Strengthening Medicaid
Insights from Focus Groups and a National Voter Survey
March 2008
Overview
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Lake Research Partners
In April 2007, Lake Research Partners conducted a national survey of 803 registered voters about Medicaid and SCHIP and ideas for strengthening both programs. The study also included nine focus groups with voters in five states. The Center on Budget and Policy Priorities and the Georgetown Center for Children and Families sponsored this research. The purpose was to understand voter opinions about various reform ideas; this memo reports on findings related to Medicaid.
The ideas tested in the study represent some of the current Medicaid reform proposals offered from a range of perspectives. The communications advice we offer, however, is geared toward organizations seeking to strengthen Medicaid without curtailing health benefits or cutting beneficiaries from the program.
The starting point for this research, reaffirmed by this survey, is understanding that there is broad support for the Medicaid program. While voters may be vague on the details of Medicaid, they actually have strong opinions about the program. They believe the government should play a role in helping to cover low-income, uninsured children and parents, seniors, and people with disabilities. They worry about the uninsured and the majority supports efforts to expand Medicaid to reach more of the uninsured, particularly children.
Voters also want all children enrolled in Medicaid to receive the same basic health benefits and not leave it to states to determine which benefits to cover or not cover. Voters do not like enrollment barriers and red tape that keep eligible children and others out of Medicaid. They are sensitive to the costs of Medicaid but perceive the problem is really with the health care system overall, not with the Medicaid program. Finally, they believe the federal government should invest more in Medicaid to ensure the program remains strong. Following are highlights from this study.
§ Voters value Medicaid. More than three-quarters of voters (78%) consider Medicaid to be a very important program.
§ Voters are concerned about the uninsured. The majority of voters (59%) are very concerned about the number of uninsured adults and children in the country. An additional one-third (32%) say they are somewhat concerned about the number of uninsured.
Top Reform Ideas
§ Voters do not want to leave decisions about children’s benefits to states: Most voters want all state Medicaid programs to offer the same basic health coverage for children. Two-thirds say this is an excellent idea (62%). Voters are concerned that without standard benefits, states could drop essential services that children need. Indeed, the survey shows there is much less support for letting states decide what services to cover – only 13 percent say this is an excellent idea, particularly when told pediatricians are against taking benefits away. This finding shows voters want all Medicaid-enrolled children to have access to the wide arrange of services that children need to flourish. ( See Table 1)
§ Voters want to simplify Medicaid eligibility rules: Half (50%) say simplifying Medicaid eligibility rules is an excellent idea. The focus groups suggest that voters dislike the red tape and bureaucracy involved with Medicaid enrollment.
§ Many voters support creating more competition in Medicaid. They like the idea of making Medicaid more like the private market and allowing beneficiaries to choose private health plans – 46 percent say this is an excellent idea. A big reason is that they believe competition will reduce Medicaid’s costs.
Reforms with Less Support
§ Voters show less support for providing vouchers to purchase plans: While the survey indicates this reform has moderate support on the surface – 46 percent say providing vouchers so that Medicaid beneficiaries can choose their own health plans is an excellent idea – the focus groups reveal that voters have problems with “vouchers.” They are unclear about how this concept would work in health care and the term has negative connotations for many voters.
§ Voters also show only moderate enthusiasm for more Medicaid outreach: Only about one-third of voters (35%) say spending more on education about Medicaid so that more children enroll is an excellent idea. The problem may be in the language used – “spending more” always concerns voters with public programs.
§ A number of voters express concern about “tailoring” Medicaid benefits to fit the needs of the beneficiary: Only 31 percent say tailoring Medicaid benefits – or offering different benefits packages to different groups -- is an excellent idea. The focus groups suggest voters find this impractical and also worry that some beneficiaries will unnecessarily lose benefits as a result .
Personal Responsibility
The idea of promoting “personal responsibility” through ideas such as greater cost sharing, putting more responsibility on beneficiaries to choose health plans, and reducing benefits for those who do not purportedly live healthy lifestyles has permeated some recent state debates on Medicaid. These ideas seem to imply that Medicaid beneficiaries are irresponsible and that the program needs to require greater accountability. However, as Table 2 shows, progressives can also evoke the value of responsibility in ways that can build support for the program. Specifically, the study found:
§ Voters believe that enrolling a child in S-CHIP or Medicaid is being responsible: Three-quarters (74%) strongly agree that a parent is being responsible when he/she enrolls their uninsured child in these programs. This is an important finding and a way to counter negative images of Medicaid beneficiaries.
§ Most voters also believe that a responsible parent can have an uninsured child: Two-thirds strongly agree that working parents may have uninsured children if their jobs do not offer coverage or if they cannot afford it on their own. Indeed, the focus groups reveal that there is substantial empathy currently for working parents who do not have health coverage for their children.
