By Mollyann Brodie, Elizabeth C. Hamel, and Mira Norton
In the fifty years since Medicare’s passage, the public has been polled frequently on their opinions of the program and potential changes to it. A search of the Roper Center for Public Opinion Research archives reveals more than 6,000 individual survey questions about Medicare, asked since 1962 by academic, commercial, nonprofit, and media pollsters. Three key themes emerge: Medicare is a popular program; the public is concerned about Medicare’s financial future; and, despite this concern, the public is resistant to most proposed changes, particularly to those that involve scaling back benefits.
Before delving into public opinion on Medicare today, it’s helpful to examine the historical context of opinion before the program was launched. In the 1940s, there was widespread support for the idea of expanding Social Security to include paying for medical care for the nation’s older adults. Surveys conducted in 1944 and 1945 showed that about two-thirds of the public were in favor of such a plan, and a majority supported it, even if it meant increasing taxes (Hamel, Deane, and Brodie, 2011).
The idea remained popular in the years leading up to Medicare’s enactment; in 1961 about two-thirds of the public favored “having the Social Security tax increased in order to pay for old age medical insurance.” About a year before its passage, when asked specifically about Congress’s plans regarding Medicare, six in ten Americans said they approved. And, in 1965, a few months after Medicare was signed into law, a survey showed that about eight in ten Americans approved of the bill passed by Congress (Hamel, Deane, and Brodie, 2011).
Medicare’s popularity has continued since its launch. Such reliably positive public opinion likely is due to its nearly universal impact; most Americans either are enrolled in the program themselves, know someone in their family who is enrolled, or will enroll at some point in their lives. Evidence of Medicare’s popularity abounds in surveys. Since 1996, roughly seven in ten Americans have expressed a favorable view of the program (Hamel, Deane, and Brodie, 2011; Harvard School of Public Health, 2013). About three-quarters describe the program as important for themselves and their family, and nearly all say it is important to the country as a whole (Kaiser Family Foundation, 2009, 2014a).
As another measure of the program’s popularity, in the years leading up to the passage of the Affordable Care Act (ACA), when the public was asked about different ways to expand health insurance coverage to the uninsured, expanding Medicare was among the most popular options. Surveys conducted between 1999 and 2009 showed consistent majorities, ranging from about six to eight in ten, saying they favored expanding Medicare to cover people between the ages of 55 and 64 as a way to cover more uninsured (Hamel, Deane, and Brodie, 2011).
Across most measures of Medicare’s popularity, older adults express even more positive opinions than younger adults. Still, those younger than age 65 also place a lot of value on the program, with majorities saying they have a favorable opinion of Medicare and that it’s important for their families. And while Medicare is popular across partisan groups, there are some differences in the intensity of that sentiment that are consistent with partisan differences on government programs in general. For example, Democrats are more likely than Republicans or Independents to say they have a “very” favorable impression of Medicare and that the program is “very” important for them and their families (see Figure 1, below).
In addition to thinking Medicare is important, a majority of Americans (including about eight in ten older adults) think it works well (Kaiser Family Foundation, 2012). This sense that Medicare is working well is borne out in surveys examining the experiences of people enrolled in the program. Compared with adults younger than age 65 with private health insurance, older adults enrolled in Medicare are more likely to rate their health insurance as “excellent,” and more likely to say they are very satisfied with their insurance deductibles, co-pays, and choice of providers (Kaiser Family Foundation, 2014b). Older adults with Medicare also are less likely to report having experienced problems paying medical bills in the past year compared to younger adults with private insurance (14 percent versus 22 percent) (Kaiser Family Foundation, 2013a). Notably, however, a 2008 survey found that among people on Medicare, beneficiaries younger than age 65 with disabilities were much more likely than older adults to report problems with coverage and access (Cubanski and Neuman, 2010).
Despite their overall favorable views, many Americans lack knowledge about Medicare, particularly when it comes to some of the more intricate aspects of the program. We’ve all heard the anecdote about the elderly protester at a town hall meeting shouting, “Keep the government out of my Medicare!”, but three-quarters of Americans are aware that Medicare is a federal government program (Harvard School of Public Health, 2013).
Public knowledge is less complete when it comes to details of Medicare benefits and coverage. A 2013 survey found just one-fifth of Americans were aware that wealthier beneficiaries pay higher Medicare premiums than their lower income counterparts (Kaiser Family Foundation, 2013b). Historically, there also has been public confusion about which services are—and are not—covered by Medicare. Before the enactment of Medicare Part D, about half the public incorrectly thought that Medicare already covered prescription drugs (Kaiser Family Foundation/Harvard School of Public Health, 2003). More recently, a 2014 survey of adults ages 40 and older found that 42 percent incorrectly think Medicare pays for ongoing nursing home care and 38 percent think the program covers ongoing care by a home health aide (Associated Press-NORC Center for Public Affairs Research, 2014).
