Health care is clearly back as a top

Size: px

Start display at page:

Download "Health care is clearly back as a top"

Marcus Gray
5 years ago
Views:

1 Perspective: Polls Perspective Déjà Vu All Over Again: The Similarities Between Political Debates Regarding Health Care In The Early 1990s And Today Manyofthesameforcesarestillatwork,buttheyhavebeenjoinedby new pressures for reform, two veteran pollsters report. by William D. McInturff and Lori Weigel ABSTRACT: With health care vaulting back to a foremost concern for voters, strong similarities exist between the zeitgeist today and during the last major debate on this issue. The strong desire for change, economic insecurities, and a desire for a more active role for government not to mention Hillary Clinton at the forefront of a major policy proposal all hark back to However, opinion research demonstrates that many fundamental psychological and philosophical barriers that doomed the previous major reform proposal still exist. The politician who best grasps the lessons from the failure of Clinton Care may become our next president. [Health Affairs 27, no. 3 (2008): ; /hlthaff ] Health care is clearly back as a top issue for voters. In terms of issues of personal importance, more Americans rate health care as very important to them personally than say the same regarding the situation in Iraq (84 percent and 81 percent, respectively, extremely important or very important ). 1 This personal focus has propelled health care to the top of the required issues for the presidential candidates. Our polls demonstrate that in the states where the candidates cut their political teeth, real people were talking to them about this issue. Surveys we conducted before the critical vote decisions in the early primary and caucus states demonstrated that more than any issue, the candidates were likely hearing about health care when they visited New Hampshire diners and Iowa parades. When voters were asked what issues they would most like to hear the candidates talk about, health care topped the list of their volunteered responses in these early decision states. Four in ten (40 percent) named health care, followed by Iraq at 32 percent. The same was true for Democratic primary voters/caucus goers (55 percent volunteered health care, while 44 percent named Iraq) and, perhaps most significantly, for Republican primary voters/caucus goers, although they had a much more diffuse focus than their Democratic counterparts (26 percent volunteered health care, and 19 percent named Iraq). 2 Reasons For Health Care s Return Health care is once again on the minds of the voters. Why? The reasons are similar to thosethatpropelledtheissuetotheforefront in the early 1990s. A strong desire for change. Americans aremorelikelytowantanewdirectionin Bill McInturff is a partner in Public Opinion Strategies LLC in Alexandria, Virginia. Lori Weigel is a partner in Public Opinion Strategies Denver, Colorado, office. HEALTH AFFAIRS ~ Volume 27, Number DOI /hlthaff Project HOPE The People-to-People Health Foundation, Inc.

2 Perspectives health care than any other major public policy issue, including the war in Iraq. Four in ten (39 percent) call for a new direction and approach to health care, while 35 percent say the same about Iraq. 3 Thepercentageofpeoplesayingthatthey want radical change to the health care system is at one of its highest levels since Today, 36 percent of the national electorate says that the system should be radically changed nearly three times the number who say that it should be kept basically the same. A majorityfallinthemiddleofthespectrum,advocating for it to be reformed. 4 The last two times we saw a comparable proportion of the electorate advocating radical change to the health care system, major reforms were proposed: first, in 1992, prior to the Clinton health careproposals;andthenin1998,priortomajor reforms to health maintenance organizations (HMOs), as shown in Exhibit 1. Health care is typically an issue of great concern to Democrat-leaning subgroups, such as working women and ethnic minorities. However, the political system does not respond when only these groups are focused on health care. It does respond when Independents demonstrate nearly the same intensity in their desire for change. Fully 45 percent of Democrats and 43 percent of Independents call for radical change to the health care system, followed by 20 percent of Republicans (data not shown). 5 Health care as a secondary indicator of a softening economy. Economic insecurities often first manifest themselves as concerns about health care. For example, when we asked the public which element of the economy most concerns them, the cost of health care topped all other concerns. 6 So why, in a country where the vast majority has health coverage, would economic jitters spill over into rumbling in the boardrooms of hospitals and private insurance companies? Yes, most voters are happy with their personal situation. Seven in ten say that the health care system is meeting their needs. This sentiment increases to 77 percent of those who have had health insurance consistently for the past three or more years. 7 However, health care has morphed into a security issue. Access to affordable health care was chosen as one of Americans two greatest worries (41 percent) far exceeding the level of worry about such things as saving forretirement(25percent)orthecostofgasoline (24 percent). 8 This worry is based in fact. A study by Harvard University researchers found that 50 percent of all bankruptcy filings were in part the result of medical expenses, and 68 percent of those who filed for bankruptcy had health insurance. 9 Moreover, Americans increasingly view be- EXHIBIT 1 American Voters Views On The Need For Radical Change In The U.S. Health Care System, Selected Time Periods, January 1992 June 2007 Percent 60 Kept the same Reformed Radically changed /92 3/92 10/94 2/95 1/96 11/96 1/98 6/98 10/99 10/00 10/05 6/07 SOURCE: Data from multiple public opinion national surveys; specific surveys are cited in the Notes of the text. NOTE: Respondents were asked: And, do you think the health care system in the U.S. should be kept basically the same, should be reformed,... or... should be radically changed? 700 May/June 2008

