The Public and Health Care Reform Mollyann Brodie, PhD Vice President, Public Opinion Survey Research Kaiser Family F

4. The Public Opinion Landscape and the Prospects for Health Care Reform Challenges… So we know that public is receptive to health care policy discussions and desires action on the health care front – particularly in terms of addressing the affordability of health care…… but does that mean that a significant, comprehensive health care reform agenda would be sure to meet a PUBLIC filled with support, enthusiasm, engagement, and willingness to see major legislation quickly enacted? I’m not so sure……. We have already in just the past few weeks since the election – heard quite a bit from key actors like those I mentioned at the start, interest groups, and the media about the potential of major health care reform making its way onto the policy agenda……. What I want to do with the remainder of my time…. Is talk about the challenges and the opportunities in terms of garnering and maintaining public support for policy change facing those policymakers who want to bring a major effort forward. Let’s start with the challenges…. So we know that public is receptive to health care policy discussions and desires action on the health care front – particularly in terms of addressing the affordability of health care…… but does that mean that a significant, comprehensive health care reform agenda would be sure to meet a PUBLIC filled with support, enthusiasm, engagement, and willingness to see major legislation quickly enacted? I’m not so sure……. We have already in just the past few weeks since the election – heard quite a bit from key actors like those I mentioned at the start, interest groups, and the media about the potential of major health care reform making its way onto the policy agenda……. What I want to do with the remainder of my time…. Is talk about the challenges and the opportunities in terms of garnering and maintaining public support for policy change facing those policymakers who want to bring a major effort forward. Let’s start with the challenges….

5. However, even though affordability is at the top of the list and outpaces expansions of coverage when they are forced to choose between competing priorities…when we instead ask them directly about trying to increase coverage …. We find that –goals are easy –Americans are pretty nice people – they want to help kids, the elderly, protect the environment… They believe everyone should have health insurance and as you see here the vast majority believes government should do more to help in this arena and large majorities say it’s an important issue to be addressed…. … goals are often fairly simple to get agreement on….. However, even though affordability is at the top of the list and outpaces expansions of coverage when they are forced to choose between competing priorities…when we instead ask them directly about trying to increase coverage …. We find that –goals are easy –Americans are pretty nice people – they want to help kids, the elderly, protect the environment… They believe everyone should have health insurance and as you see here the vast majority believes government should do more to help in this arena and large majorities say it’s an important issue to be addressed…. … goals are often fairly simple to get agreement on…..

6. However when it comes to agreeing on the best solutions to meet those goals – we often face the crux of a tough public debate. So first – when we ask about specific approaches to expanding coverage….we find that fairly large majorities favor 6 of 7 mechanisms to expand coverage…… majorities favor using tax credits for businesses or individuals, expanding public programs, requiring employer’s to provide coverage or put money into a pool and individual mandates. Only a national single government plan fails to receive a Majority. But we need to watch getting too overly enthusiastic about the apparent support for many of these mechanisms in the abstract and restrain ourselves from thinking this gives policymakers a free pass to take any direction on health expansion they might favor. When asked about by themselves virtually every approach to expanding coverage was popular, but here you see when forced to choose among proposals we find none that garners close to a majority…. Instead opinion splits about evenly 7 ways….. If I had just 4 options – it would’ve split 4 ways – 3 – 3 ways – two – two ways…. So what does this mean….. no matter what solution a policymaker chooses… there’s many people who think that they could’ve picked a better option – making it easy for the opposition to convince people that the offered policy is on the wrong track…. So when leaders talk about goals there’s no doubt in my mind that the American public can agree, but when the conversation shifts to HOW to achieve those goals… I know things get much tougher…However when it comes to agreeing on the best solutions to meet those goals – we often face the crux of a tough public debate. So first – when we ask about specific approaches to expanding coverage….we find that fairly large majorities favor 6 of 7 mechanisms to expand coverage…… majorities favor using tax credits for businesses or individuals, expanding public programs, requiring employer’s to provide coverage or put money into a pool and individual mandates. Only a national single government plan fails to receive a Majority. But we need to watch getting too overly enthusiastic about the apparent support for many of these mechanisms in the abstract and restrain ourselves from thinking this gives policymakers a free pass to take any direction on health expansion they might favor. When asked about by themselves virtually every approach to expanding coverage was popular, but here you see when forced to choose among proposals we find none that garners close to a majority…. Instead opinion splits about evenly 7 ways….. If I had just 4 options – it would’ve split 4 ways – 3 – 3 ways – two – two ways…. So what does this mean….. no matter what solution a policymaker chooses… there’s many people who think that they could’ve picked a better option – making it easy for the opposition to convince people that the offered policy is on the wrong track…. So when leaders talk about goals there’s no doubt in my mind that the American public can agree, but when the conversation shifts to HOW to achieve those goals… I know things get much tougher…

