One Doctor’s Orders for How To Really Fix Our System

By Arthur M. Feldman

Sunday, September 6, 2009

Washington Post – link to original

As a cardiologist and the administrator of a large practice that includes general internists and specialists, I spend much of my time trying to figure out how to provide care for a growing number of uninsured or underinsured patients. I also have to battle billion-dollar private insurance companies that don’t adequately cover patients with preexisting illnesses and often deny coverage for necessary treatments.

On a basic level, I’m with the president: Our health-care system needs to be changed so that all of my patients, and all citizens, have access to the care they need. But I don’t agree with how he wants to fix things. Most of my colleagues and I strongly oppose the health-care reform bills that Congress will take up again this week. The proposals leave enormous gaps unfilled.

Before President Obama addresses a joint session of Congress on Wednesday, I hope he will consider these 10 major reasons why I — and doctors like me — worry that the legislation on the table will leave us worse off.

1. Private insurance companies escape real regulation.

This is what makes my colleagues and me so cynical about the reform proposals. Every physician has insurance company horror stories: patients who went untreated because their carriers wouldn’t pay, endless hours on the phone to get administrators’ approval for necessary tests and mountains of paperwork to collect reimbursements. It will be hard for doctors to buy into health-care reform if insurance companies get a free pass.

2. We urgently need tort reform, but it’s nowhere to be seen.

Malpractice costs rise each year, as do the number of frivolous lawsuits. Our practice has seen a 10 percent increase in malpractice expenses this year. Sure, doctors make mistakes, and patients deserve fair compensation for their injuries and lost wages, but in this area of the law, physicians and hospitals are too often at the mercy of capricious juries.

When the president brought up the “fear of lawsuits” in his address to the American Medical Association in June, he got a huge response from the crowd. That’s because practically every doctor has a story about a jury that awarded huge damages to a plaintiff despite the absence of wrongdoing by the physician. The best from our practice group is the physician who was sued — even though he was out of town during the patient’s entire hospitalization. Without fixing these spiraling insurance costs and the legal environment that allows large payments in unjust suits, physicians will continue to practice expensive “defensive” medicine or simply leave states that do not enact tort reform.

3. “Prevention” won’t magically make costs go down.

Obama has called for disease prevention on a national scale, but that won’t be a cure-all. Louise Russell,, a researcher at Rutgers University, analyzed hundreds of studies on prevention and medical costs and found that, in general, prevention adds to costs instead of reducing them. That’s because it often means medication for hypertension and elevated cholesterol, and screening and early treatment for cancer. Unless Congress outlaws McDonald’s, cigarettes, alcohol and idleness and cleans up the environment, no amount of “prevention” will put a dent in the cost of keeping Americans healthy.

4. Reform efforts don’t address our critical shortage of health-care workers.

Many people believe that the fix for our physician deficit is simple: expand class sizes at existing medical schools and create new ones. Sorry, it’s not that easy. There is a cap on the number of federally funded training positions for newly minted M.D.s. It hasn’t changed since 1996. If the number of graduates of U.S. medical schools increases but the number of post-graduate training positions remains the same, we won’t have fixed the problem — we’ll have created a different one. Training programs will simply take more U.S. graduates and fewer foreign ones, and the total number of physicians trained each year will remain the same — too low. And foreign medical school graduates tend to practice in rural and underserved urban areas, the very places that need the most help.

5. We need more primary-care physicians — but we also need specialists.

Everyone is worried about the dwindling ranks of primary-care physicians. But we need more specialists, too. There are impending shortages in fields such as oncology, cardiology, general surgery and gastroenterology. An article in the American Heart Association’s journal Circulation noted that by 2020 there won’t be enough cardiothoracic surgeons to treat the growing number of American seniors. Surgery, the journal of the Society of University Surgeons, reported an expected shortage of 1,300 general surgeons in the United States by 2010. Few Americans will tolerate not having access to a specialist in an emergency or having care rationed because of a limited number of skilled physicians.

6. We have to streamline drug development and shake up the Food and Drug Administration.

Creating and producing new drug therapies in the United States is a nightmare. Regulatory hurdles, disorganization and a lack of leadership at the FDA, as well as burdensome conflict-of-interest policies, have made the drug-approval process grindingly slow. At the same time, development costs are close to $1 billion per drug. Federal regulations are so convoluted that most clinical trials are now performed outside the country — taking billions of dollars out of the U.S. economy and making it harder for American patients to be first in line for new treatments.

7. We can’t fund health-care reform by cutting payments to doctors.

This isn’t about one doctor looking out for his bottom line. It’s about physicians being able to provide the accessibility and quality of care that their patients want. The Centers for Medicare and Medicaid Services has proposed increasing payments to primary-care physicians by approximately 6 percent while lowering payments for many specialists, including cardiologists and oncologists, by as much as 20 to 40 percent. These drastic recommendations were based on a questionable American Medical Association physician survey showing that expenses for cardiology and oncology practices dropped precipitously over the past five years — a finding that defies logic. If these cuts are approved, the American College of Cardiology estimates that 40 percent of the cardiology practices in Florida will go bankrupt. We need to pay for performance, not automatically reduce fees for procedures that patients have come to expect.

8. We can’t forget about research.

Every modern treatment for human disease is related in some way to research at U.S. academic medical centers — much of it supported by the National Institutes of Health. These include new treatments for cancer, devices to prevent sudden cardiac death and medications that save the lives of patients having heart attacks.

However, decreased federal funding for research over the past six years has threatened to decimate a generation of young scientists and the cures they could discover. While the stimulus package provided $10 billion for NIH-supported research, the allocation was for only two years. The health-care reform legislation provides no information about the level of research funding after 2011.

9. Cutting reimbursements could shut some hospitals down.

Proponents of the current reform legislation know that no one wants their local hospital to close. So the White House’s initial call to pay for health-care reform through cuts of more than $200 billion in hospital reimbursements over the next decade was scary. Obama sought to reassure people in June, explaining that “if more Americans are insured, we can cut payments that help hospitals treat patients without health insurance.” But there is no data to support this promise. It is unlikely that the homeless, the mentally ill, the substance abusers or the illegal immigrants who now receive their care in “safety net” hospitals will carry any form of health insurance. Grady Memorial Hospital, one of the premier public hospitals in the United States, which has cared for the underserved residents of Atlanta for more than a century, would probably have closed its doors had it not been for a $200 million gift from a local benefactor.

10. We need to improve the quality of care.

Obama has said that “if doctors have incentives to provide the best care instead of more care, we can help Americans avoid the unnecessary hospital stays, treatments and tests that drive up costs.” This is an overly simplistic view of what is needed. Poor care clearly costs more money. However, as the Institute of Medicine has pointed out, poor quality of care can be divided into three types: underuse of care, misuse of care and overuse of care. While eliminating misuse and overuse will decrease the cost of care, correcting problems from underuse will actually increase costs.

