Awareness and knowledge of health insurance reform still limited three years later

Only 8% of consumers have never heard of health insurance reform under the name Patient Protection and Affordable Care Act (PPACA or ACA) or “ObamaCare” which was passed in March 2010. One-third of consumers have heard of the law, but have no idea what’s in it. Over 40% say they know something about it while only 3% boldly proclaim that they know almost everything in the 2,000+ page law.

Although the percentage who have not heard of the law has declined from 21% in Q2 2011 to 8% in Q2 2013, the percentage who say they know everything about it has remained virtually unchanged and the percentage who know a lot about it has only increased from 7% to 15% in two years.

Knowledge of ACA / Health Insurance Reform
2011 vs. 2013 results

The uninsured and those who purchase individual insurance coverage directly today are expected to receive the most benefit from ACA. Yet, the uninsured know the least about ACA and those with an individual product are polarized with 12% saying they have never heard of it and 30% saying they know a lot or everything about it.  College graduates and the highest income consumers are the most knowledgeable.   Over 57% of Disengaged consumers know nothing about the law while only 18% of Engaged consumers know nothing about it.

Testing their knowledge of ACA

Those who are at least aware of ACA were asked to select amongst six statements the ones they believe to be true.  Only 59% of consumers correctly indicated that the biggest changes due to ACA are coming in 2014 when federal and state marketplaces go into effect. Similarly, 58% correctly indicated that some parts of ACA have already been implemented (e.g. universal coverage of children up to age 26 on parents’ plans, phasing out maximum coverage limits, etc.).  However, 12% said nothing has happened so far and 4% think the law is completely implemented.  Almost 6% think the law was ruled unconstitutional by the Supreme Court and 9% incorrectly believe the law was repealed by Congress.

The 65 – 79 year olds were least likely to select any of the incorrect responses while 18 – 30 and 31 – 44 year olds were much more likely to do so.  Although the most Engaged consumers say they know more than Disengaged consumers about ACA, they do not know as much as they think. Engaged consumers were no more likely than the Disengaged to select one of the two true statements from our list and they were slightly more likely to incorrectly say the law was repealed by Congress.  Here are the percent of consumers overall who selected each statement:

  • 59% indicated that the “biggest changes go into place in January 2014”
  • 58% indicated that “parts of it have been implemented already”
  • 12% incorrectly indicated that “nothing has happened so far”
  • 9% incorrectly indicated that “it was repealed by Congress”
  • 6% incorrectly indicated that “the Supreme Court ruled the entire law unconstitutional”
  • 4% incorrectly indicated that “it has been completely implemented”

Employers are not spreading the word about ACA

Only 28% of consumers with group health insurance coverage say their employer has provided any information regarding health reform (ACA or “ObamaCare”). The low proportion could be due to inattention from less engaged employees since 51% of Engaged consumers say their employer has provided some information related to ACA while only 20% of Disengaged consumers gave this response. Whether Engaged consumers are more attentive or not, there are a lot of employers who have done nothing to let their employees know what is coming up with regard to health reform. Large employers will be required to notify their employees while small employers that do not offer coverage should find some value in promoting this new source of health insurance coverage and the potential federal subsidies that some employees will be eligible to receive.

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Lack of involvement in personal health impacts self-perceptions

Involvement is below where it needs to be, but most people know they need to be doing something

One-third of consumers say they are actively involved in their health. At the other extreme, 5% don’t even think about doing anything to improve their health. Everyone else is at least contemplating doing something about their health. Those with the lowest income levels and older consumers are most likely to be doing nothing.

Stated level of involvement in personal health

Involvement is related to perceptions

Level of involvement or engagement in personal health impacts consumers’ perceptions of their own health status. Engaged consumers are much more positive regarding their self-reported health status compared to the Disengaged consumers:

Self-reported health status
By level of health care engagement

Perceptions are often based on reality

It is not surprising that personal involvement has a direct impact on the physical state of consumers, such as being overweight. The most Engaged consumers are much more likely to be at or near a normal weight level based on their Body Mass Index (BMI) while three-quarters of Disengaged consumers are classified as obese.

