Taking The Public's Pulse On Health System Reform by Mark D. Smith, Drew E. Altman, Robert Leitman, Thomas W. Moloney, and Humphrey Taylor

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1 DataWatch Taking The Public's Pulse On Health System Reform by Mark D. Smith, Drew E. Altman, Robert Leitman, Thomas W. Moloney, and Humphrey Taylor Although health care and politics have a long history of association, health care has been conspicuously absent from the agendas of the past few presidential elections. Voting, middle-class Americans have until recently been satisfied with the state of their health care system. Elected officials feared the political clout of health care's big interest groups and avoided raising tough reform issues, as long as the electorate remained reasonably satisfied. While the number of uninsured Americans remained troublesome, as Paul Starr has noted, politically, they did not count. 1 By mid-199, the political climate has changed markedly. Democrat Harris Wofford's victory over Republican Richard Thornburgh in the Pennsylvania U.S. Senate election in November 1991 forced the Republicans to address health care directly, as a turning-point issue in a national election. The widespread response to Wofford's call for national health insurance, even among the large majority of Pennsylvanians who have private insurance, indicated that this was a concern shared by a large number of middle-class Americans who vote precisely the group to whom politicians and policymakers most often respond. The importance of health reform in the Pennsylvania election was independently confirmed by a survey conducted by The Henry J. Kaiser Family Foundation and the Harvard School of Public Health. Following their Pennsylvania postelection poll, the Kaiser Family Foundation and the Harvard School of Public Health conducted a poll after the New Hampshire presidential primary, which confirmed the staying power of health as a political issue. In New Hampshire, health stood firmly as the number-two issue in voters' minds. Mark Smith is a vice-president of The Henry J. Kaiser Family Foundation in Menlo Park, California; Drew Altman is the foundation's president. Robert Leitman is senior vice-president and Humphrey Taylor is president and chief executive officer of Louis Harris and Associates in New York City. Tom Moloney is senior vice-president of The Commonwealth Fund in New York City.

2 16 HEALTH AFFAIRS Summer 199 The apparent potency of Wofford's call for national health insurance was noted with some skepticism by the press. No one was sure if health care reform was really an important independent element in Wofford's success. The demise of Sen. Bob Kerrey's (D-NE) presidential campaign and the defeat of Rep. Marty Russo (D-IL) two prominent advocates of health system reform seemed in the eyes of some observers to counterbalance the point made by Wofford. To get a better fix on the public's appetite for health system reform, the Kaiser Family Foundation and The Commonwealth Fund commissioned Louis Harris and Associates to conduct a national survey. We were interested in exploring the experiences and concerns of a broad cross-section of Americans and providing a basis for informed speculation about how those concerns might translate into political action for health care reform. We also wanted to establish benchmarks that could be tracked over time, with an initial repeat of the survey in early 199, after the national elections in November 199. This DataWatch reports some of the survey's most important findings. The random sample survey of,000 people was carried out by telephone between 1 January and 4 February 199, with a margin of sampling error of ± percent. Findings Role of various actors. One of the raging debates in policy circles is over who is responsible for assuring that all Americans have access to care and that costs are controlled. For its part, the public is ready to settle the debate. When asked, "Who should take the lead in changing the health care system," the public responded, by nearly two to one, that government (60 percent), rather than the private sector (4 percent), should have the primary role in assuring access and controlling costs (Exhibit 1). Given a choice between federal and state governments (or a combination of the two), people overwhelmingly chose the federal government to take the lead, by 6 percent to 0 percent. 4 Interestingly, only percent believed that federal and state governments should share responsibility for solving our health care problems. This finding is all the more impressive when juxtaposed against Americans' traditional tendency to look to government for solutions as a last resort. We speculate that the public has reached this point in its consideration of health care reform. While these trends are somewhat more pronounced for those who identify themselves as Democrats, a majority of Republicans and independents agree. A divided public. Respondents were asked which of the leading

3 DATAWATCH 17 Exhibit 1 Public Preferences For Leadership In Health Care Reform Who should have the primary role in providing health insurance to all Americans and controlling health costs? Government Private sector Not sure/refused If it's a choice between the federal government or the state governments, which do you think should take the lead in changing the health care system? Federal State Federal and state Neither Not sure/refused Respondents Total Republican 60% 4 6 5% 4 5 Respondents Total Republican 6% % 1 Democrat 69% 6 6 Democrat 64% Independent 6% 5 4 Independent 6% 9 4 health care financing reform plans they preferred. As Exhibit shows, they were evenly split between "play-or-pay" proposals, single-payer options, and President Bush's tax incentive approach, 5 This split is much like that seen in earlier polling in New Hampshire. Only a small number ( percent) favored the status quo. Support for cost containment. Amidst a lack of consensus on specific approaches to health system reform, one issue emerged clearly: the need to control costs. Approximately three-fourths of Americans want the government to set prices for health insurance premiums, prescription drugs, and hospital and physician charges the single strongest verdict Exhibit Public Preferences For Health System Reform Mechanisms Play-or-pay Single payer President's tax credit plan Leave things the way they are Not sure/refused Total Republican Democrat Independent New Hampshire (N = 1,990) (n = 641) (n = 706) (n = 50) primary voters a % % 7 8 6% 1 _b 9 % 8% Note: The survey question read as follows: "Which of the following ways of financing health care would you favor?" a According to the Kaiser/Harvard New Hampshire poll, 199. b Less than 0.5 percent.