I have a close view of the limitations of our current health-care system. Not just with my patients, who are often unable to afford the care they need, but also in the plight of a young colleague. He was diagnosed with an aggressive form of lung cancer and sought treatment at a nationally renowned Boston cancer center. Most people with lung cancer undergo expensive chemotherapy and radiation therapy, but even those aggressive measures have a limited effect on long-term survival. His physicians discovered that he had a type of cancer that might respond to a new drug in clinical testing, provided free by the pharmaceutical company sponsoring the research. Although the cost of his care is far less than that of traditional chemotherapy, his insurance company refused to pay for it because it is “experimental.”

But he has been lucky. His friends and colleagues have helped support his treatment, and wherever possible his doctors have provided free care. His cancer has responded dramatically to the drug, he has suffered no side effects, and he is back at work full-time.

However, I don’t want my patients to rely on luck. I want them to have insurance that will pay for their care, and I want to be able to offer new medications and the most sophisticated treatment. I want to be able to give preventive care as well as to monitor patients effectively if they develop diseases. I want to be able care for my patients in their homes, and I want to offer palliative care if it becomes necessary. I want them to be able to afford all this. In short, I want to see major reforms in health care — I just don’t want what is on the table.

Arthur.Feldman@jefferson.edu

Arthur M. Feldman is a cardiologist and chair of the department of medicine at Jefferson Medical College. He is the author of “Pursuing Excellence in Healthcare: Preserving America’s Academic Medical Centers.” He will be online to chat with readers Tuesday at 2 p.m. Submit your questions and comments before or during the discussion.

Few Americans Seem to Hear Health Care Facts

By Howard Kurtz

Washington Post Staff Writer – link to original article

Monday, August 24, 2009

For once, mainstream journalists did not retreat to the studied neutrality of quoting dueling antagonists.

They tried to perform last rites on the ludicrous claim about President Obama’s death panels, telling Sarah Palin, in effect, you’ve got to quit making things up.

But it didn’t matter. The story refused to die.

The crackling, often angry debate over health-care reform has severely tested the media’s ability to untangle a story of immense complexity. In many ways, news organizations have risen to the occasion; in others they have become agents of distortion. But even when they report the facts, they have had trouble influencing public opinion.

In the 10 days after Palin warned on Facebook of an America “in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s ‘death panel,’ ” The Washington Post mentioned the phrase 18 times, the New York Times 16 times, and network and cable news at least 154 times (many daytime news shows are not transcribed).

While there is legitimate debate about the legislation’s funding for voluntary end-of-life counseling sessions, the former Alaska governor’s claim that government panels would make euthanasia decisions was clearly debunked. Yet an NBC poll last week found that 45 percent of those surveyed believe the measure would allow the government to make decisions about cutting off care to the elderly — a figure that rose to 75 percent among Fox News viewers.

Less than seven hours after Palin posted her charge Aug. 7, MSNBC’s Keith Olbermann called it an “absurd idea.” That might have been dismissed as a liberal slam, but the next day, ABC’s Bill Weir said on “Good Morning America”: “There is nothing like that anywhere in the pending legislation.”

On Aug. 9, Post reporter Ceci Connolly said flatly in an A-section story: “There are no such ‘death panels’ mentioned in any of the House bills.” That same day, on NBC’s “Meet the Press,” conservative New York Times columnist David Brooks called Palin’s assertion “crazy.” CNN’s Jessica Yellin said on “State of the Union,” “That’s not an accurate assessment of what this panel is.” And on ABC’s “This Week,” George Stephanopoulos said: “Those phrases appear nowhere in the bill.”

Still, some conservatives argued otherwise. On the Stephanopoulos roundtable, former House speaker Newt Gingrich said the legislation “has all sorts of panels. You’re asking us to trust turning power over to the government when there clearly are people in America who believe in establishing euthanasia, including selective standards.”

And on Fox the next night, Bill O’Reilly played a clip of former Democratic Party chairman Howard Dean saying Palin “just made that up. . . . There’s nothing like euthanasia in the bill.” O’Reilly countered that as far as he could tell, “Sarah Palin never mentioned euthanasia. Dean made it up to demean Palin.”

Ultimately, the media consensus was that Palin had attempted “to leap across a logical canyon,” as the conservative bible National Review put it, adding that “we should be against hysteria.” But the “death” debate was sucking up much of the political oxygen. President Obama kept denying that he was for “pulling the plug on Grandma.” On Aug. 13, the Senate Finance Committee pulled the plug on the provision, with Republican Sen. Charles Grassley saying the idea could be — yes — “misinterpreted.”

Perhaps journalists are no more trusted than politicians these days, or many folks never saw the knockdown stories. But this was a stunning illustration of the traditional media’s impotence.

The eruption of anger at town-hall meetings on health care, while real and palpable, became an endless loop on television. The louder the voices, the fiercer the confrontation, the more it became video wallpaper, obscuring the substantive arguments in favor of what producers love most: conflict.

Never mind if some of the fury seemed unfocused or simply anti-Obama. Katy Abram was shown hundreds of times yelling at Democratic Sen. Arlen Specter: “I don’t want this country turning into Russia. . . . What are you going to do to restore this country back to what our founders created according to the Constitution?” She later popped up on Sean Hannity’s Fox show, saying: “I know that years down the road, I don’t want my children coming to me and asking me, ‘Mom, why didn’t you do anything? Why do we have to wait in line for, I don’t know, toilet paper or anything?’ “

Twenty members of Congress might have held calm and collected town meetings on any given day, but only the one with raucous exchanges would make it on the air. “TV loves a ruckus,” Obama complained more than once. In fact, after the president convened a low-key town hall in New Hampshire, press secretary Robert Gibbs told reporters: “I think some of you were disappointed yesterday that the president didn’t get yelled at.” There was a grain of truth in that. As Fox broke away from the meeting, anchor Trace Gallagher said, “Any contentious questions, anybody yelling, we’ll bring it to you.”

If some Fox hosts seemed as sympathetic to the town-hall screamers as they were to last spring’s tea-party protesters, MSNBC focused more on conservative efforts to organize the dissenters and whether they were half-crazed characters — especially the few who rather chillingly stood outside Obama events with their guns.

Still, it was a stretch for White House officials, who have a huge megaphone, to blame media coverage for the sinking popularity of health reform. It was equally odd for Gibbs to tell reporters that stories about Obama backing away from a government-run health plan were “entirely contrived by you guys” — this after Gibbs and Health and Human Services Secretary Kathleen Sebelius had said on Sunday morning shows that such a plan was not an essential part of Obama’s proposal.

For all the sound and fury, news organizations have labored to explain the intricacies of the competing blueprints. “NBC Nightly News” ran a piece examining how Obama’s public health-insurance option would work. ABC’s “World News ” did a fact check on the end-of-life provision in the bill. “CBS Evening News” highlighted problems with the current system by interviewing some of the 1,500 people waiting at a free makeshift clinic in Los Angeles. Time ran a cover story on health care, titled “Paging Dr. Obama.” And major newspapers have been filled with articles examining the nitty-gritty details. Those who say the media haven’t dug into the details aren’t looking very hard.