3 Perspective: Polls ing uninsured as something that could affect them personally. The vast majority of voters view health insurance as a privilege that many Americans cannot afford. 10 Moreover, 88 percent find the following rationale an effective statement that would get their attention about the issue of the uninsured: Rising health care costs are putting your families health insurance coverage at risk. As the priceofhealthcaregoesup,fewerindividuals, families and businesses can afford to pay for coverage.andevenifyoucurrentlyhavehealthcoverage through an employer, you may be just a premium increase away from having your benefits cut back, or losing your coverage [altogether]. 11 Increased willingness to allow government an active role. As in the early 1990s, the public is at a cyclical point in time where it is seeking more government action in general. A solid majority (55 percent) are more likely to agree that government should do more to solve problems and help meet the needs of people rather that government is doing too many things better left to businesses and individuals (38 percent). The sentiment that government should do more has shown a steady increase over the past decade (Exhibit 2). The view that government should do more has increased twenty-three points, from a low of 32 percent in Still, this support for a more active role for government does not mean that voters are willing to allow health care to be run completely by the government, as will be seen later. Attitudinal Differences That Make Reform More Likely At least two factors are substantially different today than during the debate over Clinton Care and could actually increase the potential for major reform to make its way through the Washington juggernaut. The business bottom line. Increasing premiums have hit businesses in the pocketbook and created a new and politically atypical advocate for reform of a major U.S. industry. Fully 43 percent of small business owners call for radical change to the health care system rather than merely reform (47 percent), and very few (9 percent) argue for the status quo. 12 It is worth noting that an identical percentage (43 percent) of small business owners also tell us that the health care system is not meeting their needs and those of their families, compared to 27 percent of the entire electorate who voice this opinion. 13 High military spending. Military spending in the foreign engagements in Iraq and Afghanistan has been in the billions of dollars. This has created a political climate where the GOP is not able to provide a strong EXHIBIT 2 Americans Satisfaction With Government Involvement In General, Selected Time Periods, December 1995 September 2007 Percent 60 Government should do more Government is doing too much /95 12/97 1/02 3/07 9/07 SOURCE: Data from NBC News/Wall Street Journal surveys. NOTE: Respondents were asked: I m going to read you two statements about the role of government, and I d like to know which one comes closer to your point of view. HEALTH AFFAIRS ~ Volume 27, Number 3 701

