Health Care Reform Center

Robert J. Blendon, Sc.D., and John M. Benson, M.A.

Now that Congress has adjourned and most members are back in their own states or districts, they will be listening to what their constituents have to say about the debate over health care reform. We examined the results of 22 recent nationwide public opinion polls (see Recent Opinion Polls on Health Care Reform; polls are cited parenthetically hereafter), working with support from the Kaiser Family Foundation and the Robert Wood Johnson Foundation, to find out what our legislators might be hearing.

On issues such as health care, we believe that public support for change is shaped by the interaction of three factors: people’s perception of problems that affect the country, their assessment of their own current life situation, and their worries about their own future.¹ Currently, a majority of Americans are highly critical of the health care system (HSPH June 17), believe it requires major change (CBS July 24), and are very concerned about the problems facing the uninsured (CBS June 12). At the same time, most Americans are satisfied (”very” or “somewhat”) with the quality of the health care they receive (CNN July 31) and most insured Americans are satisfied with their own health insurance coverage (ABC June 18). Even when asked about their own health care costs, more than half say they are satisfied (ABC June 18). In contrast, the uninsured report more problems than insured Americans with their care and with health care costs (HSPH June 17).

Although most Americans are satisfied with their current arrangements, a majority say they are worried (”very” or “somewhat”) about having to pay more for their health care or insurance coverage and are concerned that the quality of care they receive will get worse. Also, a majority of insured Americans say they are worried about losing their coverage (KFF July 7). In addition, nearly half of Americans believe that their federal income taxes are already too high (Gallup April 6).

The public mood today about health care is very similar to what it was at the outset of the 1993 health care reform debate. In 2009, as in 1993, health care is seen as the second-most-important issue for government action, after the economy (Harris May 11).² More than three fourths of Americans support a major change in the health care system (CBS July 24),² and more than half favor enactment of a national health insurance program (HSPH June 17).² The biggest difference is that President Barack Obama has a much higher approval rating than President Bill Clinton did (58% vs. 38%) (CBS July 24 and CBS Aug. 2), which suggests that Obama has more opportunity for leadership.

For most Americans, reform in 2009 means lowering health care costs and providing coverage for the uninsured (KFF Feb. 3). To most people, costs principally mean their own and their employers’ costs, with lower priority placed on solving the country’s aggregate spending problem (KFF July 7). In addition, the public sees a possibility for improvement in the quality of care. Only 38% of Americans believe that health care in the United States is better than that in other industrialized countries, and 27% think it is worse (Pew April 28).

So far, neither the House nor the Senate has passed health care reform legislation. The current debate encompasses several elements that might be in the final legislation, and only a few of these are likely to gain public attention.

One key issue is the appropriate role for government in health care. The public believes the role of government should be expanded: 62% believe the government should exert more control over the health care system (CBS July 9), and 55% believe that the federal government should guarantee health insurance for all Americans (CBS July 24). But Americans don’t believe this increased responsibility should lead to a government-run system, which 58% would see as a negative outcome (QU June 23).

Another major issue is whether a public insurance plan should be offered as a competitor to private plans. Five of the six polls that raised this question show majority support (from 52 to 69%) for a public, or government-administered, health insurance plan (CBS July 24; ABC June 18; KFF July 7; QU June 23; Pew July 22); the sixth shows support of 46% (NBC June 24). Supporters of a public plan hold divergent views about whether the plan should be administered by a government agency (33%) or by an independent organization with government funding and oversight (66%) (ABC June 18).