But the healthy dose of coverage has largely failed to dispel many of the half-truths and exaggerations surrounding the debate. Even so, news organizations were slow to diagnose the depth of public unease about the unwieldy legislation. For the moment, the story, like the process itself, remains a muddle.

The Beck Boycott

The fallout continues over Glenn Beck assailing President Obama as a “racist” with a “deep-seated hatred” of white people. About 20 companies — including Procter & Gamble, Geico and ConAgra — have now pulled their ads from his Fox News show.

Beck’s charge was so incendiary — and bizarre, considering that Obama’s mother was white — that even some conservatives winced. But boycotts rarely succeed in forcing anyone off the air, and indeed, Fox hasn’t forfeited a dime. A Fox spokeswoman pointed to the network’s statement: “The advertisers referenced have all moved their spots from Beck to other day parts on the network, so there has been no revenue lost.”

Washington Post reporter Howard Kurtz is a contributor to CNN and host of its weekly “Reliable Sources” program, which is part of “State of the Union.”

Healthcare reform: What it means to you – link to original article

With some of the highest healthcare costs in the United States, South Florida has a lot at stake in the current reform proposals.

BY JOHN DORSCHNER

JDORSCHNER@MIAMIHERALD.COM

Miami Herald August 16, 2009

As the national debate about healthcare reform intensifies, South Florida stands out as a place that has a lot to gain and a lot to lose, depending on the details hammered out by Congress next month. 

A lot to gain because the region has an unusually high percentage of uninsured and people who seek to buy insurance on the individual coverage market, which is often highpriced and unavailable to those with chronic diseases. The reforms are aimed at helping both of these groups get coverage they can afford.

A lot to lose because almost all experts say the only way the country can afford reform is to reduce its healthcare costs. The United States has the highest healthcare costs in the world, and South Florida is among the highest in the nation. Under reform, quite a few of the 218,000 healthcare workers in Miami-Dade and Broward could lose their jobs.

Healthcare leaders like Brian Keeley, chief executive of Baptist Health South Florida, says these two points are closely connected: The higher the costs get, the fewer businesses can afford coverage, which increases the number of uninsured, who often delay treatment until they are extremely sick and go to the emergency room.

There, they run up big bills they can’t pay for, and hospitals compensate by hiking rates for private insurance, causing more businesses to drop coverage, which increases the number of uninsured.

“This is a `death spiral,’ ” says Keeley.

“The system is totally unsustainable for all parties. Drug companies, insurance companies, the SEIU [Service Employees International Union], you talk about strange bedfellows — all agree something has to be done.”

With accusations flying in all directions and much confusion about the details in proposals Congress will be considering when it returns from its August recess, here is a quick primer about healthcare, dealing with the misconceptions and the realities: Where the system stands now, how it stacks up to other countries, what is being proposed and what changes mean for South Florida residents.

What we have now

The United States has a public/private mixture. Fifty-three percent get their insurance at work, according to the Kaiser Family Foundation; 27 percent have a government plan (Medicare for seniors, Medicaid for the poor); 5 percent buy on the individual market.

Fifteen percent have no insurance — 45 million in 2007 and thought by many to have risen to 50 million during the recession.

In South Florida, one million are uninsured. In Miami-Dade, 625,000 have no coverage — 30.9 percent of the population under 65. In Broward, it’s 408,000 — 27.1 percent of those under 65. This is Census Bureau data for 2006, which was just released. The numbers have likely increased during the recession.

In one sense, the United States already has universal healthcare. Under federal law, everyone in the country — including immigrants here illegally — must be treated in hospital emergency rooms.

Those unpaid hospital bills get passed on to people with insurance.

A study by Families USA released this week found that in the past 10 years, family healthcare premiums rose an estimated 3.7 times faster than earnings for Florida workers.

The one group that has a hard time passing on these costs are the public hospitals, because so many of their patients are poor or uninsured.

That’s why places like Jackson Health System are in dire financial shape, which is expected to get worse.

What other countries do

The rest of the industrialized world — Europe, Canada, Australia — essentially guarantees the right to basic healthcare, as it does the right to public education.

Many critics of reform point to problems in Canada, where patients often complain about long waits for elective surgery. But experts like Steven Ullmann, director of health policy programs at the University of Miami, say Canada’s system is essentially a government entity — unlike what’s being proposed in the United States.

Ullmann and many others say a better comparison is the Netherlands, where employers and individuals pay into the system. People choose among private insurers. Costs are regulated.

The bottom line: The Dutch live to 80, on average, for an average annual healthcare cost of $3,383, according to the World Health Organization. In the United States, it’s 78 years of life for $6,714.

Most Dutch doctors have their own private practices. A survey sponsored by the Commonwealth Fund of patients with chronic diseases found that 60 percent in the Netherlands say they can get a same-day appointment with a doctor when they’re sick. Only 26 percent in the United States said they could.

Ninety-nine percent of those patients in the Netherlands said they have a doctor that they usually see, compared with 82 percent in the United States.

Even so, many are not entirely satisfied with their system: 46 percent of the Dutch want fundamental changes, and 9 percent say the system needs a complete overhaul.

In the United States, Commonwealth reported, 46 percent want fundamental changes, 33 percent demand a complete overhaul.

Much of the dissatisfaction may be based on not getting everything we want: Unlike buying, say, a television, healthcare in the industrialized world works through a third party: Patients get treated and providers get paid — by a third-party insurer.

As Keeley puts it: “We all want the very best healthcare — and we want someone else to pay for it.” In such a system, neither patients nor providers worry much about costs.

In Europe, governments generally have price controls. In the United States, private and government insurers have tried to control costs — generally without success.

Plans for reform

The proposals now before the House and Senate are complex. Some highlights:

• In all proposals before Congress, private health plans provided by employers will remain the fundamental form of insurance for most Americans. One key issue creating bitter debate is whether to add a “public plan” — a government alternative to compete with private insurers.

• Most proposals require all Americans to have health insurance. Individuals who can not afford the premiums could be eligible for subsidies, a provision that will cost billions. This would enlarge the insurance pool — and make private insurers happy. In return, the insurers promise not to reject people because of preexisting conditions, although this provision would be phased in slowly over time.

• One of the biggest uncertainties: What happens to small businesses. Should businesses of a certain size be forced to provide insurance or pay a tax? How big a tax? If there was a public plan, many small businesses might be better off paying a tax and putting their employees in a public plan, where a large risk pool would spread costs.

Some small-business owners that don’t provide coverage,like Miriam Vilariño of Las Vegas Cuban Restaurants, warn that one proposal — a payroll tax of 8 percent for companies that don’t offer insurance — could destroy the family business.

• How to pay for all this? This is the toughest part: Proposals include new taxes on the wealthy, and/or businesses that don’t offer healthcare, and/or insurers that offer “Cadillac plans,” which offer unusually rich benefit packages.

But what makes a Cadillac? Laurie Amber, a South Miami lawyer, worries that her $1,700-a-month policy might qualify, even though it includes a $2,000 deductible. “We really have a bare bones. It’s just expensive.” Expensive because healthcare in South Florida tends to cost far more than elsewhere.