Body Mass Index
By level of health care engagement

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Health plan recommendations are few and far between

39% of consumers have never recommended their current health insurance plan to a friend or family member.  Another 20% have recommended their health plan at some point, but not in the last year.   Only 16% recommended their plan once in the last year and one-quarter have recommended their health plan more than once in the past year.

18 – 30 year olds are much more likely than 65 – 79 year olds to recommend their plan multiple times (32% vs. 20%).  Those with an individual plan they selected themselves are much more likely to recommend their plan (79% have recommended it 1 or more times) compared to commercial group (59%) and Medicare members (53%).  The highest income consumers are much more likely to recommend their plan multiple times compared to the lowest incomes (31% vs. 13%). The reasons are not absolutely clear, but frequent exercisers are much more likely to recommend their current coverage multiple times compared to those who seldom or never exercise.

As you might expect, the most engaged consumers are significantly more likely to recommend their health plan with almost half the Engaged consumers recommending their plan two or more times in the last year:

 

Consumers who recommended current health plan
By level of health care engagement

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Age discrimination suspected across all age groups

One-quarter of consumers feel they have been discriminated against at some point in their life because of their age.  The 65 – 79 year olds are most likely to feel this way (36%), but 26% of 18 – 30 year olds and 26% of 45 – 64 year olds also feel they have been discriminated against due to their age.  Most consumers indicated they suspected job-related age discrimination, with 45 – 64 year olds more likely than 65 – 79 year olds to say they were told directly or it was implied that they were “too old”.  About 10% of all 18 – 30 year olds were told directly or made to feel that they were “too young” for a job or workplace opportunity.

How to described older individuals

Consumers in general prefer the terms “senior” or “senior citizen” to describe people over the age of 64.  These descriptions are even more strongly supported by consumers 65 – 79 years of age.  “Aged” and “elderly” are the least preferred names by all age groups.  Only 3% of consumers rated the term “seniors” very negatively and 4% rated “senior citizens” very negatively compared to 16% who rated “elderly” and 23% who rated “aged” this way.  Only 1% of 65 – 79 year olds rated “seniors” very negatively while 36% gave the most negative response for the term “aged.”

Percentage who rated each name a “4” or “5” on a 5-point scale
(SCALE:  1 = Very negative, 5 = Very positive)

Names for persons 65 and older Total sample 18 – 30 year olds 65 – 79 year olds
Seniors 67% 69% 76%
Senior citizens 64% 68% 75%
Medicare-eligible 47% 53% 50%
The elderly 40% 52% 36%
Aged 33% 39% 27%
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Exchanges are not the preferred channel

When asked how they would most prefer to purchase health insurance in 2014, only 25% said they would prefer to purchase through a state or federally run marketplace (exchange).  Almost half the consumers said they would prefer contacting a health insurance company directly via telephone, a retail store or online.

Uninsured are less interested in exchanges

Only 25% of the uninsured prefer a government-run marketplace, compared to 31% of those with group-based coverage (when asked to consider what they would do if  their employer no longer offered coverage) and 21% of those with individual coverage.

Although never a majority, those most interested in health insurance marketplaces are:

  • Those with group coverage (31%)
  • Males (32%)
  • Those with a college degree (30%)
  • The most Disengaged consumers (31%)

A lack of federal subsidies does not deter everyone

Those who chose any option other than a government-run marketplace were asked if they were aware that federal subsidies are not available outside of exchanges.  Only 38% of those who prefer an option other than an exchange are aware that no subsidies are available outside exchanges.  However, after everyone was told that they would lose any eligible subsidies, 36% of them would still prefer to purchase health insurance somewhere other than through an exchange.

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Conducting a Survey – What To Do and What NOT To Do

The results of a survey about conspiracy theory beliefs are making the rounds as a fluff piece in the media lately.  The survey was conducted by Public Policy Polling and asks 20 questions about beliefs and six questions at the end about political and demographic classifications.  The press release contains several paragraphs based on crosstabulated findings along with words like “bizarre” and “crazy.”  http://bit.ly/XGVrM2.  Although surveys can certainly be used for entertainment purposes, this project can provide some lessons for what not to do when conducting a survey.

AVOID AMBIVALENCE.

