Health Care Reform

by Bill Hamilton

Reprinted from Campaigns & Elections, June/July 1993

It is clear from a review of more than 15 national surveys conducted over the past three years that the American public is demanding action on the issue of health care reform. This concern is both an economic and emotional issue to the voters. They are fearful of the high costs they, a family member, or a friend might experience. At the same time, medical services deal with pain, suffering, and death -- all important aspects of life; it is a critical and very personal service which the public sees as being delivered in an inefficient and costly manner.

By and large, this concern is not about the quality of health care that each individual receives. Most voters view their own health care as superior in quality -- and they believe the U.S. has the highest quality of medical care available in the world. The electorate's real concern is over how this care is distributed, how much it costs, and how inefficient some parts of the system appear.

But this concern over health care delivery and the desire to reform the system is relatively new to the American electorate. (Remember the Harris Wofford Senate election that crystallized the issue only occurred in late '91.) While the cost of care began to escalate years ago, most voters started searching for public policy solutions only in the past few months. Into this unstructured opinion design, many pollsters (including this one) have asked different, unique questions based on a myriad of specific clients' orientations. Because these surveys have concentrated on various elements of reform, using different language and difficult concepts, little consensus regarding policy preferences has emanated. Not only have the survey questions been varied and complicated, but they are asked of a public which is relatively uninformed on the nuances of reform and therefore, susceptible to being led to "soft" responses.

This is not to say that pollsters have not developed the best questions to test potential policy options preferred. Rather, it is to say that the baseline public opinion data regarding policy options is minimal and at best, voters are reacting to larger issues, symbols, institutions, and ideologies when they respond to these more specific questions.

Below are some variances in responses to reform ideas which have been proposed and have been discussed in the media.

• National health plan vs. some type of public-private partnership (support for a national, Canada-type plan varies from 44 percent to 79 percent).
• Willingness to raise taxes to pay for "reform" ranges from 26 percent - 76 percent.
• Requirements that their own, personal physician be available in any plan ranges from 43 percent to 58 percent.

Thus, the public's recent desire for solutions, the different circumstances of individuals, and the variety of questions written by pollsters has made it clear that specific policy consensus among the American electorate is not clear.

Yet, there are some givens or verities in public opinion regarding health care reform -- basic positions which most Americans support.

• The vast majority of the public believes that the federal government must be the initiator of reform. Voters perceive the issue as large (national) and difficult (too many vested interests who do not necessarily have the public interest at heart). This doesn't mean voters know what specific role they want the government to play in the ultimately reformed system; only that the Feds should be at the center, at least to referee, the reform effort.
• The health care delivery system is seen as inefficient and wasteful. Like most problems that involve the government, voters believe that many of the extra dollars required to fix the problem can come from a national reorganization of the system and reduction in waste and duplication. Only then would they be willing to entertain additional taxes to pay for universal coverage. Also, there is some indication in the polls that the elderly voters may be the most unwilling to modify the system if it requires any additional taxes. The cost issue is paramount; even those who report being concerned most about service availability discuss this availability in terms of the dollar cost of no medical "coverage."
• There is almost total acceptance of the need for universal coverage -- not only support fora health plan to cover all individuals, at least minimally, but also to make coverage transfer able so that changing jobs does not result in an economic pinch because of medical costs.
• Voters place near-equal blame on all major institutions and players in the health arena for the problems we have in health care (attorneys and insurance companies a little more so than doctors and hospitals). Voters appear to realize that each sector or profession will not give up their perquisites and therefore, they want federal government involvement in the "fix-it" stage.

A recent study by the Times-Mirror Center for The People and The Press indicated that 55 percent of the voters believe the health care system should be "completely rebuilt," 26 percent want "fundamental changes," and 15 percent want "only minor changes."

Interestingly, 49 percent think the country as a whole is spending too little on health care, 36 percent too much, and 8 percent the right amount. Sixty-nine percent of the electorate polled say changing the system is "very important" and 24 percent say it's "fairly important." By a wide 72-20 margin, respondents said they think it's more important to guarantee access to health care to all Americans than to find a way to limit overall cost increases.

When asked to rank priority needs, "making long-term nursing home care more affordable" and "providing health insurance coverage for those who cannot now afford it" topped the list. These were closely followed by "encouraging preventive care" and "limiting the overall increase in health care costs."

The Gallup Organization, in a 1993 survey for the American Medical Association, found that 76 percent of the voters probed would rather pay more for care if they could select personal physicians than pay less and be assigned physicians. Eighty percent said they would pay more to receive immediate care, 74 percent would pay more to select hospitals, and 54 percent would pay more to ensure the local availability of the latest medical technology.

On balance, public opinion surveys have demonstrated not only the electorate's demand that government deal with health care reform, but these surveys have also provided their preferences on the general direction that reform should be headed. What is not clear to those involved in this huge undertaking is voters' preferences on the host of specific policy options which will be required in any comprehensive reform package. In this case, political leadership will need to get out front and lead, and only then will they be able to test the voters' degree of acceptance for their new policy. The implications of what they do will live with us for a long time.