Cutting costs

Republicans and Democrats agree that any reform must be funded in part by cutting costs. But they say that doesn’t mean denying care or simply cutting payments to doctors or hospitals.

Dartmouth researchers and the Midwest Business Group on Health have said about 30 percent of current health spending is completely wasted — duplicative or unnecessary tests, too many trips to specialists, too much reliance on expensive drugs when cheaper generics could do just as well.

Dartmouth studies show that South Florida is a poster child for such high costs: A Miami senior costs Medicare twice as much annually as a senior in Minneapolis, but lives no longer and gets no healthier.

“That difference is so big that if you got rid of it, you could afford to lease a Lexus 400 for every senior in Miami,” says Becky Cherney of the Florida Health Care Coalition. Of course, policy makers want the money saved to help the uninsured, not another car program.

One major issue lost in the present debate: With or without reform, Medicare is in financial trouble. “At the year 2013, Medicare starts going broke,” warns Tommy Thompson, George W. Bush’s secretary of Health and Human Services.

Reform critics say that Medicare’s problems are a good reason why Congress should not add another “public plan.”

Politics of reform

In the past month, the rhetoric of the debate has escalated so much to include even an accusation that the government is planning “death panels” to decide who should live and who should die.

There’s nothing like that in the proposed legislation. Ullmann says the fear comes from a benign provision that, if a senior wants a consultation with her doctor about end-of-life decisions, insurance should pay for this.

But with more than a thousand pages of proposals, there’s the possibility for a lot of argument. Insurers don’t want a public plan. Big Pharma is preparing to spend millions on ads supporting reform — as long as the government doesn’t set drug prices.

The intensity of the debate has clearly split voters. A Gallup Poll conducted about the time of the “death panel” accusation found that 35 percent of the nation wants Congress to pass a reform bill when it returns from its August recess, 36 percent recommend a vote against and 29 percent have no opinion.

Talk of controlling costs has many frightened. A Gallup Poll last month showed 42 percent of those over 65 believed reform will “worsen medical care in the United States.”

Many critics have concerns not about what is in the legislation, but implications about what the reform could lead to later: A public plan could open the door to “socialized medicine.” Cost controls might lead to euthanasia.

The healthcare coalition’s Cherney, who has read the entire 1,000-page House bill, says euthanasia is nowhere in the legislation. “There’s a lot of misconceptions out there.”

She says the thick package has many valuable provisions — such as the government helping doctors pay for converting their offices to electronic records.

But Ullmann at UM says the “very complex” proposal “by itself causes anxiety about what might be hidden in there.” He suggests that policymakers may have erred by including too many details. “There’s something to be said for that old saying: Keep it simple, stupid.’ says the “very complex” proposal “by itself causes anxiety about what might be hidden in there.” He suggests that policymakers may have erred by including too many details. “There’s something to be said for that old saying: Keep it simple, stupid.’

Americans’ Views On Health Policy: A Fifty-Year Historical Perspective – link to original article

Health Affairs – THe Policy Journal of the Health Sphere 

Robert J. Blendon and John M. Benson

   Abstract

A review of data from more than 100 public opinion surveys conducted over a fifty-year period finds that the American public has conflicting views about the nation’s health policy. They report much dissatisfaction with the health care system and with private health insurance and managed care companies, and they indicate general support of a national health plan. However, most Americans remain satisfied with their current medical arrangements, do not trust the federal government to do what is right, and do not favor a single-payer type of national health plan. The review also finds that confidence in the leaders of medicine has declined but that most Americans maintain trust in the honesty and ethical standards of individual physicians.

For decades public opinion researchers have sought to learn what Americans think of a variety of subjects, including health care. We now have more than fifty years’ worth of historical trends on Americans’ views related to health policies. Understanding these trends is important for a number of reasons. First, public opinion influences the outcome of elections and often sets the health policy agendas of those seeking public office. Second, studies have shown that public opinion influences government decision making beyond election outcomes and often affects policy decisions made by Congress, the executive branch, and the United States Supreme Court.1 Examining Americans’ views on the same issue in different time periods helps us to understand better the changing nature of the health policy environment.

This discussion is divided into six sections, examining the public’s views on (1) national health insurance and the enactment of Medicare; (2) the U.S. health care system; (3) health care as a national priority; (4) confidence in health professionals and institutions; (5) satisfaction with one’s own health care; and (6) the role of government in general, as a context for health policy attitudes.

Sources of data. Despite the large number of polls conducted over the past five decades, relatively few have included questions asked with similar wordings so as to provide historical trends concerning public opinion on health policy issues. The data in this paper are restricted to those issues for which the same polling questions on a health policy issue were asked for three or more years.

The data presented here consist of specific results from more than 100 opinion surveys conducted nationwide between 1945 and 2000. We compiled these results from the POLL database at the Roper Center for Public Opinion Research in Storrs, Connecticut, from the Harris Interactive subscription service, and from published research papers containing particular historical data used in our trend series. These polls involved interviews with 500 to 2,000 randomly selected adults. In the years prior to 1985 most of the polls were conducted in person; after 1985 most were conducted by telephone.2

   National Health Care Reform

Since World War II there have been four major debates over reforming the nation’s health care system: (1) the late 1940s debate about President Harry Truman’s proposed national health insurance plan; (2) the 1961–1965 debate during the Kennedy and Johnson administrations over providing health insurance for elderly Americans (Medicare); (3) the 1971–1974 debate about President Richard Nixon’s proposed national health insurance program; and (4) the 1993–1994 debate about the Clinton administration’s health care reform proposal.

Trend data on public opinion are available for three of these four debates; only the Nixon-era debate has no trend data available. The data suggest that there were common features among these three national debates.

First, prior to the introduction of each bill, public interest in some type of national health care reform already existed. In the years leading up to the Truman proposal, 82 percent of Americans said that something should be done to make it easier for people to pay for doctor and hospital care, and 68 percent thought that it was a good idea for Social Security to cover doctor and hospital bills.3 Shortly before Medicare was enacted, 75 percent of the public said that the federal government should pass a law to provide medical care for seniors.4 During the year of Bill Clinton’s first election as president, 66 percent of Americans favored national health insurance financed by tax money—up from 46 percent in March 1980 (Exhibit 1).5

View this table in original article: EXHIBIT 1 Americans’ Attitudes About National Health Insurance, 1980–2000 

There were other similarities between the Clinton and Truman plans. After each plan was introduced and the policies were made explicit, opposing groups entered the debate and argued that the enactment of the proposal would result in a health care system worse than the existing one. In spite of the general support for a national health plan portrayed in Exhibit 1, public support for the Clinton plan declined from 59 percent in September 1993 to 40 percent in July 1994.6 Also, the public became more negative toward the Clinton plan on the issues of too much government, the cost of the plan, limits on choice of doctors, and the quality of care available.7 A similar phenomenon occurred during the debate over the Truman plan. In March 1949, 38 percent opposed the Truman plan. By October 1950, after an extensive campaign by opponents, public opposition had risen to 61 percent.8 Only in the case of Medicare did the majority of Americans continue to support the specific national reform proposal after learning more about it. Polls at the time show 61 percent and 62 percent of the public supporting the proposed Medicare legislation in the fall of 1964, and 65 percent after it was enacted in 1965.9

The Clinton and Truman examples suggest the need for caution in interpreting poll results favoring national health care reform prior to the introduction of a specific proposal. Among the confounding factors is the lack of an underlying consensus among the American public over the preferred type of national health plan. Polls that offer only one plan as a possible solution often show majority support for that proposal. But when other major alternative proposals are offered, as they were in each of these two national debates, public support splinters.