4 18 HEALTH AFFAIRS Summer 199 rendered by the public in the survey (Exhibit ). At the same time, over half (55 percent) of those surveyed said that they would be interested in a health plan that limits choice of doctors and hospitals in return for real savings in out-of-pocket health care costs. How do we reconcile the strong support for both managed care and direct government intervention to limit provider costs? We suspect that, taken together, these answers reveal that what the public simply wants most is relief from rapidly inflating health care costs. Importance of health as election issue. Our findings suggest that health may be the number-two issue on the public's mind during national elections this fall (Exhibit 4). To our knowledge, this is the first time health has ranked so high in a national poll The dominant issue in the 199 presidential election will be the economy: one-half of respondents named it as one of two top issues that will determine their vote. Health ranked second, far behind the economy but far ahead of other issues such as education, taxes, and jobs. We were careful not to prompt respondents by providing them a list of options to choose from; they were asked to respond to an open-ended question, which was the first one asked in the survey, before the interviewer said the word "health." Health was also the second most frequently named issue in congressional elections, though at slightly lower levels than in the presidential context. In state elections, however, education and taxes took precedence over health, which was named by only 11 percent of people as one of their top two issues. Despite the issue's salience, neither major party nor any of the candidates has a health reform strategy that has captured the public's attention. Previous surveys show the Democratic party with a wide lead on the question, "Who would be better on health care?" 6 Yet when our survey asked if people saw "any real difference between the health care Exhibit Public Support For Three Forms Of Price Controls The government should: Set the rates that insurers can charge for health premiums Set the price for prescription drugs Set the rates that doctors and hospitals charge patients Agree strongly 45% 45 4 Agree somewhat 0% 8 8 Disagree somewhat 1% Disagree strongly 10% 11 1 Not sure %

5 DATAWATCH 19 Exhibit 4 Political Importance Of Health Care, Relative To Other Issues, In Various Elections Note: Percentages exceed 100 because respondents were asked to name two issues. reform proposals of the Republicans and Democrats," only 16 percent did. When we asked if people could identify a political leader whose health care reform plan they support, 80 percent said they could not; among those who answered affirmatively, no single candidate received significant recognition. Continued importance of health as an issue. Getting health care services is a growing problem for large numbers of Americans. Not surprisingly, those without insurance fared worse on every measure of access about which we inquired. Substantial numbers of insured and relatively affluent people also said that they had not gotten the services they felt they needed, had postponed care, or had been refused care outright (Exhibit 5). Extrapolating from the survey, twenty-two million Americans reported that they or a family member had been refused care that they believed they needed in the past year. One of the most striking findings of the survey was the sense of insecurity felt by large sections of the public (Exhibit 6). Among respondents, 8 percent expressed concern over one or more future adverse developments in their health insurance coverage. While a portion of this concern is undoubtedly related to the current recession, only about half as many people were worried about losing their jobs as were concerned about losing health insurance. While only a relatively small minority are without health insurance at any moment in time, most Americans worry that their health insurance will not be there when they

6 10 HEALTH AFFAIRS Summer 199 Exhibit 5 Respondents' Reports Of Their Access To Care In the past 1 months, was there a time when you needed medical care but did not get it? Percent who needed Characteristics care and did not get it Total 1% Income Less than $15,000 $15,000-$50,000 Over $50,000 Source of coverage Private insurance Medicaid Uninsured Main reason care not obtained Cost too much/not covered 77 Could not get appointment Didn't know clinic/doctor 1 Not easy to get to physician's office 1 All others 15 Not sure 4 In the past 1 months, have you or has any member of your family been refused health care because you didn't have insurance or you couldn't pay? Characteristics Percent refused care Total 1% a Income Less than $15,000 $15,000-$50,000 Over $50,000 Source of coverage Private insurance Medicaid Uninsured In the past 1 months, have you put off or postponed seeking health care that you felt you needed because you could not afford it? Characteristics Percent who postponed care Total 0% Income Less than $15,000 $15,000-$50,000 Over $50,000 Source of coverage Private insurance Medicaid Uninsured a By contrast, only percent of respondents to a 198 Louis Harris survey answered "yes" to this question