The first 20 questions each begin with “Do you believe…”  The only possible answers (with one exception) are “Do,” “Do not,” and “Not sure.”  It is not clear whether “Not sure” means you are taking a middle view (“maybe/maybe not”) or have no knowledge on the subject (“don’t know anything about it”)?  All scale elements should be clearly defined and align appropriately with each question.  These 20 questions could have been set up as a battery (which also allows the items to be easily rotated to avoid any order-effect).  A single lead-in instruction could then define how the scale would be applied to each assertion.

MAKE SURE THE INTENDED MEANING IS CLEAR.

Question 1 asks, “Do you believe global warming is a hoax, or not?”  What answer should a respondent give if he or she suspects that academics have jumped to a conclusion, but have not done so deceptively?  Technically, they should have answered “Do not.”  Many of those people may have chosen “Do” as the closest answer to their beliefs.  This is especially true given that this is the first question and the respondent has not yet understood the nature of the survey or how the word “hoax” should be interpreted.  The results to this question may be measuring one’s acceptance or skepticism of the theory itself and not academic dishonesty.

BE PRECISE.

Question 10 asks, “Do you believe aliens exist, or not?”  Two different cohorts could legitimately answer “Do” to this question.  The first cohort is comprised of people who believe that aliens visit the earth in space ships.  The second cohort is comprised of biologists who speculate that simple alien life forms could exist throughout the universe.  A more precise question is “How likely is it that the earth is being visited by an intelligent alien race or races?”

AVOID LOADED TERMINOLOGY.

The phrase ‘conspiracy theory’ itself is a negative term since it is always used in the context of dismissing someone’s ideas.  No one would ever call Osama bin Laden’s conspiracy to destroy the World Trade Center a ‘conspiracy theory.’  If the CIA is suspected to have conspired in overthrowing a government, that is not called a ‘conspiracy theory’ either.  Unfortunately, there is no accepted neutral term.  The questionnaire asks ‘Do you believe…”  Beliefs and theories are not synonymous.  ‘Conspiracy belief’ would at least have been an attempt to provide some neutrality.

DO NOT CONVOLUTE FACT AND OPINION.

The set of belief questions covered a wide range of topics.  The possibility of Bigfoot’s existence does not constitute a conspiracy.  Several other questions also do not involve conspiracies unless the respondent has inferred a cover-up.  Other questions try to measure beliefs in existence and events (facts).  Still other questions try to measure beliefs in the interpretation of events (opinions).  Lumping these topics together may make it difficult for respondents to provide their honest opinions on each item.

BE SERIOUS.

If you ask your respondents about “shape-shifting reptilian people,” you are presenting them with a light-hearted survey and should not expect the same level of careful thought and concern for the research objectives.

RESPECT YOUR RESPONDENTS.

You have taken up someone’s time, typically without compensation.  You have asked them to share their views with you.  Do not thereafter refer to any of those views as “the wackier ideas out there.”

THERE’S MORE THAN JUST CROSSTABS.

Here is some additional information I would like to know.  On average, how many conspiracy theories does an American voter believe in?  Which beliefs correlate positively or negatively with one another?  Can ‘conspiracy theorist’ voters be segmented in a few cohorts based on similar beliefs?

SUMMARY

This survey, its questionnaire, its results, and the conclusions have made for some good laughs.  Unfortunately, this may be all the exposure to social science some people will ever get.  And that could hurt the various social science professions and their ability to gather, analyze, and use survey data.

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Using ICH CAHPS® Survey Data to Improve Patient Experience and Satisfaction with your Dialysis Center


Background

Now that we have 2012 results for hundreds of dialysis centers, we thought it might be useful to do some overall analysis of the results in aggregate. Our discussion of these results regarding the importance of individual satisfaction items is generally relevant to individual dialysis centers. However, the discussion of performance results does not necessarily apply to any individual center, but to the group on average.

We believe that if you are doing the ICH CAHPS® survey, or any patient experience / satisfaction survey, then you should be using the results for improving the experience and satisfaction of your patients. But, it’s not immediately obvious where to focus your attention. You can’t address every issue all at once.

  • What are the things that are going to have the biggest impact on patient satisfaction?
  • How are you doing on those things now?