Concerns About Medicare’s Future
The second theme identified in surveys about Medicare is a concern among the public about Medicare’s financial future. Increasing overall U.S. healthcare costs, the aging of the population, and a declining worker-to-beneficiary ratio together create financial challenges for Medicare. The public is aware of these challenges; most Americans say the program is either in “financial crisis” or faces “major” financial problems. While still a majority, the share holding this view has declined somewhat in recent years, from three-quarters in 2009 to six in ten in 2014. This likely is a reflection of the fact that slower-than-expected growth in healthcare spending has extended Medicare’s projected solvency (Kaiser Family Foundation, 2014c), and also has pushed discussions of Medicare spending reductions further down the policy agenda than they were several years ago, at the height of the budget deficit debate.
When asked what they see as major reasons behind rising Medicare costs, large majorities of the public cite high profits by drug and insurance companies, as well as the general rise in healthcare costs, and fraud in the Medicare program. Some factors that experts often point to as drivers of Medicare costs rank further down the public’s list, including waste and inefficiency in the program, an aging population that is living longer, and too many beneficiaries receiving unnecessary treatment (Kaiser Family Foundation, 2011).
Coupled with the sense that Medicare faces an uncertain financial future, many Americans worry that the program will not be there for them when they retire. In a 2014 survey, six in ten workers said they were not confident that Medicare will continue to provide benefits of at least equal value to the benefits received by retirees today, a level of concern that has remained fairly steady since 1992. Retirees, most of whom are already receiving Medicare, are more likely than workers to express confidence in the value of future Medicare benefits, yet still nearly half of retirees said they were not confident that these benefits would continue (Employee Benefit Research Institute, 2014).
It is not only Medicare’s financial future that Americans are worried about. Recent surveys also have found public concern—and confusion—about how the ACA affects Medicare. In 2013, about a third of the public said the Medicare program would be worse off under the new law, compared with a quarter who said it would be better. Older adults were even more negative in their views of the ACA’s impact on Medicare, with 38 percent saying it would be worse and just 14 percent saying it would be better (Kaiser Family Foundation, 2013c). Many Americans also are confused about the specific ways Medicare is affected by the law. Six in ten survey participants either believe the ACA cuts benefits for people in the traditional Medicare program, or are unsure if it does, and more than half think it allows, or are unsure whether or not it allows, a government panel to make end-of-life decisions for people on Medicare—neither of which is the case (Kaiser Family Foundation, 2013c, 2014a).
Concerned about the future of Medicare, Americans typically have been more likely to say they trust the Democratic Party rather than the Republican Party to do a better job handling the program. However, particularly among older adults, the historic trust advantage that Democrats have enjoyed has narrowed in recent years. In 1998, 46 percent of older adults said they trusted Democrats more and 22 percent chose Republicans, a gap of 24 percentage points; by 2014, those percentages narrowed to 39 and 34 percent, respectively, a gap of only 5 points (Kaiser Family Foundation, 2014d; Kaiser Family Foundation/Harvard School of Public Health, 1998).
Resistance to Change
The third theme that emerges from polling on Medicare is that Americans—and particularly those older than age 65—are resistant to making changes to the program. At its most basic level, this can be measured by the public’s reluctance to see cutbacks in Medicare spending as a way to reduce the federal budget deficit. In a number of surveys between 1987 and 2013, majorities of the public were opposed to cutting back spending on Medicare to reduce the deficit (Hamel, Deane, and Brodie, 2011). In the most recent of these surveys, about six in ten said they would not support any spending reductions in Medicare, while three in ten would support minor spending reductions, and only one in ten would support major reductions. Although many experts believe that reducing Medicare spending is key to reducing the federal budget deficit, more than three-quarters of the public believe that the country’s budgetary problems can be addressed without reductions in Medicare (Kaiser Family Foundation, 2013b).
Resistance to change also is seen in the public’s reaction to more specific proposals that have been made, either as ways to ensure Medicare’s future solvency or to reduce the deficit (see Figure 2, below). Options that are perceived as cutting benefits or requiring beneficiaries to pay more historically have been the least popular (Hamel, Deane, and Brodie, 2011). In 2013, only 13 percent of the public favored increasing Medicare premiums for all older adults as a way to reduce the deficit. Increasing premiums only for higher income beneficiaries is a more popular option (favored by about six in ten Americans); however, as noted above, most people are unaware that older adults with higher incomes already pay more for their Medicare coverage.
A majority of the public (55 percent) is opposed to increasing Medicare payroll taxes as a way to reduce the federal budget deficit, with 43 percent supportive of such a proposal. Other proposals receive a lukewarm reaction from the public, including reducing Medicare payments to hospitals and other healthcare providers. While close to half the public overall (46 percent) favors this proposal, it garners lower support from older adults, who may worry that lowering Medicare payments could make it harder for them to find providers that will see them (Kaiser Family Foundation, 2013b).
The public is about evenly split on the idea of gradually raising the age of eligibility for Medicare from age 65 to age 67 for future retirees (48 percent favor, 51 percent oppose). In contrast to their reaction to reducing payments to providers, when it comes to raising the age of eligibility, older adults—who are already covered and would not be affected by the changes—are actually more likely than their younger counterparts to support such a change (Kaiser Family Foundation, 2013b).
