Politics

Americans on Healthcare Reform: Five Key Realities

by Frank Newport, Jeffrey M. Jones, and Lydia Saad

Gallup editors review patterns in data collected throughout the debate

PRINCETON, NJ -- Americans are closely divided on the issue of passing comprehensive healthcare reform, meaning that public opinion offers no real political advantage to either champions or opponents of the idea. That said, a review of Gallup polls conducted throughout the debate reveals five realities crucial to understanding public opinion on this issue.

1. Public Opinion on Healthcare Reform Is Divided, Yet Stable

Thus far, basic U.S. public opinion about healthcare reform has been little changed by the political debate that erupted in town halls this summer or the contentious arguments that have become a staple of television news. Despite this heated discourse and ever-changing estimates of the expected cost and other details of healthcare reform, Americans have remained about evenly divided on the issue of voting new healthcare reform legislation into law.

In early October, Gallup found 40% of Americans saying they would advise their member of Congress to vote for a healthcare bill this year and 36% saying they would advise voting against the bill. That result was little different from an early August reading. A separate and more recent Gallup question -- phrased differently -- also found a roughly equal divide in sentiment once those who were initially unsure were asked which way they leaned.

A number of other polling organizations show the same pattern of split sentiment on the basic question of passing a new healthcare law.

Why such stability? Partisanship is part of the answer. It appears that Republicans and Democrats dug in early on either side of the issue and have held their ground. Independents have also been remarkably fixed in their reaction, with perhaps a slight increase in support in recent weeks.

This year's relative stability contrasts with the pattern in 1994, when public opinion about President Clinton's healthcare reform initiative shifted from a solid majority in favor in January to a solid majority opposed by July.

There is an additional explanation for the current stability in healthcare attitudes. Data suggest that Americans may be more focused on the ideological underpinnings of healthcare reform than on the minutiae or specific elements that are the primary focus of ongoing debate and discussion. Gallup research has shown that supporters generally favor a new law because they want to expand coverage to the uninsured. Opponents are most likely to say they are against a new law because of worries about increased government involvement in healthcare. Both types of explanations are fundamental concerns, rather than quibbles with specific features of proposed legislation.

Reinforcing the concept of relative stability in Americans' attitudes toward the healthcare system, Gallup finds that Americans are not dramatically more likely today than they have been for much of the decade -- or as far back as 1994 -- to believe the U.S. healthcare system is in a crisis or has major problems.

Bottom Line: Americans' positions on healthcare reform appear to be fairly entrenched. It does not seem likely that the continuing debate as a bill makes its way toward the president's desk is going to change those attitudes dramatically. If and when a new bill is passed into law, it is likely that not much more than half of the American adult population will support it.

2. Americans Do Not Have a Strong Sense of Urgency About Passing Healthcare Reform

Americans have become somewhat more likely to mention healthcare as the nation's most important problem this year, and a recent USA Today/Gallup poll found more Americans saying healthcare should be President Obama's top priority than did so last November. However, in both of these instances, the economy continues to dominate healthcare and all other concerns. In particular, Americans are about as likely to select the situations in Iraq and Afghanistan or the federal budget deficit as Obama's top priority as they are to select healthcare. And all three issues rank well below the economy.

Given a choice in one recent Gallup survey, less than half of Americans say Congress should pass reform this year rather than at some point in the future.

And when asked whether it would be better to enact comprehensive reform this year or reform the system more gradually, the majority of Americans opt for gradual reform.

All of these findings, coupled with the fact that Americans are not convinced that a new healthcare law would benefit them personally (to be discussed below), underscore the conclusion that the average American is not suffused with a pressing sense of urgency to see wide-ranging healthcare reform legislation passed immediately.

Bottom Line: The apparent lack of urgency on Americans' part to fix healthcare stands in contrast to the continuing sense of urgency evinced by the president and other reform advocates. Proponents may argue that this is an area in which elected leaders need to lead, not follow, public opinion. Opponents may argue, on the other hand, that passing a major new healthcare reform bill over the objections of close to half of Americans is overreaching.

3. Self-Interest Is Only Part of the Story

The substantial majority of adult Americans have health insurance, meaning that on a relative basis, few Americans are likely to support healthcare reform specifically because they personally are in direct and immediate need of obtaining health insurance. Additionally, the majority of Americans who have health insurance appear to be satisfied with it.

Gallup research shows that even among the relatively small group of adults without health insurance, fewer than half would advise their member of Congress to vote for new healthcare legislation, while the rest either would advise their member to vote against it or are unsure. Thus, even among the uninsured -- those who in theory would be most likely to believe they would personally benefit from healthcare reform -- self-interest is not necessarily the driving force behind their political views on healthcare.

Eight in 10 Americans say they are satisfied with the quality of their own medical care. Fairly small percentages of Americans who currently have health insurance say they have experienced major problems with reductions in what their insurance plans cover or with insurance paperwork. Healthcare costs emerge as a greater concern for Americans, but mainly on a relative basis. Forty-six percent of Americans say the cost of medical care is a major problem for them, and 38% are dissatisfied with their own healthcare costs.