To address these questions and give our clients the best possible guidance we have developed our powerful SatisAction™ statistical modeling system. The DSS SatisAction™ key driver statistical modeling system is a powerful, proprietary statistical methodology used to identify the key drivers of overall dialysis center ratings and to provide actionable direction for satisfaction improvement programs. This methodology is the result of a number of years of development and testing using health care satisfaction data. We have been successfully using and improving this approach since 1997. The model provides the following:

  • Identification of the elements that are important in driving overall ratings of a dialysis center.
  • Measurement of the relative importance of each of these elements.
  • Measurement of how well patients think the center performed on these important elements.
  • Presentation of the importance/performance results in a matrix or POWeR Chart™ that provides clear direction for member experience and satisfaction improvement efforts by the center.

Survey Instrument

The analysis is based on one dependent variable and 25 independent or predictor variables from the In-Center Hemodialysis CAHPS® survey.
The independent or predictor variable:

Q35 Rating of the dialysis center?

The dependent variables:

Q03 How often kidney doctors listen carefully?
Q04 How often kidney doctors’ explanation easy to understand?
Q05 How often kidney doctors show respect for what you had to say?
Q06 How often kidney doctors spend enough time with you?
Q07 How often kidney doctors really cared about you as a person?
Q08 Rating of your kidney doctors?
Q09 Kidney doctors informed about care from other doctors?
Q10 How often dialysis center staff listened carefully to you?
Q11 How often dialysis center staff explanation easy to understand?
Q12 How often dialysis center staff show respect for what you had to say?
Q13 How often dialysis center staff spent enough time with you?
Q14 How often dialysis center staff really cared about you as a person?
Q15 How often did dialysis center staff make you as comfortable as possible during dialysis?
Q16 Dialysis center staff keep information about you and your health as private as possible from patients?
Q17 Feel comfortable asking the dialysis center staff everything you wanted about dialysis care?
Q21 How often dialysis center staff insert your needles with as little pain as possible?
Q22 How often did dialysis center staff check you as closely as you wanted while you were on the dialysis machine?
Q24 How often the dialysis center staff were able to manage problems during your dialysis?
Q25 How often dialysis center staff behave in a professional manner?
Q26 Dialysis center staff talk to you about what you should eat and drink?
Q27 How often dialysis center staff explain blood test results in a way that was easy to understand?
Q32 Rating of your dialysis center staff?
Q33 How often get put on the dialysis machine within 15 minutes?
Q34 How often the dialysis center was as clean as it should be?
Q43 How often were you satisfied with the way they handled these problems?

Twenty-one of these questions involve rating scales. In most cases, the rating is of “how often” something was done with the scale never, sometimes, usually or always.

In four instances, questions 9, 16, 17 and 26, patients are asked to respond in a yes/no fashion.

What measures are important to patients?

The importance analysis involves a multi-step process where:

  • Factor analysis is used to summarize the predictor set into a more manageable number of composite variables.
  • Regression analysis is used to measure the relative importance of each item in driving overall satisfaction with a center.

Based on this statistical analysis, six items stand out in terms of their impact on the overall rating of a hemodialysis center. These are things where lower or higher ratings or just ratings in general have a big impact on the overall rating:

Q14 How often dialysis center staff really cared about you as a person?
Q12 How often dialysis center staff showed respect?
Q10 How often dialysis center listened carefully?
Q13 How often dialysis center staff spent enough time with you?
Q11 How often dialysis center staff explanations were easy to understand?
Q15 How often did dialysis center staff make you as comfortable as possible during dialysis?

In other words, these are the areas where ratings on the individual items have the biggest impact on the overall rating of the center. Other things equal, these are the things on which you want to focus to improve patient experience / satisfaction and thereby improve overall rating of the dialysis center.

What’s important to patients is generally consistent across dialysis centers, so you can take these things as important to your patients. These results should be roughly the same for patients of any dialysis center.

How are dialysis centers performing?

The other element of our analysis relates to relative performance of a dialysis center on these same 25 items. As noted above, our results for this analysis are based on an “average” dialysis center and do not necessarily apply to any individual center.

