Health Care Reform Center

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

Congressional leaders and President Barack Obama are moving ahead to develop a single piece of major health care legislation, which will be debated, voted on by both houses of Congress, and, if enacted, sent to the President for his approval and signature. Previous research suggests that public opinion will play an important role in the outcome of this process. Experience suggests that although the final legislation is likely to be complex, the public will form an overall view leading it either to support or to oppose enactment, but this view can change substantially over time.

Multiple factors may contribute to the public’s judgment, including the popularity of major policy elements of the bill, its perceived effect on the country, and its potential effect on their own future health care. Under a contract with the Kaiser Family Foundation and with a grant from the Robert Wood Johnson Foundation, we sought to identify the factors most likely to have the greatest impact on public views about the final legislation. We did this in part by comparing the public’s response to the Clinton health plan in the final months of the 1994 debate with perceptions about the current reform debate. We examined data from 30 nationwide public opinion polls (see Opinion Polls on Health Care Reform; polls cited parenthetically hereafter by organization and date, if needed) to assess the issues that leaders inside and outside government need to focus on if they want to influence public opinion about the legislation.

Table 1 shows the level of support at the time of the two health care debates for changing the U.S. health care system, the public’s assessment of each president’s handling of health care policy, and public approval of the proposed health plans. Table 2 compares Americans’ expectations, in April 1994 and October 2009, of the ways in which health care reform will affect them. The tables show responses from the two eras to questions that are as similar to one another as possible.

In the final phase of the Clinton debate, polls showed that Americans still wanted health care reform: 85% of the public believed that the U.S. health care system needed to be fundamentally changed or completely rebuilt (Harris) (see Table 1). Nearly two thirds (63%) knew that the Clinton plan provided health insurance coverage for all Americans,¹ a goal considered very important by 82% of Americans at the time (NYT). In addition, major elements of the Clinton plan had widespread support, including a requirement that health insurance be made available for those with preexisting conditions (81%) (Newsweek) and that all employers provide health insurance for their full-time employees (73%) (ABC, 1994).

At the same time, only 39 to 43% of Americans supported the Clinton health plan (Time; Gallup, April 16–18), and 40 to 43% approved of Clinton’s handling of health care policy (Gallup, April 22–24; CBS) (see Table 2). The factors that appear to have contributed to a lower level of support for the plan than for the principle of change are also reflected in Table 2: on all three measures shown — impact on them personally, on the quality of their care, and on their health care costs — the majority of Americans did not expect to be better off under the Clinton plan. Indeed, among those who expected to be affected, more respondents thought they would be worse off than thought they would be better off.¹ The low rating of the Clinton plan appears to be related to these more personal assessments rather than to broader views about the need for reform or the popularity of key elements of the plan.

A similar picture is emerging in the current debate. The overwhelming majority of Americans want health care reform: 84% believe that the health care system needs to be fundamentally changed or completely rebuilt (CBS, October). In addition, a majority (53%) believes that the country would be better off if the legislation being discussed were enacted (KFF, October). The public also favors several of the policy elements being discussed for inclusion in the final bill, including requiring insurers to cover people with preexisting conditions (80 to 89% support) (KFF, September; CBS, September; Pew; NBC, September) and requiring employers to offer and contribute to their employees’ health insurance plans (59 to 67%) (Pew; KFF, September).

In addition, a public option — a government health insurance plan offered as a competitor to private plans — had widespread support in 8 of 10 polls, but support varies depending on how the option is described. About three fourths of respondents (76%) favor a public option described as being run by state governments and available only to people who do not have the option of affordable private insurance (ABC, October). When the public option is described as being similar to Medicare, it is favored by 57 to 62% of the public (KFF, September; CBS, October; Franklin and Marshall). Support ranges from 55 to 61% when questions ask more generally about a government-administered health insurance option (Pew; ABC, October; KFF, October; CNN, October; QU, September–October). However, when a more active role for government is emphasized, support is 48 to 50% (NBC, September; Gallup, October).

Despite widespread support for some of their key elements, the Obama proposal and congressional proposals as a whole are not widely supported by the public at this time (see Table 1). In six recent polls, support for enacting these initiatives ranged from 34 to 49% (Pew; QU, September–October; IPSOS; ABC, October; CNN, October; NBC, October). Only one polling organization has been asking about the public’s perceptions of the Obama plan regularly since April 2009. According to these polls, 41% of Americans were undecided about the plan in April, and as the proportion of those who were undecided fell to 20%, opposition more than doubled, from 20% to 42% (NBC, April, June, July, August, September, October) (see graph). President Obama’s rating for his handling of health care policy (41 to 48%) (QU, September–October; Fox; CBS, October; ABC, October; NBC, October) is similar to President Clinton’s (40 to 43%).

