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. After a year of debate, in which health care policy was covered in the media almost daily, very few people are even moderately well informed about the details of the proposals for health care reform. But many of them have strong opinions. Most people, our data would suggest, are confused, conflicted, clueless and cranky: confused because of the complexity of the many issues that are on the table; conflicted because they often favor policies that are mutually contradictory; clueless because they don’t know, let alone understand, most of what is being proposed; and cranky because Washington has failed, yet again, to provide a health reform bill they like.
The mind-boggling complexity of the system and the proposed reforms provide plenty of opportunities to attack the proposals, however unfair or unreasonable they may seem to advocates of reform. Critics say the proposed reforms would lead to a government take-over of the system, higher taxes, less choice, lower quality, higher unemployment and rationing.
Confused? One huge problem is that the American health care “system,” as it is euphemistically called, is fiendishly complicated. Health insurance coverage is provided by Medicare, Parts A, B, C, D, Medicare Advantage, Medicaid, employers and their insurance plans, the V.A., D.O.D., FEHBP, SCHIP, WIC, the Indian Health Service, community clinics, HMOS, PPOs, and the individual insurance market. There are state regulated and ERISA plans. Important federal government health care agencies include HHS, CMS, AHRQ , CDC and NIH. There are solo, small and large practices, single and multi-specialty groups, and integrated medical systems. Hospitals and doctors employ huge numbers of people at great expense to figure out how to get reimbursed by insurers, Medicare and Medicaid, and how to deal with uncompensated care.
Physicians are paid on a fee-for-service basis, by capitation, and by salaries, and can receive bonuses and pay-for performance incentives. These payments come from thousands of different health plans, each with its own rules as to what is reimbursed and how.
Complexity of reform proposals
A benign dictator who wanted to reform the health care system might decide to scrap it completely and replace it with a simpler system that would be much easier to understand, much less expensive to manage and much easier to improve. But most Washington watchers who understand the politics of health care policy believe that this is politically impossible. Too many powerful interests are involved. Therefore, most major reform proposals with significant support build on the system we have now rather than replace it. They would keep employer-provided insurance, private sector health insurance, Medicare, Medicaid, the V.A., the D.O.D., and the other third-party payers. They would keep the many government agencies that manage and regulate different parts of the system.
And then, as if the system is not complicated enough, the congressional proposals would add more complexity, new agencies, and new regulations. One or both of the House and Senate bills would create individual and employer mandates, with new subsidies for some employers and low-income individuals, reduced subsidies for Medicare Advantage, a “public option” to compete with private sector insurance, new taxes on “Cadillac plans” and the rich, the barring of medical underwriting based on health status (pre-existing conditions and recision), and health insurance exchanges. Those proposals would encourage, expand and make use of electronic medical records, electronic prescribing, and other health information technologies, comparative effectiveness research, quality measures, price transparency, wellness programs, “medical homes,” patient-centered care, evidence-based medicine and outcomes research.
Another whole layer of complexity relates to the need for fundamental reimbursement reform. Our 2008 survey of health care opinion leaders for the Commonwealth Fund found a large majority who believed that this is the most important step that needs to be taken to improve the efficiency of the system and quality of care. Reimbursement reform means changing “perverse incentives” in the way that doctors are reimbursed, reducing fee-for-service payment and moving to bundled payments, payments for episodes of care, capitation or salaried physicians. Experts argue that this would require many more accountable care organizations (ACOs) and medical homes.
Are your eyes glazing over? There are probably only a few thousand health care policy wonks who fully understand all the complexity of our system and of the proposed reforms.
What most people don’t know or don’t understand
In addition to the unbelievable complexity of the health care system and reform proposals, there are some simple and very important factors that most people do not think or talk about, and probably do not believe.
Most health care economists believe that present cost and coverage trends are not politically or economically sustainable. They believe that we will have to make really tough choices as we try to satisfy potentially infinite demand with finite resources. For how long can health care spending increase 2½ times faster than GDP? How many more uninsured people will we tolerate?