The top six items, based on performance, for our average center, in order of relative performance, from high to low are:

  • Q34. How often the dialysis center was as clean as it could be?
  • Q16. Dialysis center staff keep information about you and your health as private as possible?
  • Q17. Feel comfortable about asking the dialysis center staff everything you wanted about dialysis care?
  • Q25. How often dialysis center staff behave in a professional manner?
  • Q26. Dialysis center staff talked to you about what you should eat and drink?
  • Q15. How often did dialysis center staff make you as comfortable as possible during dialysis?

Conversely, the six items where an average dialysis center performs most poorly from low to high are:

  • Q43. How often you are satisfied with the way they handled problems?
  • Q06. How often kidney doctors spent enough time with you?
  • Q33. How often you get put on the dialysis machine within 15 minutes.
  • Q08. Rating of your kidney doctors?
  • Q21. How often dialysis center staff insert your needles with as little pain as possible?
  • Q13. How often dialysis center staff spent enough time with you?

The DSS POWeR Chart™

Results of the modeling are presented in a classification matrix. The importance and performance results for each item in the model are plotted in a matrix like the one shown below. This matrix provides a quick summary of what is most important to your patients and how your center is doing on those items. The matrix is divided into four quadrants. The quadrants are defined by the point where the medians of the importance and performance scales intersect. The four quadrants can be interpreted as follows:

  • Power.  These items have a relatively large impact on overall rating of center and your performance levels on these items are high. Promote and leverage strengths in this quadrant.
  • Opportunity.  Items in this quadrant also have a relatively large impact on overall rating of center but your performance is below average. Focus resources on improving processes that underlie these items and look for significant improvements in overall health plan ratings.
  • Wait.  Though these items still impact overall rating of center, they are somewhat less important than those that fall on the right hand side of the chart. Relatively speaking, your performance is low on these items. Dealing with these items can wait until more important items have been dealt with.
  • Retain.  Items in this quadrant also have a relatively small impact on overall rating of center but your performance is above average. Simply maintain performance on these items.

The results of this analysis can be displayed in a DSS POWeR Chart™ (see sample below):

Results for average center for 2012.

In the POWeR™ Chart below, you can see how the different survey items fall in the different chart quadrants for the “average center. For example, the quadrant at the lower right shows those items that are highly important to patients on which dialysis center performance is below average, the items included are:

  • Q14.  How often dialysis center staff really cared about you as a person?
  • Q13.  How often dialysis center staff spent enough time with you?
  • Q32.  Rating of your dialysis center staff?
  • Q07.  How often kidney doctors really cared about you as a person.
  • Q04.  How often kidney doctors’ explanation easy to understand.

These are the items where improvement is going to have the biggest positive impact on the patient experience and satisfaction.

The themes that we find in these items – caring, spending enough time, overall rating – can be elusive. However, studies show that simple things like involving family and friends in the patient’s treatment and care, showing respect for patient’s choices and listening carefully to patients’ aspirations and concerns have a big positive impact on these items. Keep in mind that “staff” is not just the doctors and the nurses. Staff includes social workers, billing representatives, housekeeping and maintenance, dietary aides, and all staff at the dialysis facility. It’s important that all staff showing care and concern for the patients. It’s also important to provide access to understandable information. This empowers patients to participate in their treatment and care.

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Doctors are trusted sources, but how can they help?

In study after study, consumers consistently rate their personal physician as the most influential source they would like to turn to when selecting health insurance coverage. Their physician is consistently selected ahead of health insurance companies and online sources and generally considered equal to or better than friends and family for this purchase decision.

In a recent DSS survey, we asked consumers 18 and older to rate the level of influence of various sources if they were required to select a new health insurance plan in the near future. Personal doctors were the highest rated source with over 50% of respondents saying their doctor is “extremely influential” or “very influential.” By comparison, 48% indicated health insurance companies would have this level of influence and only 22% said the same about brokers or agents. Consumers that are very engaged in their personal health are much more likely to rate their doctor as highly influential than are disengaged consumers (64% versus 42% respectively).

