A majority of Americans put the creation of state-based health insurance exchanges at the top of the priority list for health policy in their state this year, according to a survey released on Jan. 24 by the Kaiser Family Foundation, the Robert Wood Johnson Foundation and the Harvard School of Public Health.

Fifty-five percent of the public, including majorities of Republicans and Democrats, say that establishing the exchanges —a key element of the Affordable Care Act (ACA) and one whose implementation has divided states along partisan political lines—is a “top priority” for their governor and legislature. So far 18 states and the District of Columbia have declared that they will create their own state-based exchanges, seven other states have opted to establish exchanges in partnership with the federal government and 25 others—some driven by resistance to the ACA—appear set to default to a federally-run exchange. The survey did not make a distinction as to whether the exchange was run by the state or the federal government.

When it comes to another key state decision regarding the implementation of the ACA—whether to adopt the Medicaid expansion built into the ACA— the survey finds more Americans think their state should undertake the expansion (52 percent) than oppose it (42 percent). Unlike exchanges, which enjoy bipartisan support, these views differ sharply by party identification, with most Republicans saying they prefer to keep their Medicaid program as is (66 percent) and most Democrats (75 percent) supporting their state’s expansion. Independents are evenly divided. In terms of overall state-level priorities, three in 10 call the Medicaid expansion a “top priority,” and another 35 percent say it is important but a lower priority.

In the bigger picture, the survey finds just over half of Americans (52 percent) – including 78 percent of Republicans – agree that opponents of the ACA should continue trying to change it so that the law has “less impact on taxpayers, employers, and healthcare providers”, while 40 percent agree that “those opposed to the healthcare law should accept that it is now the law of the land and stop trying to block [its] implementation”.

Meanwhile, policymakers involved in budget deficit negotiations at the federal level face a familiar conundrum. Even as most Americans (65 percent) say that Washington should act quickly to bring down the deficit, there is little public appetite for major reductions in federal spending on healthcare. Overall, six in ten (58 percent) oppose any spending cuts to Medicare and 46 percent oppose any cuts to Medicaid.

As millions of baby boomers are becoming eligible for Medicare, the president and congressional lawmakers face tough choices about whether and how to rein in spending on federal healthcare programs to help reduce the deficit.

In his inauguration speech on Jan. 21, President Barack Obama said America must make “hard choices to reduce the cost of healthcare and the size of our deficit. The commitments we make to each other— through Medicare and Medicaid and Social Security—these things do not sap our initiative. They strengthen us. They do not make us a nation of takers; they free us to take the risks that make this country great,” the President said.