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Informing Policy. Advancing Health.

Income Drives Changes in Views of the Health System

Opinions Improved After Medicaid Expansion, Particularly Among Coloradans in the Lowest Income Group

Key Takeaways:

  • Coloradans have expressed steadily improving views of the health care system since 2011.

  • Lower-income Coloradans have voiced the most improved views of the system since the Affordable Care Act went into effect.

  • Coloradans tend to say the health care system works better for their families than for most people in the state.

In a historic shift, lower-income Coloradans are feeling as well-served by the health care system as people who are much better off financially.

That’s part of an ongoing change in attitudes about health care captured by the Colorado Health Access Survey (CHAS). The shift appears to have been set in motion by the Affordable Care Act, which expanded insurance coverage and benefits.

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The question of whether the health care system is working was on the minds of many Americans in early 2017, when the latest CHAS was conducted. Health care had been a major issue in the 2016 presidential election, and Congress was considering whether to repeal and replace the Affordable Care Act. In Colorado, a drastic increase in insurance premiums made headlines, further elevating the issue.

Despite all this, some three-quarters of Coloradans reported that the state’s health care system works for their families, according to the CHAS.

Coloradans’ views of the health care system have improved since 2011, with lower-income people driving the change. But not everyone has confidence in the system. Rural and middle-income Coloradans are less likely to think the system serves everyone well, and the proportion of Coloradans who think the system works for most people dropped slightly in 2017.

Better for My Family Than for Most Coloradans

The CHAS has asked Coloradans their views of the health care system since 2011.

Over the years, Coloradans have consistently reported that the health care system does a better job for their family than for Coloradans as a whole. The gap has narrowed slightly over time (see Figure 1).  Still, the strikingly different answers to two related questions — does the system work for your family, and does it work for most Coloradans? — shows that people’s personal experience with health care differs from their perception of how the system works overall.

The share of Coloradans who feel the health care system works for them and their families has increased steadily since 2011, though it plateaued after 2015. But in 2017, after several years of improvement, there was a dip in how many give the system as a whole high marks — perhaps reflecting the political turmoil over health policy.

More Lower-Income Coloradans Say The System Works for Their Families

Income and insurance coverage expansions influence how people think about health care.

Colorado expanded Medicaid in 2014, allowing those who make less than 138 percent of the federal poverty level (about $28,000 for a family of three in 2017) to be eligible for public insurance.

These lower-income Coloradans grew significantly happier with the health care system over the past six years, with the biggest jump between 2013 and 2015 — just when Medicaid expanded. In 2017, they reported feeling as well-served as those who make more than 400 percent of the federal poverty line — $80,000 a year for a family of three in 2017.

People with public insurance (Medicare or Medicaid) had the most favorable impressions of the health care system in 2017, followed by those with employer-sponsored insurance, the CHAS shows.  People who buy their coverage on the individual market had the most negative views of the health care system.

Meanwhile, Coloradans in the middle — those who aren’t eligible for Medicaid but make less than 400 percent of the federal poverty line — are less pleased. This group has consistently been the least likely to think the health system meets the needs of their family, and in 2017, their approval rate dipped from the 2015 level.

The difference among income groups is even more striking when people are asked how well the system as a whole is working. Lower-income Coloradans have grown more and more satisfied with the health care system. But in 2017, middle-income and more-affluent Coloradans’ opinions took a downward turn.

Different Settings, Different Views

Fewer rural Coloradans approve of the system and think it works for them (see Map 1 and Figure 4 below).

Western Slope residents were least likely to approve of the system as a whole. But different regions have different experiences: Residents of the mountain counties of Grand, Eagle, Summit, Pitkin and Garfield and counties in northwest Colorado, which had some of the state’s highest insurance premiums, were less likely to feel their needs were met.

Attitudes in a Time of Change

The last six years have been a time of significant change: The state has expanded Medicaid and created a marketplace for people to buy insurance. The ACA brought sweeping changes to health care.  And now, the Trump administration and its allies in Congress are chipping away at many provisions of the health care law.

All of this and more has affected Coloradans differently, and that shows up in their views towards the health care system. The state’s least well-off people — the very people the Affordable Care Act was designed to benefit the most — have the most optimistic views of the system.

The CHAS will be an important source of information on how Coloradans’ attitudes towards the health system evolve as health policy continues to change.