Health Care Reform: What do People Really Want?

Humphrey Taylor is Chairman of The Harris Poll.  Prior to joining Harris, Taylor worked in Britain where he conducted all of the private political polling for the Conservative Party and was a close adviser to Prime Minister Edward Heath in the 1970 campaign and subsequently to Margaret Thatcher.

What do people really think about health care reform?  When political issues are difficult and complicated, published polls sometimes confuse rather than enlighten the debate.   And health care reform is fiendishly complicated, with many different issues and many different proposals for addressing them.  No wonder that the debate is generating more heat than light.  This is surely one of the times when political leaders should lead rather than follow public opinion.  As Winston Churchill once said, “The problem with politicians who keep their ear too close to the ground is that it is difficult to look up to them in that ungainly posture.”

While policy makers have to address the details of the proposed policies, most people do not.  They know what they want, or don’t want, but have only a very limited understanding of which policies will actually achieve their aims.  They are often strongly influenced by political rhetoric that varies from the accurate to the simplistic to the completely false. Many different words and phrases are used to describe different policies.  It is unreasonable to expect the public to understand the details of the proposed reforms or how they work in practice.

However, if you study all the polls, as opposed to cherry picking them as many politicians do, a  clear picture of public opinion emerges:

  1. Most people are unhappy with the current health care system and favor reform.  They want to have a system that gives them affordable access to quality care for the rest of their lives.  International surveys show that Americans are more dissatisfied with the U.S. health care system than are people in all, or almost all, other developed countries.
  2. Most people think that some kind of government intervention is needed to fix the system, to expand coverage, and to contain costs.  However, support for government intervention does not, in most case, translate into support for a “government-run” system.  (Though what people understand by that phrase is far from clear.)
  3. While most people believe that fundamental changes are needed in our health care system, only a minority wants to completely rebuild it.  Most people favor building on the present system and the bits of it that seem to work well.
  4. There is substantial support for health care reform not only among the public but from large majorities of almost all major interest groups.  Only small minorities of doctors, employers or insurers think that the system works pretty well now.  However, they also have different interests and tend to see very different problems and support or oppose different proposals.
  5. Most people are at least reasonably satisfied with their own health insurance (if they have it) and with the quality of care that they receive.  However, that does not mean that they like the system.  Most people believe that the costs are too high and that everyone should be covered.
  6. More people think that both the total cost and the out-of-pocket costs of care are too high, but their perceptions of why this is so are different from those of most health economists.  They often blame greedy insurers and pharmaceutical companies and think there is a lot of fraud and abuse.  But they are less likely to focus on over-utilization, the impact of fee-for-service incentives and the relatively (compared to other countries) high price of medical services.
  7. Few people seem to worry much about the unfunded liability for Medicare that economists tell us is a huge problem.
  8. Proposals that people believe will take away the health insurance they have now, or force them to change doctors, that “ration” care, or prevent them from getting the treatments they think they need are deeply unpopular.
  9. There is no consensus on the appropriate roles of the government, employers and individuals.  Half of the population thinks that health insurance and health care should be “an entitlement paid for by taxes,” while a third believes that it should be like other products and services, where you get what you can pay for.
  10. Republicans and Democrats are highly polarized on many aspects of reform.  Most Democrats think that this is a very important issue and focus on expanding coverage and limiting out-of-pocket costs.  They tend to favor an expanded role for government.  Most Republicans focus on cost containment and oppose a bigger role for government.  Democrats are much more likely than Republicans to think that health care is a “right.”
  11. There are many things that many people do not want.  They do not want to pay much higher taxes and out-of-pocket costs.  They don’t want to damage the economy or increase unemployment.  They dislike the idea of rationing and oppose anything that they think might reduce the quality of their care or limit their choices.
  12. Most people do not think or talk about the issues that are the focus of much debate among policy wonks, think-tanks, and legislators.  They rarely mention health information technology, comparative effectiveness reviews, a health information exchange, reimbursement reform, pay-for-performance, quality measures, or outcomes research.  When asked about these issues, the public’s replies vary dramatically, depending on whether the language used is that of the proponents or opponents of proposals.  For example, a new agency to provide information on which treatments work better or worse sounds pretty good – but not if it is used to deny care that a doctor or patient wants.
  13. Most people do not seem to see a conflict between giving patients every test and treatment they and their doctors  want, however expensive, and containing costs.

As a pollster, I believe that it is unreasonable to expect the public to understand health care reform policies because the issues are so tough and so complicated.  As H.L. Menken wrote, “For every complex and difficult issue, there is a simple solution – and it is wrong.”  The enormous complexity of the issues and the emotional public response to misleading political rhetoric, make one think fondly of Bismarck’s famous maxim that the public should not be allowed to watch the making or sausages or laws.  We should also remember that almost all health care systems in all countries seem to be almost permanently “in crisis” and that no matter what reforms are implemented, the demand for more reform – like death and taxes – will always be with us.  Democracy may be better than all alternatives but it sure is messy.

Humphrey Taylor is Chairman of The Harris Poll, Harris Interactive.  Prior to working at Harris Interactive, Taylor worked in Britain where he conducted all of the private political polling for the Conservative Party and was a close adviser to Prime Minister Edward Heath in the 1970 campaign and subsequently to Margaret Thatcher. In 1970, Taylor’s firm was acquired by Louis Harris and Associates, and Taylor took responsibility for building the Harris organization’s international business. In 1976, he moved to New York. He was appointed president of Harris in 1981, chief executive officer in 1992 and chairman in 1994.

Taylor has testified to congressional committees and subcommittees on Social Security, health care cost containment, Medicare, aging, policies affecting the disabled, drug exports, taxation of employee benefits and privacy. He has presented on these subjects in the White House and on Capitol Hill. He has published many articles and papers on survey research and public policy, he has also written editorial page articles for the New York Times, Wall Street Journal and the London Times. Taylor has been a guest lecturer at the University of California at San Francisco, the Kennedy School and the School of Public Health at Harvard, Oxford, New York University. He writes a weekly column that is syndicated in over 100 newspapers, and he broadcasts frequently on radio and television. He is the author of chapters on opinion polls in two leading textbooks on marketing research in both the United States and Europe (published by AMA and ESOMAR).

A few Harris polls on health care (PDFs):

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