7. ,…. And this lack of agreement of solutions isn’t anything new…. This is data from the Truman health care reform debate in 1945 – see exactly same dynamic….. People like all approaches in the abstract, but when forced to choose no one ends up victorious – made it EASY for opponents to kill the plan Truman choose. ,…. And this lack of agreement of solutions isn’t anything new…. This is data from the Truman health care reform debate in 1945 – see exactly same dynamic….. People like all approaches in the abstract, but when forced to choose no one ends up victorious – made it EASY for opponents to kill the plan Truman choose.

8. First, Despite all the clamoring for change and fixing the health care system, the vast majority of the public is satisfied with their current health care arrangements…. …. For the most part, and with the VERY IMPORTANT CAVEAT, that this is true if you have some form of health insurance coverage, you mostly think you are doing OK….. You are satisfied with your quality of care, with your access, and you are even satisfied with your health insurance coverage ….. the status quo for you personally isn’t so bad…. Again, this is consistent over the past decade or more….. As you can see in this chart. And in fact, people are considerably more satisfied with their own situation, than they are with the situation in the country as a whole… so for example about 9- 10 say they are satisfied with their quality of care, but that that falls almost in half to 45% when instead it comes to the QOC for the nation as a whole…. Now we see this same phenomenon all the time in evaluations of schools, congress, etc… - the nation’s schools are awful – my kid’s school is great – teachers are horrible, my kid’s teacher is great – congress is horrible, my congressperson is fabulous……. So we get lots of responses to questions like “the system needs changing, the health care system needs major fixes…….but…. When it comes time to hear about policy proposals that would addresses their desire for change….. We often find people quickly backing away from their initial demands….. First, Despite all the clamoring for change and fixing the health care system, the vast majority of the public is satisfied with their current health care arrangements…. …. For the most part, and with the VERY IMPORTANT CAVEAT, that this is true if you have some form of health insurance coverage, you mostly think you are doing OK….. You are satisfied with your quality of care, with your access, and you are even satisfied with your health insurance coverage ….. the status quo for you personally isn’t so bad…. Again, this is consistent over the past decade or more….. As you can see in this chart. And in fact, people are considerably more satisfied with their own situation, than they are with the situation in the country as a whole… so for example about 9- 10 say they are satisfied with their quality of care, but that that falls almost in half to 45% when instead it comes to the QOC for the nation as a whole…. Now we see this same phenomenon all the time in evaluations of schools, congress, etc… - the nation’s schools are awful – my kid’s school is great – teachers are horrible, my kid’s teacher is great – congress is horrible, my congressperson is fabulous……. So we get lots of responses to questions like “the system needs changing, the health care system needs major fixes…….but…. When it comes time to hear about policy proposals that would addresses their desire for change….. We often find people quickly backing away from their initial demands…..

9. The second and a related challenge is that in the course of a public debate about a topic that is as personal as health care people begin to evaluate how the policy options will affect them and their family…. We see a disconnect between the BIG PICTURE evaluations – how it will affect others or the nation and the “individual level evaluations” And, unfortunately, so far few people have been convinced that a proposals that would either lead to universal coverage or to separating health insurance from employment based system would be any benefit for themselves…. So first, note here how few believe their costs, their access to treatments, their quality, OR their choices would be BETTER under a universal health insurance system…….Fewer than 1-3 in any case think they would be better under universal coverage Again, this is nothing new – we saw basically the same thing in people’s evaluations of how the Clinton Health Care Reform plan would impact them….. The second and a related challenge is that in the course of a public debate about a topic that is as personal as health care people begin to evaluate how the policy options will affect them and their family…. We see a disconnect between the BIG PICTURE evaluations – how it will affect others or the nation and the “individual level evaluations” And, unfortunately, so far few people have been convinced that a proposals that would either lead to universal coverage or to separating health insurance from employment based system would be any benefit for themselves…. So first, note here how few believe their costs, their access to treatments, their quality, OR their choices would be BETTER under a universal health insurance system…….Fewer than 1-3 in any case think they would be better under universal coverage Again, this is nothing new – we saw basically the same thing in people’s evaluations of how the Clinton Health Care Reform plan would impact them…..

