Public Opinion on Medicaid Expansion

This piece was co-authored by Civitas Elections Policy Fellow Andy Jackson. 

• Polling for Medicaid expansion reveals that people support it in concept, but reject it once they learn the facts.
• North Carolina lawmakers should not take support for expansion at face value.
• The reality of Medicaid expansion is unpopular in North Carolina and across the nation.

In North Carolina, around 1 in 5 people are currently enrolled in Medicaid.

Medicaid is a government administered insurance program that operates in a state-federal partnership. The current Medicaid program determines eligibility based on income and categorical criteria – meaning that low-income children, people with disabilities, parents, and pregnant women are eligible if they meet the income requirements for their category.

Under the Affordable Care Act, states can choose to expand Medicaid coverage to all low-income individuals, regardless of lack of categorical eligibility. Since the most vulnerable populations are already covered under the current system, expansion would extend coverage to mostly able-bodied, working-aged, childless adults.

But the above explanation is pretty “in the weeds” for anyone who is not a healthcare professional. Most people just know that Medicaid is an insurance program for poor people. This makes the battle over public opinion around Medicaid expansion extremely important.

In the United States, there is a generally held belief that we should support the neediest among us. The concept of the “social safety net” is one that many Americans support. However, policies that sound good in concept often have unintended consequences that far outweigh their surface appeal.

In 2018, expansion-related initiatives passed in 4-of-5 states where they were on the ballot. Three of those states (Idaho, Nebraska, and Utah) had votes on expansion itself while the other two (Montana and Oregon) had votes on tax increases related to expansion.

The success of these initiatives can be at least partly explained by the fact that expansion proponents have a relatively simple message to convey – “Help poor people” – while opponents must build a more nuanced argument based on facts related to expansion.

Of the four states that passed expansion initiatives, three saw support decrease from pre-election polling to actual election day results. Part of this can probably be accounted for in turnout factors. But the dramatic drop in some states – such as Utah and Idaho – shows that there may be hope for swaying public opinion through education on the realities of expansion.

Comparison of Polling and Election Results on Medicaid Expansion Initiatives in 2018
State (initiative #)	Polling: favor-oppose (gap)	Election: approve-disapprove (gap)	Difference (polling gap -voting gap)
Idaho (2)	61-20 (41 points)	61-39 (22 points)	19 points
Montana (I-185)	41-41 (0 points)	47-53 (-6 points)	6 points
Oregon (101)	52-20 (32 points)	62-38 (24 points)	8 points
Nebraska (427)	No polling	54-46 (8 points)	—
Utah (3)	59-33 (26 points)	53-47 (6 points)	20 points
Average	53-29 (24 points)	55-45 (10 points)	14 points

Election results are from the Ballotpedia page for each initiative.

 

Montana was the one state where voters rejected tax increases to pay for Medicaid expansion. Montanans defeated an initiative after opponents pointed out several problems with the bill including cost, how the real beneficiaries were hospital administrators and how Medicaid expansion would lock the state into entitlement expenses over which the legislature would have no control. However, the most common argument against expansion was over the tax increases associated with the initiative – mainly on tobacco products. That suggests that when people know the cost of expansion, support declines among taxpayers.

In North Carolina, Medicaid expansion can only be approved through the state legislature. It cannot be approved through direct voter referendum. However, public opinion in North Carolina seems to follow a similar pattern found in other states – people like the idea of Medicaid expansion, but not the reality of it.

The February 2019 Civitas Poll found that 62 percent of North Carolinians support Medicaid expansion at face value. This is similar to the 61 percent that supported expansion in the November 2018 Civitas Poll.

However, when given more information about the costs and beneficiaries of expansion, support drops. The infographic listed below illustrates the poll questions and responses:

 

Perhaps the most telling insight from these questions is how the results from the first question (initial support for expansion) change when people learn the details. Digging into the poll’s crosstabs, a pattern becomes clear: Even those who initially support expansion can be persuaded when given the facts.

When informed about the population that will be covered under expansion and the cost, 38 percent of respondents who initially favored expansion said they were less likely to do so. That number was even higher for those who “somewhat” supported expansion. When presented with the reality, around 56 percent of this group were less likely to support Medicaid expansion.

The Civitas Poll reveals that North Carolina is similar to other states that considered expansion through voter referenda. The bottom line is that strong support for Medicaid expansion in polling is driven in large part by a lack of knowledge of its actual impact and consequences. Providing more information to the public tends to decrease support for expansion.

As previously mentioned, the state legislature must approve Medicaid expansion in North Carolina. It is wise for lawmakers to remember that people tend to like the idea of expansion, but then reject the reality of it.