What would you ask your doctor?
Those who rated their personal doctor as a strong influence were asked to indicate what information they would expect their doctor to provide to aid in the selection of a health plan. Consumers most often responded with questions that would best be possed to a health insurance plan such as:

  • What services does the plan really cover? (27% of mentions)
  • Which doctors and hospitals are included in the provider network? (22% of mentions)
  • How much various services will cost? (19% of mentions)
  • What are the copays and out-of-pocket costs? (9% of mentions)

Twenty-six percent of consumers were unable to come up with a single question they would ask their doctor, despite believing that doctor would be highly influential in their decision. Even fewer consumers posed questions that are directly relevant to physicians such as:

  • What plan would you recommend based on my health / condition? (11% of mentions)
  • How well does the health plan’s customer service respond to issues? (4% of mentions)
  • What is your experience with specific health plans? (3% of mentions)

Although personal physicians are a logical choice for feedback, based on their level of knowledge and interaction with health insurance plans, consumers have not thought through how they might leverage this knowledge for their benefit. Health plans may want to get out in front of this issue before millions of consumers rush to their physician in search of advice on which health plan to choose under health reform.

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DSS Clients Show Big Improvements in Key HH-CAHPS® Measures

We now have three years of data collected for our hundreds of clients and we have compared the results in the aggregate. A number of patterns emerge:

Two of the overall measures improved significantly from 2010 to 2012:

  • Overall satisfaction, those who gave 8, 9 or 10 ratings on the 11 point 0-10 scale, increased from 74% in 2010 to 81% in 2012.
  • Likelihood to recommend the agency to family and friends (definitely or probably recommend) increased from 53% in 2010 to 58% in 2012.

The biggest gains in sub measures are found in the area of communications:

  • Providers “always or usually” talking to patients about their medications increased significantly from 83% in 2010 to 97% in 2012.
  • In 2012, patients gave their providers significantly higher marks on being informed and up-to-date about the care the patient is receiving (81% in 2010 and 94% in 2012 – percentage usually plus always).
  • Providers are also perceived to be doing a significantly better job keeping their patients informed about when they would arrive (86% in 2012 vs. 74% in 2010 – percentage usually plus always).
  • Finally, the percentage reporting they got the help they needed when they contacted the agency improved from 64% in 2010 to 71% in 2012 (percentage who said “yes”).

These results suggest that the implementation of the HH-CAHPS® survey has spurred patient experience improvement by home health agencies.

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Health reform creeping into our consciousness

Knowledge of PPACA and health reform in general has increased over the last year. After declining during 2011, when the legislation received less attention, the percentage of consumers who said they know something about health reform increased from 27% in Q1 2011 to 46% in Q4 2012. The percentage who said they never heard of the legislation declined during the same time, from 22% in Q1 2011 to 9% in Q4 2012. Almost no one believes they know almost everything that is in the law, which is the true in Q1 2011 (1.8%) and in Q4 2012 (2.2%).
 
Self-reported knowledge of health reform legislation

Consumers were asked 'How knowledgeable do you consider yourself regarding the health care reform legislation (Patient Protection and Affordable Care Act) passed by Congress in March 2010?' and results are shown for Q1 2011 and Q4 2012.


In 2011, over 40% of consumers anticipated that health reform will have no impact on the US health care system. This perception has changed dramatically in Q4 2012, with only 6% believing the law will have no impact. In 2011, 41% felt the law will have a somewhat positive or very positive impact on the health care system. The percentage expecting a positive impact increased to 56% in Q4 2012. However, the percentage of consumers who expect a negative impact from reform increased from 16% in 2011 to 38% at the end of 2012.

Despite greater awareness of health reform and a more positive attitude towards its impact on the health care system, the percentage of consumers expecting to purchase health insurance through an exchange did not change much between 2011 (26%) and 2012 (25%). Most consumers still expect to buy direct if they no longer receive coverage through their employer (44% in 2011 and 47% in 2012 indicated they would buy direct from the carrier).

As expected, Engaged consumers are far more knowledgeable concerning health reform. Only 3% of Engaged consumers said they never heard of health reform, while 56% know something about it, 19% know a lot about it and 6% believe they know almost everything in the law in Q4 2012. None of the Disengaged consumers said they know everything in the law, but 18% said they have never heard of it and 42% have only heard of it, but don’t know what is in it. Engaged consumers are more positive concerning the potential impact of reform with 60% saying they are very positive or somewhat positive, compard to 48% of Disengaged consumers who gave these responses. However, one-third of the Disengaged know so little about the law that they have no idea what the impact of health reform will be on the US health care system.

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