In 1946, 1963, and 1993, when the public was given the choice of more than one type of national health reform legislation, none gained majority support. Of particular interest is that when proposals are introduced involving a major private-sector role, the option of a government health plan never achieves majority support from the public (37 percent in 1946, 42 percent in 1963 for the elderly, and 28 percent in 1993).10

Recent polling presents another example of this lack of consensus. In 2000, when asked in general about national health insurance financed by taxes, 56 percent of the public (54 percent of registered voters) said that they were in favor.11 But when a clause was added specifying that all Americans would get their health insurance from a single government plan, support fell to 38 percent of registered voters (Exhibit 1).12 This illustrates the lack of public consensus on what a national health plan financed by taxes should entail.

   Views Of The Health Care System

Much of the efforts of health policymakers have been focused on improving aspects of the nation’s health care system. An important measure of public ferment for change in the health system is how satisfied Americans are with the current system and how much change they believe is needed.

One trend question assessing satisfaction with the health care system asks Americans if they think that our system works pretty well and needs only minor changes, has some good things but needs fundamental changes, or has so much wrong with it that we need to rebuild it completely (Exhibit 2).13 The first response implies satisfaction with the status quo, and the last response suggests a high level of public dissatisfaction and support for major change.

View this table in original article: EXHIBIT 2 Americans’ Overall View Of The Nation’s Health Care System, 1982–2000

 By this measure, starting in 1982, the majority of Americans have never been completely satisfied with the health care system. Americans were the most positive in 1987, when 29 percent reported that they saw the system working pretty well. In 1991, often seen as the starting point of the great health care reform debate of the early 1990s, only 6 percent held this favorable view. In that year Democrat Harris Wofford won a special Senate election in Pennsylvania on a platform calling for national health insurance. In that same year 42 percent of Americans expressed the view that the health care system should be completely rebuilt, the highest level ever reported. By 2000 only 29 percent held this view. Taken together, this trend shows that most of the public has never been completely satisfied with the system during the past eighteen years, but never has a majority supported developing an alternative system.

In a second trend, starting in 1993, a majority of Americans has expressed dissatisfaction with the availability and affordability of health care in this country. However, the proportion who reported that they were not at all satisfied has declined from 45 percent in 1993 to 26 percent in 1997 and 27 percent in 2000.14

One last specific measure of the health system concerns the adequacy of the supply of physicians. In the post–World War II period, U.S. health policymakers have gone from having great concerns about shortages of physicians to concerns about a physician surplus. Over the past two decades the proportion of Americans who think that there are too few physicians in their community has declined, from 38 percent in 1981 to 28 percent in 2000.15 However, only 10 percent perceive a physician surplus in their community, and this figure has not changed in two decades. This suggests that if a physician surplus is developing, it is not yet visible to the public.

   Health As A National Priority

Over the years a number of experts and commentators have expressed concerns about the high level of health spending in the United States. These concerns have not been shared by the general public. Since 1973 the majority of Americans has said that the United States is spending too little rather than too much on improving and protecting the nation’s health (Exhibit 3).16

View this table in original article: EXHIBIT 3 Americans’ Attitudes About Spending To Improve And Protect The Nation’s Health, 1973–1998 

The lowest levels of support for more spending occurred in 1978 and 1980, when national health care cost containment was being debated. The highest levels occurred in 1990 and 1993 during the debate over national health care reform. At no time in this quarter-century trend did more than 9 percent of the public feel that the nation was spending too much on health. The question wording is rather broad and is likely to include public support for increased spending on health care, public health, prevention, and/or medical research.

Although Americans may have continuously supported more spending on health, the priority for health spending and activity has fluctuated over time. Since 1993 Americans have been asked what they think should be the two most important issues for government to address (Exhibit 4).17 In January 1993, 31 percent of Americans selected health care (excluding Medicare) as one of these two issues. The high point in public priority for health care was in October 1993, again at the height of the health reform debate.

View this table in original article: EXHIBIT 4 Percentage Of Americans Naming Health Care Or Medicare As One Of The Two Most Important Issues For Government To Address, 1993–2000

   Public Confidence In Health Professionals And Institutions

Historically, because of their expertise and their unique role in patient care, physicians have played a dominant role in health policy. Over the past thirty years, however, public confidence in the leaders of medicine, as well as most other major American institutions, has declined (Exhibit 5). In the longest trend series, the proportion of Americans reporting a great deal of confidence in the leaders of medicine has declined from 73 percent in 1966 to 44 percent in 2000.18 The lowest level of public confidence occurred in 1993 (22 percent), during the debate over national health care reform.

View this table in original article: EXHIBIT 5 Public Confidence In The People Running Medicine And Assessment Of The Honesty And Ethical Standards Of Medical Doctors, 1966–2000

This decline in public confidence in the institutional leaders of medicine has not affected Americans’ high level of respect for practicing physicians, who have consistently been among the highest-ranked professionals. The past twenty-five years have witnessed no change in Americans’ assessment of the honesty and ethical standards of physicians.19

Unfortunately, there is no comparably long trend for health care institutions. A shorter series, starting in 1997, asks the public to rate the job various industries and institutions are doing for their consumers (Exhibit 6).20 Hospitals are the health care institution seen by the most people (72 percent) as doing a good job for its constituents; managed care companies, by the fewest (29 percent).

View this table in original article: EXHIBIT 6 The Public’s Assessment Of The Job Various Industries Are Doing Serving Their Consumers, 1997–2000

Since 1997 there has been a twenty-two-percentage-point decline in the proportion of the public saying managed care companies are doing a good job for consumers and a twenty-point decline in positive assessments of the pharmaceutical industry. Of note, both of these declines occurred during a period when there was a major national debate about the desirability of expanding government’s regulatory role in these two areas.

The proportion of Americans who believe that the growth of managed care is a bad thing has increased from 28 percent in 1995 to 52 percent in 2000. In addition, Americans are more likely now than in 1995 to believe that the growth of managed care will harm the quality of medical care (59 percent in 2000, 39 percent in 1995) and not help to contain costs (53 percent in 2000, 31 percent in 1995).21

    Americans’ Views Of Their Own Health Care

Health policy differs from many other policy areas in that the public’s views on issues are shaped at least in part by their own experiences. Two historical trends—one concerning Americans’ satisfaction with their own medical care, the other with confidence in ability to pay for a major illness—measure these experiences.

