Reforming reform: public assessments of the affordability of health insurance policies

Background: Republicans have moved rapidly to repeal the Affordable Care Act, replacing progressive elements of the plan with regressive elements. We draw on an earlier affordability exercise to evaluate how Americans might view these elements of health care reform. Methods: Immediately prior to passage of the ACA, we conducted a telephone survey of a representative sample of U.S. households. Respondents were presented vignettes representing different insurance plans, each held by people with differing life characteristics. Respondents were then asked to assess the affordability of the presented plans given the characteristics of the policyholders. Results: Respondents felt that households should be expected to pay about 5% of income for health insurance coverage, irrespective of their income. They also tended to view older households as less able to afford coverage than younger households, and households with sicker occupants as less able to afford healthcare than households with healthy occupants. Results did not differ between respondents in red states and those in blue states. Conclusions: Most Americans, including those who reside in red states, believe that subsidies for health insurance premiums should be based on a fixed percentage of household income, not a fixed dollar amount. These perceptions may make it challenging to replace the ACA with a less costly alternative plan.