current law and stabilizing healthcare markets: 75% of voters tell us they would be more likely to support their senator or congressperson if he or she “supported a bipartisan effort to bring more stability to the health insurance markets in order to keep premiums down and make sure people continue to have affordable healthcare options,” including 85% of Democrats, 72% of independents, and 65% of Republicans. When framed explicitly in terms of the ACA (“supported a bipartisan effort to keep what works in the Affordable Care Act and make the necessary improvements so it can work better”), 68% of voters are supportive, with even Republican voters more likely to support their representative (47% to 38%). On the other side of the coin, however, voters tell us by 38 points that they would be less likely to vote for someone who “supported efforts by President Trump to destabilize the health insurance markets and sabotage the Affordable Care Act” (22% more likely, 60% less likely).