In the twenty-two years the first question has been asked, more than 80 percent of Americans have reported that they are satisfied with their last visit to a physician (Exhibit 7).22 Also, confidence in ability to pay for a major illness has improved over the years.23 Despite the increase in the number of uninsured Americans nationally, the proportion reporting such confidence has risen from 50 percent in 1978 to 67 percent in 2000. This improvement in financial confidence may be related to more comprehensive insurance and increased benefit coverage for the insured population, or it may reflect the effects of increased family incomes and assets that could be drawn upon in case of large medical bills.

View this table in original article: EXHIBIT 7 Americans’ Satisfaction With Their Own Medical Care And Confidence In Their Ability To Pay For A Major Illness, 1978–2000

  The Role Of Government

For those involved in health policy today, the public opinion environment is very different from what it was a generation ago. The period from 1964 through the early 1970s saw the enactment of Medicare, Medicaid, the War on Poverty’s health care programs, and a plethora of new government regulatory measures aimed at improving the health care system. Those decisions were made in an era when there was less widespread citizen distrust of government, a greater public willingness to have government regulate the private sector, and less public concern with the level of federal taxation.

In 1964, the year before Medicare and Medicaid were enacted, only one-fourth of Americans expressed distrust in the federal government (Exhibit 8).24 When the Clinton health plan ultimately failed in Congress in 1994, distrust of the federal government had risen fifty-four percentage points. These same years have also seen a decline in public support for government regulation of the private sector. In 1964 only 43 percent of Americans agreed with the statement that the government has gone too far in regulating business and the free enterprise system.25 This figure rose to 60 percent in 2000. Americans are clearly less willing today to see expanded government regulation in general than they were during the 1960s. Similarly, in 1961 only 46 percent of Americans thought that their federal taxes were too high.26 This figure rose to 69 percent in 1969 and stood at 63 percent in 2000.

View this table in original article: EXHIBIT 8 Americans’ Attitudes About The Federal Government, 1956–2000

  Discussion

A number of key questions arise from this historical review of public opinion. First, what do we know about the stability of public opinion on health care policy over the past five decades? The picture presented here is mixed. On many of the issues we examined, public opinion has been stable over long periods of time. However, in the cases of national health care reform, the priority for government action on health care, confidence in the leaders of medicine and government, and concerns about federal taxation, public opinion has changed markedly over the years. Even more dramatic is the decline of public support for both the Clinton and Truman health plans over a short period of time.

Second, what do we learn about the consistency of public opinion over these many areas of health policy? Americans hold many beliefs that are consistent with a general view of what is right or wrong about health care in the United States. However, it is striking to see how many conflicting views the public holds on health policy issues.

On the one hand, Americans report substantial dissatisfaction with our mixed private/public health care system and with the private health insurance and managed care industries. A majority of Americans indicate general support for a national health plan financed by taxpayers, as well as increased national health spending. On the other hand, these surveys portray a public that is satisfied with their current medical arrangements, in many years does not see health care as a top priority for government action, does not trust the federal government to do what is right, sees their federal taxes as already too high, and does not favor a single-payer (government) type of national health plan. Over the years these conflicts in beliefs have been difficult to resolve in legislative debates, particularly around the issues of large-scale national health care reform. This is likely to remain the case in the years ahead.

Finally, are there any lessons for better interpreting public opinion on health policies in the future? The answer from this review is clearly yes. Because Americans do hold many conflicting values and beliefs that affect their views on health care policy, it is important to be cautious in interpreting the public mood based on single, isolated public opinion questions. To be a useful guidepost for policymakers, opinion surveys require enough depth in their question wordings so that respondents can work their way through their conflicting values and beliefs to come to judgment on the issue.

   Editor’s Notes

Bob Blendon is professor of health policy and political analysis at the Harvard School of Public Health. John Benson is managing director of the Harvard Opinion Research Program, Harvard School of Public Health.

This work was supported jointly by the Henry J.Kaiser Family Foundation and the Robert Wood Johnson Foundation. The views expressed are solely those of the authors, and no official endorsement by either sponsor is intended or should be inferred.

   NOTES

R.J. Blendon and M. Brodie, “Public Opinion and Health Policy,” in Health Politics and Policy, ed. T.J. Litman and L.S. Robins (Albany, N.Y.: Delmar Publishers, 1997).

When interpreting these findings, one should recognize that all surveys are subject to sampling error. Results may differ from what would be obtained if the whole population of adults had been interviewed. The size of the error varies with the number surveyed and the magnitude of difference in the responses to each question. Most national public opinion surveys have sample sizes of about 1,200 persons, in which the results will, with a 95 percent degree of confidence, have a statistical precision of plus or minus three percentage points of what would be obtained if the entire population had been interviewed. The sampling error for 500 respondents is plus or minus five percentage points; for 2,000 respondents, plus or minus two percentage points. Possible sources of nonsampling error include nonresponse bias, as well as question wording and ordering effects. Nonresponse produces some known biases in survey-derived estimates because participation tends to vary for different subgroups of the population. To compensate for these known biases, the sample data are typically weighted in analysis, using parameters from the most recent available census data. Other techniques, including random-digit dialing, replicate subsamples, callbacks staggered over times of day and days of the week, refusal conversions, and systematic respondent selection within households, are used in telephone surveys to ensure that the sample is representative.

S.L. Payne, “Some Opinion Research Principles Developed through Studies of Social Medicine,” Public Opinion Quarterly (Spring 1946): 93–98.

National Opinion Research Center/Anti-Defamation League of B’Nai B’Rith (Storrs, Conn.: Roper Center for Public Opinion Research, October 1964).

CBS News/New York Times polls (Roper Center, 12March 1980 and 8 July 1992). The complete trend also includes results from the following polls: CBS News/New York Times polls (Roper Center, 13 February 1980, 22 April 1981, 30 March 1990, 28 October 1990, 3 June 1991, 18 August 1991, 22 January 1992, 12 January 1993, and 28 March 1993); New York Times poll (Roper Center, 3 December 1995); and Harvard School of Public Health/International Communications Research poll (Roper Center, 16 August 2000). Question wording: “Do you favor or oppose national health insurance, which would be financed by tax money, paying for most forms of health care?”

Gallup poll (Roper Center, 24 September 1993); and Gallup/CNN/USA Today poll (Roper Center, 15 July 1994).

Gallup/CNN/USA Today polls (Roper Center, 22 September 1993 and 28October 1993); and Gallup polls (Roper Center, 24 September 1993 and 16 April 1994).

Gallup polls (Roper Center, 6March 1949 and 8 October 1950).

Gallup/Potomac Associates polls (Roper Center, September 1964 and October 1964); and Harris poll (Roper Center, April 1965).

Gallup poll (Roper Center, 12 April 1946);Opinion Research Corporation poll (Roper Center, 15 March 1963); and Henry J. Kaiser Family Foundation/Commonwealth Fund/Louis Harris and Associates poll (Roper Center, 6 August 1993).

Harvard/ICR poll, 16 August 2000.