Then there is the question of mandates. Some reform proposals would require all individuals to have health insurance coverage. Public support for such an individual mandate ranges from 49 to 56% if no mention is made of subsidies for people who cannot afford insurance (ABC June 18; Gallup July 10). If a mandate were to include such subsidies, support ranges from 53 to 70% (CBS July 24; ABC June 18; KFF July 7; Pew July 22). On the other hand, when people are told about penalties that people would have to pay for not having coverage, support drops to 44% (ABC June 18). Public support for an employer mandate, under which employers would be required to offer health insurance to their employees or pay a penalty into a fund, ranges from 61 to 64% (KFF July 7; Pew July 22; Gallup July 10). As for mandates for insurers, support for requiring insurers to cover all applicants, even if they have a preexisting condition, ranges from 75 to 79% (CBS July 24; ABC June 18; Pew July 22).

In terms of paying for reform, 58 to 68% of Americans support raising taxes on people with higher incomes (in some polls, those earning more than $250,000 a year) (Pew July 22; Gallup July 10; KFF June 1); 30% support taxing all employer-provided health insurance benefits (QU June 23), with 25 to 43% in support of taxing only more expensive health plans (Pew July 22; Gallup July 10; KFF June 1); and 33 to 38% support using savings from Medicare to help pay for reform (Pew July 22; Gallup July 10). Support for the use of Medicare savings, however, rises to 53% when the savings come from limiting increases in payments to physicians and hospitals (KFF June 1). Only 32% support increasing the deficit to help pay for health care reform (KFF Dec. 4).

As we examine these key issues, we see that three elements — requiring insurers to cover people with preexisting conditions, increasing taxes on people with higher incomes, and an employer mandate — have widespread public support. Introduction of a public plan as a competitor is supported in most polls, but respondents vary in their beliefs about how such a plan should function. There is widespread opposition to taxing employer-provided benefits and increasing the deficit to help pay for reform. On the other three issues — an individual mandate, an increased role for government, and using Medicare savings — the public is more divided.

These mixed results do not suggest how the public will come down on the questions that will determine their support for health care reform legislation. Other, broader factors will ultimately affect support. For many Americans, three questions remain unanswered: Will reform improve the nation’s health care system? Will their own care get better? Will their own costs become less burdensome?

At this point in the debate, the public has not come to a firm judgment on these questions. About half (47%) think that access to health care in the United States will expand if health care reform passes (Gallup July 24). About 4 in 10 (41%) believe the quality of care in the United States will improve (KFF July 7). The public is divided on the question of how reform will affect health care costs nationally, with one poll showing a plurality thinking that cost growth will slow and another showing a plurality thinking that costs will increase (KFF July 7; Gallup July 24) (see table).

At a personal level, most Americans do not think the current reform legislation will improve their own health care or lower their costs (KFF July 7; Gallup July 24). In addition, more than three fourths believe that their own taxes will increase (Fox July 21). Uncertainty about the potential effect of legislation appears to be leading to volatility in the level of public support for the reform plans of President Obama (with 42 to 56% in support) (NBC July 24; CNN July 31; NPR July 22) and Congress (with 38 to 54% in support) (Pew July 22; ABC July 15).

It is clear that most of the public wants a major change in the health care system. But majority support for a specific legislative proposal will depend on Americans’ believing that they and the country will be better off if such a change is enacted.

The views expressed in this article are solely those of the authors, and no official endorsement by the Kaiser Family Foundation or Robert Wood Johnson Foundation is intended or should be inferred.

Dr. Blendon reports serving on the board of directors of and holding stock in Assurant, and he and Mr. Benson report receiving grant support from the Blue Cross Blue Shield of Massachusetts Foundation. No other potential conflict of interest relevant to this article was reported.

Source Information

From the Harvard School of Public Health, Boston (R.J.B., J.M.B.); and the John F. Kennedy School of Government, Cambridge, MA (R.J.B.).

This article (10.1056/NEJMp0906392) was published on August 12, 2009, at NEJM.org.

References

1. Blendon R, Benson J. How Americans view their lives. Challenge 2007;50:5-25.
2. Blendon R, Benson J. Americans’ views on health policy: a fifty-year historical perspective. Health Aff (Millwood) 2001;20:33-46. [Free Full Text]