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12. Now, the fifth challenge is one that is so obvious that it often gets forgotten…. the sometimes contentious partisan nature of policy debates in Washington often reflects the underlying divisions in partisan opinions outside the beltway. So, mostly we’ve been talking about the views of all adults – but when we look more deeply at the views of self identified republicans, democrats and independents we often find considerably more divergent views. So for example -when we frame the question as what the MAIN GOAL should be to improve the US health care system …..we find that Democrats overwhelmingly choose to ensure everyone has health insurance coverage, while the Republicans pick making H ins more available and affordable in the private marketplace even if everyone doesn’t get covered as the main goal. Interestingly, Independents are more split, but we do see our Majority in RED – that is, a slight preference for ensuring coverage as the main goal.Now, the fifth challenge is one that is so obvious that it often gets forgotten…. the sometimes contentious partisan nature of policy debates in Washington often reflects the underlying divisions in partisan opinions outside the beltway. So, mostly we’ve been talking about the views of all adults – but when we look more deeply at the views of self identified republicans, democrats and independents we often find considerably more divergent views. So for example -when we frame the question as what the MAIN GOAL should be to improve the US health care system …..we find that Democrats overwhelmingly choose to ensure everyone has health insurance coverage, while the Republicans pick making H ins more available and affordable in the private marketplace even if everyone doesn’t get covered as the main goal. Interestingly, Independents are more split, but we do see our Majority in RED – that is, a slight preference for ensuring coverage as the main goal.

15. …. Let’s just remember the massive and sometimes bitter public debate between the time President Clinton introduced his health plan in Sept 1993 and when it was largely considered a dead proposal in April 1994…. There was a vast amount of news coverage and of issue ads – much of which sponsored by opponents who used messages like “get the govt too involved in your health care…” You can see here that over that time period – the initial public support that plan had, fell away as the months went on. …. Let’s just remember the massive and sometimes bitter public debate between the time President Clinton introduced his health plan in Sept 1993 and when it was largely considered a dead proposal in April 1994…. There was a vast amount of news coverage and of issue ads – much of which sponsored by opponents who used messages like “get the govt too involved in your health care…” You can see here that over that time period – the initial public support that plan had, fell away as the months went on.

16. and again this is nothing new, the public debate on Truman’s plan caused the same trend in public’s support in 1950….. The implications here are that keeping a coalition and consensus among as many actors as possible, particularly those who are well funded is critical to help ensure that public does not only hear from opponents and that the impacts of strategic opposition messages alone doesn’t determine the outcome. and again this is nothing new, the public debate on Truman’s plan caused the same trend in public’s support in 1950….. The implications here are that keeping a coalition and consensus among as many actors as possible, particularly those who are well funded is critical to help ensure that public does not only hear from opponents and that the impacts of strategic opposition messages alone doesn’t determine the outcome.

17. Opportunities… Ok – so there were a few of the challenges facing policymakers trying to maintain public support for a major change in health care….. But what about the opportunities available to them….Ok – so there were a few of the challenges facing policymakers trying to maintain public support for a major change in health care….. But what about the opportunities available to them….

18. People are WORRIED about their COSTS and their coverage….. Particularly during a recession and with unemployment expanding…. These personal concerns can only be expected to increase…..People are WORRIED about their COSTS and their coverage….. Particularly during a recession and with unemployment expanding…. These personal concerns can only be expected to increase…..