Washington Post/Henry J. Kaiser Family Foundation/Harvard University poll (Roper Center, 5 July 2000). The complete trend for this question wording also includes results from Henry J. Kaiser Family Foundation/Harvard School of Public Health/Princeton Survey Research Associates polls (Roper Center, 4 November 1998, 8 October 1999, and 3 December 1999). Question wording: Do you favor or oppose “a national health plan, financed by taxpayers, in which all Americans would get their insurance from a single government plan”?

Question wording: “Which of the following statements comes closest to expressing your overall view of the country’s health care system? On the whole, the health care system works pretty well and only minor changes are necessary to make it work better; there are some good things in our health care system, but fundamental changes are needed to make it work better; the health care system has so much wrong with it that we need to completely rebuild it.”

Gallup/CNN/USA Today polls (Roper Center, 8 January 1993, 10 January 1997, and 7 January 2000).

American Medical Association poll (Roper Center, 24 July 1981); and Harvard/ICR poll, 16 August 2000.

Question wording: “We are faced with many problems in this country, none of which can be solved easily or inexpensively. I’m going to name some of these problems, and for each one I’d like you to tell me whether you think were spending too much money on it, too little money, or about the right amount. Are we spending too much, too little, or about the right amount on… improving and protecting the nation’s health?”

Harris polls (Roper Center, 22 January 1993, 4 March 1993, 28 April 1993, 24 June 1993, 13 August 1993, 1 October 1993, 11 November 1993, 20 December 1993, 2 February 1994, 4 April 1994, 23May 1994, 17 September 1994, 8November 1994, 9 December 1994, 8 June 1995, 26 October 1995, 9 January 1997, 5 June 1997, 20 August 1997, 15 October 1997, 14 January 1998, 18 February 1998, 27 April 1998, 17 July 1998, 12 August 1998, 9 September 1998, 11 November 1998, 7 January 1999, 11 February 1999, 8 April 1999, 14 May 1999, 10 June 1999, 12 August 1999, 17 September 1999, 22 October 1999, 2 December 1999, 6 January 2000, and 8 September 2000); for February–July 2000, Harris poll (New York: Harris Interactive, 25 July 2000). Question wording: “What do you think are the two most important issues for the government to address?”

Harris poll (New York: Harris Interactive, 26 January 2000). Question wording: “As far as people in charge of running medicine are concerned, would you say you have a great deal of confidence, only some confidence, or hardly any confidence in them?”

Gallup polls (Roper Center, 11 June 1976, 19 August 1977, 24 July 1981, 20May 1983, 12 July 1985, 23 September 1988, 8 February 1990, 16 May 1991, 26 June 1992, 19 October 1995, and 4 November 1999); and Gallup/CNN/USA Today polls (Roper Center, 19 July 1993, 23 September 1994, 9 December 1996, 6 November 1997, and 23 October 1998). Question wording: “Please tell me how you would rate the honesty and ethical standards of people in these different fields [medical doctors]—very high, high, average, low or very low.”

Question wording: “Do you think [each of these industries] generally do a good or bad job of serving their consumers?”

Harris poll (New York: Harris Interactive, 19 July 2000).

Question wordings: “Thinking about the last time you saw a medical doctor about yourself, would you say you were very, fairly, not too, or not at all satisfied with the medical care you received?” (1978–1987); and “Thinking about your most recent visit to a medical doctor, would you say you were very satisfied, somewhat satisfied, not very satisfied, or not at all satisfied with the medical care you received?” (1990–2000).

Question wording: “How confident are you that you would have enough money or health insurance to pay for a major illness? Are you very confident, somewhat confident, not very confident, or not at all confident?”

National Election Surveys, “The NES Guide to Public Opinion and Electoral Behavior,” <www.umich.edu/~nes/nesguide/toptable/tab5a_1.htm> (14 September 2000), for 1958–1994, 1996, and 1998; Washington Post/Kaiser/Harvard polls (Roper Center, 28 November 1995 and 30 June 1999); and ABC News/Washington Post poll (Roper Center, 30 March 2000). Question wordings: “How much of the time do you think you can trust the government in Washington to do what is right: just about always, most of the time, or only some of the time?” (1958–1994, 1996, 1998, 2000); and “How much of the time do you think you can trust the government in Washington to do the right thing: just about always, most of the time, or only some of the time?” (1995, 1999).

Gallup/Potomac Associates poll (September 1964); CBS News/New York Times polls (Roper Center, 8 January 1978, 7 November 1980, and 22 April 1981); Council on Excellence in Government/Hart and Teeter Research Companies poll (Roper Center, 16 March 1995); Pew Center for the People and the Press/Princeton Survey Research Associates poll (Roper Center, 25 September 1997); Washington Post/Kaiser/Harvard poll (Roper Center, 10 August 1998); and NPR/Kaiser/Kennedy School poll (26 May 2000). Question wording: (Agree/disagree) “The government has gone too far in regulating business and interfering with the free enterprise system.”

Gallup polls (Roper Center, 16 February 1956, 6 April 1957, 4 March 1959, 10 February 1961, 8 February 1962, 11 January 1963, 28 February 1964, 10 February 1966, 9 March 1967, 12March 1969, 16 February 1973, 14 May 1982, 7 June 1985, 8 March 1990, 28March 1991, 26 March 1992, 29March 1993, and 16 December 1994); and Gallup/CNN/USA Today polls (Roper Center, 9 April 1996, 24 March 1997, 17 April 1998, 6 April 1999, and 7 April 2000). Question wording: “Do you consider the amount of federal income tax you have to pay as too high, about right, or too low?”

Posted by NEJM • August 12th, 2009 • Printer-friendly

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

New England Journal of Medicine – link to original article

Now that Congress has adjourned and most members are back in their own states or districts, they will be listening to what their constituents have to say about the debate over health care reform. We examined the results of 22 recent nationwide public opinion polls (see Recent Opinion Polls on Health Care Reform; polls are cited parenthetically hereafter), working with support from the Kaiser Family Foundation and the Robert Wood Johnson Foundation, to find out what our legislators might be hearing.

On issues such as health care, we believe that public support for change is shaped by the interaction of three factors: people’s perception of problems that affect the country, their assessment of their own current life situation, and their worries about their own future.1 Currently, a majority of Americans are highly critical of the health care system (HSPH June 17), believe it requires major change (CBS July 24), and are very concerned about the problems facing the uninsured (CBS June 12). At the same time, most Americans are satisfied (”very” or “somewhat”) with the quality of the health care they receive (CNN July 31) and most insured Americans are satisfied with their own health insurance coverage (ABC June 18). Even when asked about their own health care costs, more than half say they are satisfied (ABC June 18). In contrast, the uninsured report more problems than insured Americans with their care and with health care costs (HSPH June 17).

Although most Americans are satisfied with their current arrangements, a majority say they are worried (”very” or “somewhat”) about having to pay more for their health care or insurance coverage and are concerned that the quality of care they receive will get worse. Also, a majority of insured Americans say they are worried about losing their coverage (KFF July 7). In addition, nearly half of Americans believe that their federal income taxes are already too high (Gallup April 6).