§ Most voters believe government has a role in helping children access health coverage: Only a third of parents strongly agree with the idea that parents, not government, are solely responsible to make sure their child is insured. Rather, they believe there is a role for government to help out when a working parent cannot get health coverage for their child.
§ Voters understand that parents sometimes are unable to provide coverage: Only one-quarter (26%) strongly agree that parents should be able to provide health coverage for their children on their own.
Healthy Behaviors
Currently there is discussion about promoting healthier lifestyles among Medicaid beneficiaries. There is a difference of opinion about how best to achieve this, however, through incentives or penalties. Focus group and survey findings suggest this issue is still new for voters and that they need more time and information. Following are insights:
§ Voters prefer “educating” beneficiaries over making them sign an agreement to be healthy: By a margin of 2-to-1 (64% vs. 33%), voters prefer that Medicaid “promote good health by working together with patients to learn about healthy lifestyles” and offering “incentives to make good choices.” Voters seem to reject the argument that beneficiaries should be required to sign an agreement to show up for doctor appointments, take their medicines, and do things like sign up for smoking cessation classes or else lose health benefits.
§ “Signing an agreement” is not a popular idea: The focus groups suggest that voters do not support beneficiaries “signing an agreement” stating that they will make healthy choices – they feel such an agreement could never be enforced. Some also feel this crosses the line of an appropriate role for government.
§ However, voters are conflicted over whether benefits should be taken from those who do not try to improve their health: The majority (57%) agrees that “if taxpayers are paying for your care, you should be required to do certain things like go to doctor visits” or “have benefits taken away if you do not.” A sizable minority (40%) disagrees with this statement, however.
§ Arguments against “taking benefits away” do not necessarily change opinions: These arguments assert that “families should not lose benefits because there are many reasons why they might miss a doctor’s appointment” (37% very convincing); “the government should not be in the business of trying to change the way people behave” (36% very convincing); and “children could lose benefits if their parents do not keep their appointments” (33%). It is unclear why these arguments did not resonate and more study is required.
Medicaid Messages
The survey tested a number of messages about investing more in Medicaid and they received strong support. (See Table 3) Following are specific findings:
§ A Health Care Crisis, Not a Medicaid Crisis: The survey and focus groups show that voters believe there are problems with the overall health care system, not necessarily with Medicaid. They prefer broadening the conversation beyond Medicaid to address the bigger problems in health care, like prescription drug costs. This message advocates that while we reform the health care system we need to keep Medicaid strong for those who need it.
§ Federal Government Should Take More Financial Responsibility for Medicaid: This is a theme in two messages that do surprisingly well in the survey and which explicitly call for more federal investment in Medicaid. Both messages receive strong voter support because they focus on a crisis that voters know is looming – aging Baby Boomers and the growing burden on state Medicaid programs to pay for long-term care.
§ Medicaid Is First and Foremost a Children’s Program: Presenting Medicaid as the primary health program for children helps build support among voters for keeping the program strong so that children can get the health services they need.
§ Medicaid Is a Safety Net for Families that Lose Coverage: This message did moderately well and focuses on the role that Medicaid plays for people who lose health coverage. This message may have more resonance now than when it was tested because of the worsening condition of the economy and higher concern about jobs.
Implications
Based on these findings, here are some ideas about how to build support for Medicaid among voters:
§ Do not be on the defensive: Voters do not need much information to believe Medicaid is a valuable program. They are concerned about the uninsured and feel government has a role in helping low-income children, seniors, and people with disabilities get health coverage. Medicaid has strong bipartisan voter support.
§ Consistently use the strongest messages: Remind voters/policymakers that we have a health care crisis, not a Medicaid crisis. Focus on the need for more federal investment to offset the growing burden on states for caring for seniors. Present Medicaid as a children’s coverage program and emphasize the need to keep the program strong for children.
§ Progressives should talk about responsibility too: The survey shows that voters believe a parent is being responsible when they enroll their uninsured children in S-CHIP or Medicaid.
§ Voters prefer the “carrot” to the “stick” approach with healthy behaviors: They oppose making beneficiaries sign pledges and prefer education about healthy lifestyles instead.
However, they are torn about whether it is appropriate to ever take benefits away from beneficiaries who do not take basic steps to improve their health. It is likely that voters need a fuller discussion of this issue before making up their minds.
§ Voters support many changes to Medicaid that could enhance the program: They support simplifying eligibility, which is an important finding. They also support making sure that all states offer basic health care services to children rather than each state deciding on the benefits package themselves.
For more information about this research, please contact Joan Alker at the Georgetown Center for Children and Families at 202/784 4075 or Donna Cohen Ross at the Center on Budget and Policy Priorities at 202/408 1080.
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Lake Research Partners