One set of proposals that has been historically popular involves having Medicare obtain discounts from drug companies. In 2008 and 2009, about nine in ten Americans were in favor of allowing the federal government to negotiate lower prices with drug companies as part of the Medicare drug benefit, and in 2013, 85 percent said they would favor requiring drug companies to charge low-income Medicare beneficiaries less for medications (Hamel, Deane, and Brodie, 2011; Kaiser Family Foundation, 2013b).
Medicare and Private Plans—the Future?
One type of proposal that has perhaps gotten more attention than any other in recent years is changing Medicare from a “defined-benefit” program, in which the government guarantees health insurance and provides coverage, to a “defined-contribution” program, under which the government would provide beneficiaries with a fixed amount of money that they could use toward the purchase of a private health plan. Before exploring public opinion on this proposal specifically, it’s helpful to provide some context of the public’s (and older adults’) views of Medicare compared with private plans.
While the role of private plans in Medicare has increased in recent years due to the growth of Medicare Advantage and the Part D benefit, Medicare is still by-and-large a government program, and many Americans distinguish what they see as differences between Medicare and private plans, with divisions along generational lines. When asked about their perception of the generosity of benefits and the choice of providers available through Medicare compared with private employer-sponsored plans, younger adults are more likely to say private plans offer greater choice and more generous benefits than Medicare, while older adults are more likely to say there is no difference between the two (Kaiser Family Foundation, 2014e).
So what does the public think of so-called voucher or “premium support” plans, like the one most recently proposed by Congressman Paul Ryan, in which the federal government would provide beneficiaries a fixed amount of money annually to purchase either a private health plan or traditional Medicare? In polls asking about this type of approach, dating back to 1995, the public consistently has expressed a preference for continuing with the current system (Hamel, Deane, and Brodie, 2011). In the most recent survey, only about a quarter of the public said they would support changing Medicare to a defined-contribution system, while two-thirds said they prefer to keep the current system intact (Kaiser Family Foundation, 2014e).
While majorities across political parties prefer keeping Medicare as it is today, Republicans are more likely than Democrats and Independents to support such a change. And while the most recent premium support proposal that was discussed in Congress would have exempted adults ages 55 and older, Americans in this age group are significantly more likely than younger adults to prefer keeping the system as it is. Those younger than age 55, most of whom have not yet had personal experience with the current Medicare program and may be more comfortable with the idea of private coverage, are more likely than their older counterparts to favor a shift to a premium support system, but still, most people in this age group—the ones who stand to be directly impacted by such a change—prefer to keep Medicare as is (see Figure 3, below).
Most recent policy discussions have focused on changes to Medicare that would reduce costs to government, but it’s worth noting that polls show there is interest among the public in changes that would enhance Medicare’s benefits or fill some of the gaps in current coverage. For example, a 2010 survey found that two-thirds of the public would favor adding dental and vision coverage “at an extra charge for Medicare recipients” (Associated Press-GfK Poll, 2010), and a 2014 survey found that nearly six in ten Americans ages 40 and older favored a “government administered long-term care insurance program similar to Medicare” (Associated Press-NORC Center for Public Affairs Research, 2014).
Conclusion and Future Challenges
The future of Medicare presents numerous challenges to policy makers as they seek to design and adapt policies that finance care for an aging population. This is particularly difficult when surveys show that Medicare remains popular among the public and that people are resistant to making major changes. Despite experts’ concerns about financing challenges, there is widespread public resistance to cutbacks and changes, either as an effort to ensure Medicare’s financial health or to reduce the federal budget deficit. Although there have been recent improvements in Medicare’s financial solvency forecasts, many Americans still worry about the program’s financial future, including many younger people who are concerned that the program will not be around for them when they retire. Although current public opinion research shows that the public is resistant to changing Medicare to a defined-contribution system, such proposals are likely to resurface in the future, particularly in light of the new Republican majority in Congress and the naming of Paul Ryan as Chair of the House Ways and Means Committee.
As younger generations—who are more comfortable with private insurance, and more likely to support a defined-contribution system—near the age of Medicare eligibility, it’s possible that the public’s resistance to change in this direction could be mediated somewhat. Politics is also likely to remain at the center of this debate, and although older adults historically have put more trust in Democrats than in Republicans to handle Medicare’s future, the Democrats’ advantage has narrowed in recent years. This trend, along with older adults’ generally unfavorable views of the ACA and their worries about the law’s impact on Medicare, suggests that Republican ideas and proposals may have an opportunity to gain traction with this audience in the future.
Mollyann Brodie, Ph.D., is senior vice president for executive operations and executive director, Public Opinion and Survey Research, at the Kaiser Family Foundation in Menlo Park, California. Elizabeth C. Hamel is director, Public Opinion and Survey Research, at the Kaiser Family Foundation, Menlo Park. Mira Norton is a survey analyst, Public Opinion and Survey Research, at the Kaiser Family Foundation, Menlo Park.
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