7 DATAWATCH 11 Exhibit 6 Public's Worries About Future Of Health Care Concern that health insurance will become so expensive that one won't be able to afford it Concern that one will have to pay very expensive medical bills not covered by health insurance Concern that one will not be able to get the health care one needs when one is very ill because one can't afford it Concern that benefits under current health care plan will be cut back substantially Concern that if one has large medical bills, one's health plan will refuse to insure one Concern that employer's health care costs will limit wage increases Concern that employer will stop providing any health insurance Concern that one will not be able to maintain standard of living Concern that one or one's spouse will lose job in 199 Note: The original question read as follows: "I will read you a list of things that people worry about. Please say for each one if it is something you worry about a great deal, quite a lot, not much, or not at all." Results here indicate percentage responding "a great deal" or "quite a lot." Of all respondents, 8 percent answered at least one of the first seven conditions with "a great deal" or "quite a lot." 61% need it. Perhaps most significant of all, in this survey we saw a real change in people's level of dissatisfaction with their own care. It has long been the conventional wisdom that Americans were dissatisfied with the health care system but quite satisfied with their own medical care. 7 Indeed, one reason often given for the health care system's resistance to fundamental reform is a presumed disinclination on the part of the public to support proposals that might tamper with their own health care arrangements. 8 The survey documents a growing number of Americans (though still a minority) who are somewhat or very dissatisfied with their own health care (Exhibit 7). The percentage of dissatisfied Americans has doubled in the past five years, from 1 percent to 6 percent. Exhibit 7 Respondents' Dissatisfaction With Health Care Services Used By Respondent Or Family Over Past Few Years Very/somewhat satisfied 84% 79% 71% Very/somewhat dissatisfied Not sure/refused Sources: For 1987 and 1990, Louis Harris surveys. For 199, Kaiser/Commonwealth survey of public preferences for health system reform, 199.

8 1 HEALTH AFFAIRS Summer 199 Health Care And The Election Outcome This survey tells us that the problems of cost and access are changing profoundly in scope and degree. The environment is increasingly ripe for significant reform. The public is expecting the federal government, not the states or private sector, to lead the way and supports strong government cost containment measures. Whether this translates into votes in the upcoming election and action beyond that remains to be seen. For one thing, people have more than issues on their minds when they enter the voting booth; concerns about candidates' values and character dominate the news and are an inescapable factor in election decisions. If the economic recovery stalls or if there is sudden unrest in the nation or elsewhere in the world, health care could move further to the back burner. Moreover, the fact that the public sees no difference between the health system reform proposals of either party or any candidate means that health is only a potential factor in the upcoming election. No candidate or party has yet tapped the profound underlying concern about health problems that is evident in our survey. Perhaps this will change once the campaign has moved beyond the primary stage. In a simpler world with just one Democratic and one Republican candidate arguing for philosophically and substantively opposed plans differenees may crystallize more readily for the American people. Will we see federal legislation that will control costs and assure universal coverage in the next two to five years? The answer depends on much more than public opinion. Perhaps most importantly, the prospects for reform depend fundamentally on who occupies the White House and who holds leadership roles in Congress, and how much these leaders really care about health system reform. Few observers believe that broad-scale health system reform can happen without strong presidential leadership and priority setting. The reality of our "divided" government is also an issue. Neither the Democrats nor the Republicans have reached an internal consensus on the specifics of health financing reform proposals; nevertheless, the Democratic leadership leans strongly toward governmental responsibility and authority, while the Republicans prefer solutions based on the private sector. As long as one party controls the White House and another controls Congress, national consensus will be difficult. Therein lies the real story on polls and surveys such as this one. Polls can take the public's pulse and describe the environment for political leaders and policymakers. But within that environment, hard choices must be made, and reform programs must be sold; the polls do not, by themselves, tell us what can, will, or even should be done. This is

9 DATAWATCH 1 especially true when public opinion is volatile, as it is with health care reform. We are under no illusion about the strength of the public's convictions on many of the issues covered on the survey. But we should not assume that more education, or stronger convictions, will necessarily lead to overwhelming consensus. There is, after all, no perfect health reform plan. Public education will help people to make up their minds about reform proposals, but it is useful to remember that the "experts" who occupy their days and nights with health system reform are themselves divided on the best route to take. Can we expect the public to be different? NOTES 1. P. Starr, "The Middle Class and National Health Reform," The American Prospect (Summer 1991): R.J. Blendon et al., "The 1991 Pennsylvania Senate Race and National Health Insurance," Journal of American Health Policy (January/February 199): M. Hinds, "Senate Hopefuls Withhold Attacks," The New York Times, Special, 5 November The question was worded as follows: "If it's a choice between the federal government or the state governments, which do you think should take the lead in changing the health care system?" 5. The survey question described the three options as follows: ( 1 ) Play-or-pay: "A national health plan in which businesses are required to either offer private health insurance for their employees or contribute to a government program that would cover them. Those who are unemployed or work part-time would be enrolled in the same government program, financed by taxpayers. To control costs, government would set fees charged by doctors and hospitals." () Single payer: "A national health plan financed by taxpayers in which all Americans would get their insurance from a single government plan. To control costs, government would set fees charged by doctors and hospitals." () President's tax credit: "A national health plan which would offer low and moderate income uninsured Americans an income tax refund to help purchase private health insurance. Those who are not insured would have access to care through tax supported public health clinics. Financial incentives would encourage enrolling in less costly health care plans." 6. Gallup polls, September 1991, October 1991, and January C. Jajich-Toth and B.W. Roper, "Americans' Views on Health Care: A Study in Contradictions," Health Affairs (Winter 1990): R.J. Blendon and D.E. Altman, "Public Attitudes about Health-Care Costs: A Lesson in National Schizophrenia," The New England Journal of Medicine (0 August 1984):