Similarly, and importantly, relatively few Americans believe various aspects of their own healthcare coverage or medical care will improve under healthcare reform. Most believe their healthcare either will not change or will in fact worsen, with close to half expecting their costs to increase. Fewer than half of reform supporters believe that if a new healthcare bill passes this year, it would benefit them in terms of cost, quality, coverage, or insurance company requirements. In other words, at least half of Americans who support a bill are doing so for reasons other than the belief that it will benefit them personally. By contrast, large majorities of Americans who oppose healthcare reform believe the bill would negatively affect all four aspects of their own health insurance coverage.

These findings on the perceived impact of healthcare reform on Americans' personal situations are robust, and have been replicated across a number of different surveys conducted by different organizations.

When healthcare reform supporters are asked to provide their reasons for favoring legislation, nearly half of the reasons they give have to do with providing access for those who don't have it. Another 16% cite needing to fix the system, generally, or control costs. Only 7% say they personally or a family member needs healthcare coverage. Additionally, 8% say healthcare reform would help control costs, something that could have a personal benefit.

Finally, Gallup polling in recent years has consistently shown that a majority of Americans believe it is the government's responsibility to make sure all Americans have healthcare coverage.

Bottom Line: It may be surprising to some that even close to half of Americans support the concept of new healthcare legislation when far fewer than half appear to believe that such a new bill will benefit them personally. Others may argue from a positive perspective that Americans are willing to support the idea of legislation that, while it doesn't help them, may help others.

4. Specific Elements of Healthcare Reform Have Strong Appeal; a Few Do Not

President Obama has remarked that there is widespread agreement in Washington on certain aspects of reform, such as requiring insurance companies to cover those with pre-existing medical conditions, prohibiting insurance companies from dropping those who get sick, and providing assistance to lower-income Americans to help them obtain insurance. Despite lukewarm support for a new healthcare bill in general, existing polling from Gallup and other firms finds Americans expressing strong support for provisions such as these, or saying these are highly important to include in healthcare legislation.

The public also seems to favor requiring employers to provide health insurance to their employees, or to pay fines for not doing so.

But the fate of the healthcare legislation may ride on some of the more controversial provisions, the most notable being whether Americans would be able to purchase a government-sponsored insurance plan that would compete with private insurance plans. Gallup recently found the public essentially divided on this, with 50% in favor of including a government plan and 46% opposed. Other polls have shown slightly higher support for the "public option," results that no doubt partly reflect some confusion among Americans about such a plan.

Gallup has tested various proposals that have been suggested as ways to pay for healthcare reform. The most popular appears to be the imposition of income-tax surcharges on upper-income Americans (Gallup polling has usually found majority support for raising taxes on upper-income Americans to pay for government programs, such as Social Security reform, for example). Americans have shown consistent opposition to reducing Medicare payments, and also to taxing insurance plans that offer the most generous benefits.

Bottom Line: Emphasizing the most popular aspects of healthcare reform -- of which there are several -- could potentially help reform proponents expand public support for the plan more generally. This assumes Americans are not already fully cognizant that healthcare reform would achieve these objectives. Alternatively, Americans may already well appreciate these benefits, but have overriding reservations about other aspects of the bill, such as the cost.

Additionally, Americans may harbor doubts about how well government and healthcare bureaucracies can implement a highly complex new set of laws encompassing a large segment of the U.S. economy. This "practical" doubt is reinforced by recent data showing that Americans give Congress a low job approval rating, have relatively low levels of trust in the federal government, and believe that about half of all federal tax dollars are wasted.

5. Obama Retains the Upper Hand

Although passage of healthcare legislation is far from assured, President Obama has helped move healthcare reform far down the legislative track. Americans say they trust the president more than the Democrats or Republicans in Congress on the issue, and he is the only one of these three major political actors whom a majority of Americans trust. These findings are underscored by the fact that the president's job approval ratings have been running more than 20 points higher than job approval ratings for Congress.

However, at 55%, trust even for Obama is not overwhelming. And as of mid-September, a majority of Americans said they disapproved of the way Obama was handling the healthcare issue (43% approved, similar to what Gallup found in prior readings).

Americans have more confidence in President Obama than in the insurance and pharmaceutical companies that are lobbying so hard in Washington. They have roughly the same confidence in Obama as in hospitals and healthcare professors or researchers. Only doctors generate significantly more confidence on healthcare than does Obama.

Bottom Line: One major advantage held by the proponents of healthcare reform is political -- healthcare reform has a more popular communicator in President Obama than the opponents of healthcare reform have in congressional Republicans. And of course, from a practical perspective, if the Democratic Party can hold together its majorities in both houses of Congress, it would be assured of passing healthcare legislation.

More broadly, six months of polling on healthcare reform has left even some seasoned political analysts scratching their heads about what Americans really want Washington to do on the issue. As reviewed above, most Americans say the healthcare system has major problems or worse, and they believe fixing healthcare needs to be a priority. Still, Americans are closely divided in their preferences for passing a healthcare reform bill, are skeptical of Obama's promise to make reform revenue neutral, and would prefer to pass healthcare reform gradually, rather than this year.

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