20. So there is a real opportunity to frame policy solutions in terms of addressing people’s health care cost concerns…. As you see here - health care costs are something people believe the government can and should do something about, so proposals that address this will help to get the public engaged and committed and help them to see the potential upsides for themselves and their family. I should be clear here – people are worried about their OWN PERSONAL health care costs… when we ask about the nation as a whole – they say WE spend TOO LITTLE on health, not too much– I say that just to remind you all that that the average American is NOT the same as your average economist in evaluating costs. I fear that this might be a challenge to those who want to take this potential window of opportunity and try focus the discussion on reigning in national health care spending. That’s not something that many in the public are going to jump up and down about even we will all know they should care more about it! So there is a real opportunity to frame policy solutions in terms of addressing people’s health care cost concerns…. As you see here - health care costs are something people believe the government can and should do something about, so proposals that address this will help to get the public engaged and committed and help them to see the potential upsides for themselves and their family. I should be clear here – people are worried about their OWN PERSONAL health care costs… when we ask about the nation as a whole – they say WE spend TOO LITTLE on health, not too much– I say that just to remind you all that that the average American is NOT the same as your average economist in evaluating costs. I fear that this might be a challenge to those who want to take this potential window of opportunity and try focus the discussion on reigning in national health care spending. That’s not something that many in the public are going to jump up and down about even we will all know they should care more about it!

21. There is also a bipartisan opportunity available here - since even though I showed you partisan divisions in the priority and goals of health care policy - notice that when we ask about their view of the health care system we see here that majorities of all three partisan groups agree that major changes are needed… the red part, versus minor changes in the blue or it works fine as is in the light blue. So focusing on the problems nationally, making sure the affordability stays front and center and linking the policy solutions to individuals health care arrangements – remembering to make them none to scary but very helpful to individuals….. Will help keep a broad host of the public on board. There is also a bipartisan opportunity available here - since even though I showed you partisan divisions in the priority and goals of health care policy - notice that when we ask about their view of the health care system we see here that majorities of all three partisan groups agree that major changes are needed… the red part, versus minor changes in the blue or it works fine as is in the light blue. So focusing on the problems nationally, making sure the affordability stays front and center and linking the policy solutions to individuals health care arrangements – remembering to make them none to scary but very helpful to individuals….. Will help keep a broad host of the public on board.

23. And since we saw above that lots of solutions have wide appeal….. On the other hand, it gives us a clue to a fourth opportunity to achieve widespread public support and that’s to approaches so that more people “like what they hear” as those solutions become publicly debated. The MA plan and proposed CA plans largely followed this model as do the proposals discussed during the election campaign and outlines we’ve heard about lately set forth by various key national actors. As just one example – note here that when we ask about a individual mandate by itself we see much less support than when we have a broader approach that lays out more specific roles for employers, government, insurance companies and individuals. BASIC: Next, I’m going to read you a description of a plan to make sure everyone has health insurance, and then I’m going to ask you if you support or oppose this plan. This proposal would require all Americans to have insurance. Most people would still get insurance through their work. People who don’t get insurance from work would have to buy it themselves, or pay a fine if they don’t. People with lower incomes would get help from the government paying the cost of health insurance. Would you support or oppose this kind of plan? EXPANDED: Next, I’m going to read you a description of a plan to make sure everyone has health insurance, and then I’m going to ask you if you support or oppose this plan. This proposal would place requirements on individuals, employers, the government, and insurance companies so that everyone shares in the responsibility. Individuals who don’t already have insurance would be required to buy it or pay a fine, with financial help from the government for people with lower incomes. Employers would be required to cover their workers, or pay money into a pool that helps people buy insurance. Government health insurance programs would be expanded. Insurance plans would be required to take anyone who applies, even if they have a prior illness. Would you support or oppose this kind of plan?And since we saw above that lots of solutions have wide appeal….. On the other hand, it gives us a clue to a fourth opportunity to achieve widespread public support and that’s to approaches so that more people “like what they hear” as those solutions become publicly debated. The MA plan and proposed CA plans largely followed this model as do the proposals discussed during the election campaign and outlines we’ve heard about lately set forth by various key national actors. As just one example – note here that when we ask about a individual mandate by itself we see much less support than when we have a broader approach that lays out more specific roles for employers, government, insurance companies and individuals. BASIC: Next, I’m going to read you a description of a plan to make sure everyone has health insurance, and then I’m going to ask you if you support or oppose this plan. This proposal would require all Americans to have insurance. Most people would still get insurance through their work. People who don’t get insurance from work would have to buy it themselves, or pay a fine if they don’t. People with lower incomes would get help from the government paying the cost of health insurance. Would you support or oppose this kind of plan? EXPANDED: Next, I’m going to read you a description of a plan to make sure everyone has health insurance, and then I’m going to ask you if you support or oppose this plan. This proposal would place requirements on individuals, employers, the government, and insurance companies so that everyone shares in the responsibility. Individuals who don’t already have insurance would be required to buy it or pay a fine, with financial help from the government for people with lower incomes. Employers would be required to cover their workers, or pay money into a pool that helps people buy insurance. Government health insurance programs would be expanded. Insurance plans would be required to take anyone who applies, even if they have a prior illness. Would you support or oppose this kind of plan?

