As health care reform enters the phase of serious legislation, it becomes vital to understand what the American people expect and believe ... and how the forthcoming debate is likely to affect their views. Because no one has tracked these matters more carefully and professionally than the Kaiser Family Foundation, I reviewed a number of documents they've published during the past eight months and supplemented their findings with other credible sources. What I found suggests that little happened, during either the campaign or the first four months of the Obama administration, to educate the people about the real choices their elected representatives now face. As the discussion of legislative options becomes more precise, the people will be in for some rude surprises--and advocates of fundamental reform will have a harder time making their case than they now believe.
I take as my point of departure a survey Kaiser conducted in October of 2008, on the threshold of the presidential election. It shows that twice as many voters cared about making health care and health insurance more affordable as about expanding coverage for the uninsured, and that only one in ten gave high priority to improving the quality of care and reducing medical errors. Not surprisingly, voters were very concerned about increases in their health insurance premiums and other out-of-pocket costs--indeed, more concerned about this than about increasing employer, government, and national spending combined. It is hard to avoid the conclusion that in evaluating proposed health reform legislation, voters will be looking first and foremost at its impact on their own pocketbooks, with broader issues trailing well behind.
I looked next at Kaiser's first 2009 health care tracking survey, issued in February 2009. It found that while 59 percent of respondents thought that reform would make the country as a whole better off, only 38 percent believed that they and their families would benefit. To be sure, a plurality thought that they wouldn't be affected much, one way or the other. Still, "it won't hurt you" is not exactly a ringing reform slogan, especially in the context of the survey's other striking finding: 58 percent believed that "if policymakers made the right changes, they could reform the health care system without spending more money to do it." If the people mean what they say, they are likely to regard requests for additional funds as evidence that Congress has made the wrong changes--that is, unless President Obama and congressional leaders explain why health reform cannot succeed without substantial upfront investments.
This brings me to the April tracking survey. It showed that respondents think reforming health care is only the fourth most important priority (on a list of eight), behind improving the economy, stabilizing Medicare and Social Security, and reducing the federal budget deficit. It is hardly surprising that partisans divide sharply: Democrats rank health reform second from the top, Republicans second from the bottom. Independents, whose ranks have swelled since the election, place it fifth.
As for financing options, majorities support increasing taxes on cigarettes, alcohol, and "unhealthy snack foods" but not soda and soft drinks, which experts regard as major contributors to the rising tide of obesity. (When those who favored this approach heard the argument that so-called "sin taxes" would hit low-income people the hardest, however, six in ten changed their minds and opposed it.) As for taxing employer-provided benefits, a solid majority are opposed, even when they are told that only the "most generous" benefits would be affected.
In mid-May, Kaiser's respected CEO Drew Altman published a short piece entitled "The Experts versus The Public on Health Reform," which should be required reading for everyone involved in this enterprise. Among his key points:
- While experts believe that up to 30 percent of medical care is unnecessary, 67 percent of the people say that Americans don't get the tests and treatment they need, and only 16 percent say that they themselves have received unnecessary care.
- While experts say that technology and not enough consumer "skin in the game" are principally responsible for high and rising health care costs, the people blame drug and insurance companies.
- While experts believe that there are huge differences among doctors in quality of care, 70 percent of the people disagree.
- While experts argue that health IT is critical if we are to improve quality, minimize errors, and reduce costs, more than three times as many people believe it will raise costs as lower them, and most of them have privacy concerns as well.
- While experts tout comparative effectiveness research, 55 percent of the people say their insurers should pay even if their doctor recommends a treatment that has not been proven to be more effective than a cheaper one.
Consider, finally, the proposition that all individuals, including those who are young and healthy, should be required to purchase health insurance. Most experts and policymakers agree that without this "individual mandate," insurance companies will continue to screen out prospective beneficiaries with preexisting conditions and other discouraging health profiles, and the linchpin of current reform proposals will snap. Unfortunately, the people don't agree: A Rasmussen survey published in late May indicates that only 31 percent of Americans favor requiring everyone--including young adults and those in good health--to purchase insurance. And when they were asked what should happen when those who choose not to buy insurance end up in emergency rooms, three quarters say they should receive treatment even if they can't pay.
I don't mean to suggest that in cases of disagreement the people are necessarily wrong and the experts right. For example, the case often made for the benefits of health IT may well be wildly overblown, and CBO has indicated that it will score savings from this source very conservatively. My point is rather that when the outlook of average Americans diverges so sharply from that of officialdom, reform proposals are likely to prove hard to explain, or even harder to justify. And if the people really believe that they can get reform without paying for it, then reformers are cruising for a bruising.
It's not the people's fault. Up to now, candidates and elected officials have been expansive about benefits and virtually silent about costs. When John McCain proposed taxing employer-provided benefits during last year's presidential campaign, Barack Obama slammed the door on the idea with a vehemence that some of his advisors are said now to regret. In a recent White House meeting, the president himself--bowing to the laws of arithmetic--quite deliberately reopened that door.
This is a first step toward reality, but it's only a start. It's time to begin leveling with the people about the choices they face if we are finally to achieve universal health insurance with meaningful cost containment. On a matter that touches every American directly, agreement among stakeholders and elected officials is not enough. The people themselves must be brought into the discussion, and they must understand--in advance--what they are being asked to accept. The alternative to candor, however risky it may appear in the short-term, could be yet another catastrophic failure.
William Galston is a former policy advisor to Bill Clinton and current senior fellow at the Brookings Institution.