Public Perceptions of President Obama’s Health Care Plan.

Data are from NBC News–Wall Street Journal, April 23–26, 2009; June 12–15, 2009; July 24–27, 2009; August 15–17, 2009; September 17–20, 2009; and October 22–25, 2009.

As was the case with the Clinton plan, most Americans do not believe they will be better off if the current legislative proposals as a whole are enacted. Most, but not all, of the polls show that among people who see the plan as affecting them personally, more believe they will be worse off personally and in terms of the cost and quality of their care than believe they will be better off (CBS, October; NBC, October; Gallup, October).

The public also has other worries about the current proposals. About two thirds (66%) of Americans believe that Obama’s health care plan would increase the taxes they pay (QU, July–August); 43% believe that the current proposals entail too much government involvement in the country’s health care system (ABC, October); and 43% think that these proposals would weaken Medicare — only 18% think they will strengthen the program (ABC, October). In addition, the proposals do not include at least one element that is popular with the public: limits on the amount of money patients can collect in medical malpractice lawsuits. Such limits are favored by 63 to 66% of Americans (ABC, September; Pew).

An issue that is likely to raise considerable public concern in the last stages of the debate is the legal requirement that Americans obtain health insurance or pay a penalty. With the national focus on the question of a competing public insurance plan, little attention has been paid to the mandate’s impact on individuals. Today, only the state of Massachusetts has such a requirement, and when its universal coverage law was enacted, the individual mandate was one of the most controversial issues — 61% of the public supported the law overall, whereas only 52% favored the individual mandate. The public’s views were affected when they heard how much uninsured people would have to pay for unsubsidized insurance plans.² To date, national polls generally show support for the policy when the questions mention subsidies (50 to 71%) (CBS, October; KFF, October; Pew; Franklin and Marshall; ABC, October) but much lower approval when a financial penalty is mentioned (26 to 34%) (QU, July–August; NBC, July). The details about the plans’ affordability may not emerge until the final weeks of legislative activity. To judge by the Massachusetts experience, the answer to this question may influence Americans’ ultimate assessment of the legislation.

In the final phase of this debate, we believe that Americans’ impressions of the legislation’s likely impact on their own situation will be the most important factor in determining the level of public approval. Support for or opposition to specific elements of the legislation and concerns about the need for reform in general will be secondary influences.

We believe that public opinion is still fluid on the key question about the impact of the legislation. When asked whether they thought they would support or oppose a final health care bill or whether it would depend on decisions that still have not been made about the bill, 25% said they would support it, 33% said they would oppose it, 39% said it would depend on the bill’s final form, and 3% were unsure (Gallup, October).

Most Americans are not health policy specialists, and they are unlikely to read a long and complex piece of legislation. Instead, they will rely on trusted intermediaries to clarify its likely impact on them. The President and congressional leaders play a critical role, but public confidence in leaders in Washington is not universally high. Less than half of Americans say they have a great deal or a fair amount of confidence in the Democratic (45%) and Republican (39%) leaders in Congress to do the right thing when it comes to health care reform, and 56% have confidence in President Obama (Pew). Polls show that the public has greater trust in the views of some nongovernmental groups, including physicians’ groups (in which 65% of the public expresses a great deal or a fair amount of confidence), nurses’ groups (79%), groups representing seniors (64%), and groups representing patients (70%) (NPR). If the leaders of these groups and others address the public’s bottom-line concerns about the impact the legislation will have on individuals, they may have a substantial effect on the ultimate state of public opinion and the legislation that is enacted.

Financial and other disclosures provided by the authors are available with the full text of this article at NEJM.org.

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.

Source Information

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

This article (10.1056/NEJMp0906394) was published on November 4, 2009, at NEJM.org.

References

1. Blendon RJ, Brodie M, Benson J. What happened to Americans’ support for the Clinton health plan? Health Aff (Millwood) 1995;14:7-23.
2. Blendon RJ, Buhr T, Sussman T, Benson JM. Massachusetts health reform: a public perspective from debate through implementation. Health Aff (Millwood) 2008;27:w556-w565.