Some political leaders and media seem to encourage this ignorance and the simplistic belief that if only their policies were adopted we could have it all – access to high quality care at an affordable cost with no new taxes, and secure access to all needed services for the rest of our lives. Most people seem to believe that it would be possible for everyone to have access to all the wonders of modern medicine without much higher taxes or other costs. Most people believe that insurers should insure anyone who wants insurance, without requiring the young and the healthy to buy insurance. Adverse selection and moral hazard are not just incomprehensible insurance jargon; few people have ever thought about the concepts.
A recent Pew survey found that only two percent of all adults could correctly answer twelve very simple questions about politics (e.g., how many Senate votes are needed to break a filibuster; who, of four well-known politicians is the Senate Majority leader). One can only speculate as to what percentage of the public would pass a similar test of “health reform literacy.”
Most people believe that the health care system “has so much wrong with it that fundamental changes are needed.” They believe health care costs too much and that everyone should have health insurance. So where’s the conflict? The problem is that many people tend to support contradictory positions. They oppose cutting benefits but don’t want their taxes , their out-of-pocket costs, or their premiums to increase. They believe that everyone should have affordable access to every test, treatment and procedure that they or their doctors want but don’t stop to think what this would cost or how it would be paid for. They favor universal coverage but oppose an individual mandate. They favor an employer mandate but don’t want to make it more expensive for employers to hire people. They favor a “public option” but oppose a “government-run insurance plan.” They believe every patient should have access to high quality care, but don’t think the young and the healthy should to have to pay for it.
It is tough to win public support for proposals when very large numbers of people are misinformed and believe many of the strange criticisms made by those opposing reforms. In recent polls, two-thirds (65%) of the public believed that “the proposed reforms would result in a government-run health care system,” even though the reforms would greatly increase the number of people with private sector insurance. More than half the public believed that the proposed reforms would “reduce the choices many people have now” (55%), that health insurance would be “too expensive for many people to buy” (52%), or “would make it harder for many people to get the care they need “ (51%). A 45% to 30% plurality believed that “the proposed reforms would hurt Medicare.” And more than a third (37%) that the “proposed reforms would create death panels that would decide who should live and who should die.”
The public was split 41% to 41% as to whether health care would be “rationed,” and do not realize that we already ration care by reimbursing or not reimbursing it. Large minorities believed that “Medicare will be phased out” (32%), that the “plan promotes euthanasia to keep costs down (25%), and (where did this come from?) that “the government will be able to access individual bank accounts to help pay for services” (23%).
The polls sometimes mislead their readers by suggesting that people already have opinions when they ask questions about the details of the policy. These polls can be useful; they can test the public’s reactions to issues and policies and the language used to present them. But reactions to a question do not mean that people actually had opinions on the issue (let alone understood it) before they were surveyed. However, most people do have opinions about health care reform, even if they do not know much about what is being proposed.
What is striking now is the contrast between the large 78% majority of the public who thinks that “fundamental reforms are needed” or that the “system needs to be completely rebuilt” and the hostility to the proposed reforms. Attitudes to proposed reforms seem to have much more to do with the popularity of who is proposing them than what is being proposed. In September 2009, we found that a 53% majority thought that President Obama’s proposed reforms were “a good thing” while a 54% majority believe the proposals of the Democrats in Congress were “a bad thing.” But what was the difference between their policies? Since September, support for the president’s proposals has declined along with his job rating. And while the Democratic proposals are unpopular, the Republican proposals (whatever they are) are much more unpopular.
The polling data underline the truth of the advice to “keep it simple, stupid.” Unfortunately, the system we have now is absurdly complicated and health care reform could only be simple if we nuked the system we have and re-built it from scratch. And that won’t happen.
Rhetoric trumps substance. In the absence of a simple, comprehensible reform, it is easy to criticize any package of reforms. People who are misinformed and have little understanding of what is actually being proposed often hold very strong opinions.
The introduction of Social Security and Medicare (which were bitterly opposed at the time) involved relatively simple concepts that could be explained to most people. The health reform proposals now on the table, and some of those proposed in the past, cannot. This helps explain why so many presidents, Democratic and Republican, have failed to pass substantial health care reform that would greatly reduce the number of uninsured and help contain costs.