4 Perspectives rationale for restrained government spending. The price tag for health care reforms seems fairly affordable when contrasted with the level of spending required to support these military efforts overseas. Moreover, it has created an opening for Democratic candidates to argue that the United States can afford to provide coverage for the millions of uninsured people if only our priorities were adjusted. Perceptual Barriers That Have Not Changed The data continue to demonstrate that incremental policy tweaks are more likely to take place than any wholesale change. We have demonstrated that despite the majority of voters having health insurance and being fairly satisfied with the care they receive, they do worry about the potential for things to go wrong in their personal situation and empathize with Americans who lack coverage. So fifteen years from now, will we be seeing a different end to the story than the fate that befell Clinton Care? Only if the presidential candidates have learned the lessons of the health care debate in the early 1990s and address several perceptual barriers that continue to exist today: namely, an unwillingness to accept certain trade-offs in return for covering all Americans, and a desire to rein in other problems plaguing the system before abandoning the system entirely. Clearly, the first major difference today is that there is not a single specific plan on the table. Most plans that have been proposed by various candidates espouse broad goals, rather than specific policy changes. A host of public opinion polls demonstrate the lack of consensus around any specific reform proposal today, as voters have very different responses depending on the language used to describe a reform. Even without considering a specific reform plan, voters resist a host of potential trade-offs that could occur as we move toward meeting the broad goal of providing coverage to greater numbers of Americans (a goal inherent in most candidates reform plans). 14 (1)Havemoregovernment involvement in managing the health care system (45 percent find this to be unnecessary,and57percentfindittobeunacceptable). (2) Raise taxes to cover the costs of providing health care to more of the uninsured population (59 percent unnecessary and 61 percent unacceptable). (3) Reduce access to health care services among people who currently have health coverage (77 percent unnecessary and 80 percent unacceptable). Having conducted the research on behalf of what became the Harry and Louise advertising campaign, which raised questions about the original Clinton health care plan, we know what reduced access translates into for most Americans. It means fewer choices. Clearly, this is why Hillary Clintondubbedherpresidential campaign s reform proposal the American Health Choices Plan. 15 This is what sports commentators refer to as a good offense being the best defense. It was a clear attempt on the part of the Clinton campaigntowardoffpotentialcriticismsofher plan as thwarting patients choices a tradeoffthatwefoundintheearly1990stobeunacceptable to most voters and one of the Achilles heels of the Clinton administration s reform plan. In addition, we cannot convey fully the deep distress that accompanies a majority of voters imaginings of government acting as the sole deliverer of care. One of the most memorable comments from our careers in opinion research came during probing of concerns about the nature of government involvement in the Clinton Care plan in the early 1990s. I like national health insurance, patiently explained one focus-group respondent. I just don t want the government to run it. Moreover, the flip side to the Iraq situation is that voters may be less willing today to increase their taxes to fund health care when they perceive a large pool of money being spent on a war many voters oppose. For example, when people were asked whether they would 702 May/June 2008

5 Perspective: Polls be willing to pay higher taxes so that everyone can have health insurance, public support stood at 66 percent in March 1993 at the height of the Clinton Care debate. Today it stands at 58 percent among the general public, and support is much lower among registered voters. 16 Finally, it is worth noting that voters would prefertofirsttweakthesystemwehavenow, rather than shaking up a system that is working well for most of them personally. Although there are a number of factors that voters point to as driving up health care costs, one notable element is the litigious environment in which American medicine is practiced. A majority of 56 percent say that trial lawyers filing frivolous lawsuits is very responsible for the cost of care within the margin of error of such perennial targets as drug companies and insurers. 17 In addition, a majority point to the health consequences of the American lifestyle as driving up costs. Specifically, smoking, lack of exercise and overeating which leads to significant increases in cancer, diabetes and heart problems are perceived as very responsible for increasing health care costs by 51 percent of the electorate. 18 Voters in focus groups we have conducted over the years point to reforms and incentives to reduce frivolous lawsuits and encourage greater personal responsibility for one s health (for example, discounts on insuranceforthosewholoseweightorstartexercise plans) as worthwhile actions that should either precede or accompany other reforms. The Implications Barring a major unforeseen event such as another terrorist attack on the United States, health care will continue its newfound primacy in the presidential campaign. The desire for change is simply too strong to ignore for anyone wanting to capture the votes of the American people. That being said, the data continue to demonstrate that incremental policy tweaks are more likely to take place than any wholesale change. This is because voters can clearly articulate their frustrations and a desire for change, but there is no clarity or consensus about a specific set of ideas or reforms that would attract and hold the support of a majority of the electorate. In addition, the current stakeholders can easily attack any one policy once the details are outlined. Being fairly satisfied with their own health care, most voters are unwilling to accept a number of trade-offs. These include greater government involvement in their own care, fewer choices, or higher taxes as the necessary medicine to cure the system s ills. Health care will continue to be on the agenda no matter who wins in November. How much the next president addresses and overcomes the persisting barriers from the last health care debate will likely determine the fate of reform these fifteen years hence. NOTES 1. Survey of 1,005 adults age eighteen and older, conducted by Ipsos Public Affairs, January 2007 (margin of error, ±3.1 percent). 2. Survey of 600 likely November 2008 voters, with oversamples of Republican and Democratic primary/caucus voters, conducted in Iowa, Nevada, New Hampshire, and South Carolina by Public Opinion Strategies, October 2007 (margin of error, ±4.0 percent). Thinking about the campaign for the presidential election in 2008, what one or two issues would you most like to hear the presidential candidates talk about? Is there another issue you would like to hear about? 3. Survey of 1,509 adults nationally conducted by Street Journal, 1 5 November 2007 (margin of error, ±2.5 percent). Let me read you several issues. Please tell me the one or two, if any, where you feel America is most in need of a new direction and a new approach. Responses: health care, 39 percent; Iraq, 35 percent; immigration, 29 percent; foreign policy in places other than Iraq, 22 percent; family values issues, 20 percent; global warming, 13 percent; trade, 10 percent; other (volunteered), 1 percent; none of these, zero; and not sure, 1 percent. 4. Survey of 800 likely November 2008 voters, conducted by Public Opinion Strategies, 9 11 October 2007 (margin of error, ±3.5 percent). Do you think the health care system in the U.S. should be kept basically the same, should be reformed, or should be radically changed? 5. Ibid. 6. Survey of 1,007 adults nationally, conducted by Street Journal, January 2007 (margin of error, ±3.1 percent). Which ONE of the following ele- HEALTH AFFAIRS ~ Volume 27, Number 3 703