24. And lastly – I’d say this is an ideal time and opportunity for leadership …. In fact in this case of health care, since political messaging can easily sway opinion off things people initially favor and people generally start from a place of thinking that change may not be good for them personally…. I think it requires the ultimate in leadership and commitment amongst a President and Congress, and a supportive vocal, well funded and coordinated coalition to lead the effort and “bring the public along” and conversely, I think it would be a big mistake to believe that national health reform can be stimulated from the bottom up There’s a perception among some that the Clinton Health Care Reform Debate was stimulated by massive public demand –I actually believe that’s a misperception…. here’s the long term trend on the percent of the public who names HC as a top issue for government action… [CLICK] notice that early 90s and the past decade we see consistent 10-20% naming it as the most important issue--- [CLICK] but what was that big mountain of interest in 93 and 94 – it was the RESULT of the nation’s leaders talking about the issue…..these number in the 30‘s and 50’s reflected what people were hearing about all the time in the media as a result of the intense policy debate…they were measures taken in 1993 and 1994 during the debate – NOT PRIOR TO IT….. It was the President and Congress taking it on in a serious way that generated the MASSIVE public interest. The public certainly was concerned about the issue at the time and certainly told pollsters that it mattered to them as they do now, but the widespread public interest stemmed during the public debate generated by the President, Congress and the media…. And lastly – I’d say this is an ideal time and opportunity for leadership …. In fact in this case of health care, since political messaging can easily sway opinion off things people initially favor and people generally start from a place of thinking that change may not be good for them personally…. I think it requires the ultimate in leadership and commitment amongst a President and Congress, and a supportive vocal, well funded and coordinated coalition to lead the effort and “bring the public along” and conversely, I think it would be a big mistake to believe that national health reform can be stimulated from the bottom up There’s a perception among some that the Clinton Health Care Reform Debate was stimulated by massive public demand –I actually believe that’s a misperception…. here’s the long term trend on the percent of the public who names HC as a top issue for government action… [CLICK] notice that early 90s and the past decade we see consistent 10-20% naming it as the most important issue--- [CLICK] but what was that big mountain of interest in 93 and 94 – it was the RESULT of the nation’s leaders talking about the issue…..these number in the 30‘s and 50’s reflected what people were hearing about all the time in the media as a result of the intense policy debate…they were measures taken in 1993 and 1994 during the debate – NOT PRIOR TO IT….. It was the President and Congress taking it on in a serious way that generated the MASSIVE public interest. The public certainly was concerned about the issue at the time and certainly told pollsters that it mattered to them as they do now, but the widespread public interest stemmed during the public debate generated by the President, Congress and the media….

25. Challenges and opportunities to mobilize public interest in health reform Linking solutions to individual concerns, particularly affordability is key

26. Kaiser Family Foundation, Public Opinion Polls on Health Care http://www.kff.org/kaiserpolls/index2.cfm Kaiser Family Foundation and Roper Center , Health Poll Search http://www.kaisernetwork.org/health_poll/hpoll_search.cfm KaiserEDU.org, Public Opinion 101: Designing Public Opinion Surveys http://www.kaiseredu.org/tutorials/public_opinion/brodie_tutorial_v6_buttons.html News University, Understanding and Interpreting Polls http://www.newsu.org/courses/course_detail.aspx?id=aapor_polling07 American Association for Public Opinion Research, http://www.aapor.org/ Ok – so there were a few of the challenges facing policymakers trying to maintain public support for a major change in health care….. But what about the opportunities available to them….Ok – so there were a few of the challenges facing policymakers trying to maintain public support for a major change in health care….. But what about the opportunities available to them….