The public mood today about health care is very similar to what it was at the outset of the 1993 health care reform debate. In 2009, as in 1993, health care is seen as the second-most-important issue for government action, after the economy (Harris May 11).2 More than three fourths of Americans support a major change in the health care system (CBS July 24),2 and more than half favor enactment of a national health insurance program (HSPH June 17).2 The biggest difference is that President Barack Obama has a much higher approval rating than President Bill Clinton did (58% vs. 38%) (CBS July 24 and CBS Aug. 2), which suggests that Obama has more opportunity for leadership.

For most Americans, reform in 2009 means lowering health care costs and providing coverage for the uninsured (KFF Feb. 3). To most people, costs principally mean their own and their employers’ costs, with lower priority placed on solving the country’s aggregate spending problem (KFF July 7). In addition, the public sees a possibility for improvement in the quality of care. Only 38% of Americans believe that health care in the United States is better than that in other industrialized countries, and 27% think it is worse (Pew April 28).

So far, neither the House nor the Senate has passed health care reform legislation. The current debate encompasses several elements that might be in the final legislation, and only a few of these are likely to gain public attention.

One key issue is the appropriate role for government in health care. The public believes the role of government should be expanded: 62% believe the government should exert more control over the health care system (CBS July 9), and 55% believe that the federal government should guarantee health insurance for all Americans (CBS July 24). But Americans don’t believe this increased responsibility should lead to a government-run system, which 58% would see as a negative outcome (QU June 23).

Another major issue is whether a public insurance plan should be offered as a competitor to private plans. Five of the six polls that raised this question show majority support (from 52 to 69%) for a public, or government-administered, health insurance plan (CBS July 24; ABC June 18; KFF July 7; QU June 23; Pew July 22); the sixth shows support of 46% (NBC June 24). Supporters of a public plan hold divergent views about whether the plan should be administered by a government agency (33%) or by an independent organization with government funding and oversight (66%) (ABC June 18).

Then there is the question of mandates. Some reform proposals would require all individuals to have health insurance coverage. Public support for such an individual mandate ranges from 49 to 56% if no mention is made of subsidies for people who cannot afford insurance (ABC June 18; Gallup July 10). If a mandate were to include such subsidies, support ranges from 53 to 70% (CBS July 24; ABC June 18; KFF July 7; Pew July 22). On the other hand, when people are told about penalties that people would have to pay for not having coverage, support drops to 44% (ABC June 18). Public support for an employer mandate, under which employers would be required to offer health insurance to their employees or pay a penalty into a fund, ranges from 61 to 64% (KFF July 7; Pew July 22; Gallup July 10). As for mandates for insurers, support for requiring insurers to cover all applicants, even if they have a preexisting condition, ranges from 75 to 79% (CBS July 24; ABC June 18; Pew July 22).

In terms of paying for reform, 58 to 68% of Americans support raising taxes on people with higher incomes (in some polls, those earning more than $250,000 a year) (Pew July 22; Gallup July 10; KFF June 1); 30% support taxing all employer-provided health insurance benefits (QU June 23), with 25 to 43% in support of taxing only more expensive health plans (Pew July 22; Gallup July 10; KFF June 1); and 33 to 38% support using savings from Medicare to help pay for reform (Pew July 22; Gallup July 10). Support for the use of Medicare savings, however, rises to 53% when the savings come from limiting increases in payments to physicians and hospitals (KFF June 1). Only 32% support increasing the deficit to help pay for health care reform (KFF Dec. 4).

As we examine these key issues, we see that three elements — requiring insurers to cover people with preexisting conditions, increasing taxes on people with higher incomes, and an employer mandate — have widespread public support. Introduction of a public plan as a competitor is supported in most polls, but respondents vary in their beliefs about how such a plan should function. There is widespread opposition to taxing employer-provided benefits and increasing the deficit to help pay for reform. On the other three issues — an individual mandate, an increased role for government, and using Medicare savings — the public is more divided.

These mixed results do not suggest how the public will come down on the questions that will determine their support for health care reform legislation. Other, broader factors will ultimately affect support. For many Americans, three questions remain unanswered: Will reform improve the nation’s health care system? Will their own care get better? Will their own costs become less burdensome?

At this point in the debate, the public has not come to a firm judgment on these questions. About half (47%) think that access to health care in the United States will expand if health care reform passes (Gallup July 24). About 4 in 10 (41%) believe the quality of care in the United States will improve (KFF July 7). The public is divided on the question of how reform will affect health care costs nationally, with one poll showing a plurality thinking that cost growth will slow and another showing a plurality thinking that costs will increase (KFF July 7; Gallup July 24) (see table).

At a personal level, most Americans do not think the current reform legislation will improve their own health care or lower their costs (KFF July 7; Gallup July 24). In addition, more than three fourths believe that their own taxes will increase (Fox July 21). Uncertainty about the potential effect of legislation appears to be leading to volatility in the level of public support for the reform plans of President Obama (with 42 to 56% in support) (NBC July 24; CNN July 31; NPR July 22) and Congress (with 38 to 54% in support) (Pew July 22; ABC July 15).

It is clear that most of the public wants a major change in the health care system. But majority support for a specific legislative proposal will depend on Americans’ believing that they and the country will be better off if such a change is enacted.

Recent Opinion Polls on Health Care Reform*

ABC News–Washington Post polls (July 15–18, 2009; June 18–21, 2009)

CBS News polls (July 9–12, 2009; August 2–3, 1993)

CBS News–New York Times polls (July 24–28, 2009; June 12–16, 2009)

CNN–Opinion Research Corporation poll (July 31–August 3, 2009)

Fox News–Opinion Dynamics poll (July 21–22, 2009)

Gallup polls (July 24–25, 2009; April 6–9, 2009)

Gallup–USA Today poll (July 10–12, 2009)

Harris Interactive poll (May 11–18, 2009)

Harvard School of Public Health (HSPH)–Robert Wood JohnsonFoundation poll (June 17–21, 2009)

Kaiser Family Foundation (KFF) polls (July 7–14, 2009; June 1–8, 2009; February 3–12, 2009)

KFF–HSPH poll (December 4–14, 2008)

NBC News–Wall Street Journal poll (July 24–27, 2009)

National Public Radio (NPR) poll (July 22–26, 2009)

Pew Research Center for the People and the Press polls (July 22–26, 2009; April 28–May 12, 2009)

Quinnipiac University (QU) poll (June 23–29, 2009)

* The Harris Interactive poll is available from Harris Interactive, New York. All other polls are available from the Roper Center for Public Opinion Research, Storrs, CT.

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.

Dr. Blendon reports serving on the board of directors of and holding stock in Assurant, and he and Mr. Benson report receiving grant support from the Blue Cross Blue Shield of Massachusetts Foundation. No other potential conflict of interest relevant to this article was reported.

Source Information

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

This article (10.1056/NEJMp0906392) was published on August 12, 2009, at NEJM.org.

References

Blendon R, Benson J. How Americans view their lives. Challenge 2007;50:5-25.

Blendon R, Benson J. Americans’ views on health policy: a fifty-year historical perspective. Health Aff (Millwood) 2001;20:33-46. [Free Full Text]