6 Perspectives ments of the economy, if any, causes you the most concern? Responses: the cost of health care, 33 percent; jobs going overseas, 24 percent; the federal budget deficit, 13 percent; lack of goodpaying jobs, 12 percent; the cost of higher education, 7 percent; the cost of housing, 6 percent; none of these cause concern, 2 percent; other (volunteered), 1 percent; and not sure, 2 percent. 7. Survey of 800 voters nationally, conducted by Public Opinion Strategies, December 2006 (margin of error, ±3.5 percent). Just generally speaking, is the current health care system meeting the needs of you and your family? 8. Survey of 1,509 adults nationally, conducted by Street Journal, 1 5 November 2007 (margin of error, ±2.5 percent). Let me read you several things that people worry about in their own lives. Please tell me the one or two, if any, that you worry about in your own life. Well, if you had to choose just two, which would you choose? Responses: access to affordable health care, 41 percent; quality of education, 26 percent; saving enough for retirement, 25 percent; the cost of gasoline, 24 percent; crime and violence, 19 percent; job security, 15 percent; the cost of housing and mortgages, 15 percent; other (volunteered), 1 percent; none of these, 4 percent; and not sure, zero. 9. D.U. Himmelstein et al., Illness and Injury as Contributors to Bankruptcy, Health Affairs 24 (2005): w63 w73 (published online 2 February 2005; /hlthaff.w5.63). 10. Survey of 800 likely November 2006 voters, conducted by Public Opinion Strategies, 4 8 December 2005 (margin of error, ±3.5 percent). 11. Ibid. 12. Survey of 800 likely November 2008 voters, conducted by Public Opinion Strategies, 9 11 October 2007 (margin of error, ±3.5 percent). 13. Survey of 800 voters nationally, conducted by Public Opinion Strategies, March 2006 (margin of error, ±3.5 percent). Just generally speaking, is the current health care system meeting the needs of you and your family? 14. Survey of 800 likely November 2008 voters, conducted by Public Opinion Strategies, 9 11 October 2007 (margin of error, ±3.5 percent). 15. Hillary for President, American Health Choices Plan, healthcareplan (accessed 12 February 2008). 16. Survey of 1,007 adults nationally, conducted by Street Journal, January 2007 (margin of error, ±3.1 percent), compared to similarly conducted survey, March Please tell me whether you agree or disagree with the following statement. I would be willing to pay higher taxes so that everyone can have health insurance. 17. Survey of 800 likely November 2006 voters, conducted by Public Opinion Strategies, March 2006 (margin of error, ±3.5 percent). 18. Ibid. 704 May/June 2008

Marist College Institute for Public Opinion Poughkeepsie, NY Phone Fax

Marist College Institute for Public Opinion Poughkeepsie, NY 12601 Phone 845.575.5050 Fax 845.575.5111 www.maristpoll.marist.edu POLL MUST BE SOURCED: NBC News/Wall Street Journal/Marist Poll* Cruz and