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Between 1991 and the summer of 2007, about 90% of Americans were fairly consistent in agreeing that the U.S. health care system should be completely rebuilt or required fundamental changes (see line graph). About 70% of Americans consistently believed that the system was in a state of crisis or had major problems (see line graph), and the proportion dissatisfied with it had increased to 81% by November 2007. Despite this negative consensus, however, there is no convergence on proposals for reform. Instead, public opinion is characterized by ambivalence or divergence regarding future directions, which may foil efforts to forge agreement on the best way to improve the system.
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Survey questions posing alternative options may be more revealing. When given a choice between "replacing the current health care system with a new government-run health care system" and "maintaining the current system based mostly on private health insurance," 51 to 63% of respondents in five Gallup polls conducted since 2001 said they preferred to maintain the current system, though the proportion had declined to about 48% in November 2007.
Even supporters of reform may be uneasy with government intervention, which makes their endorsements unreliable. Although a 2006 poll conducted by ABC News, the Kaiser Family Foundation, and USA Today found that 56% of Americans favored government health insurance over the current system, support eroded when these respondents were told that such a program could mean reduced access to some medical treatments (64% of initial supporters became opponents), limits on the choice of doctors (49% became opponents), increased waiting times (40% opposed), and greater cost sharing (36% opposed). Whether these downsides would actually materialize and, even if they did, how much the resulting system would differ from current managed-care practices are matters of debate. The point is that public perceptions appear fragile and susceptible to change.
Despite their conservative leanings, Americans are also pragmatists who favor the use of concrete government programs to address specific threats to citizens. In nine Gallup polls conducted since 2000, the majority (59 to 69%) of respondents have favored the idea of the federal government taking responsibility for ensuring that all Americans have health care coverage. In 11 surveys conducted between 1980 and 2000 by the New York Times and CBS News, 10 found majorities of 50 to 66% in favor of national health insurance, financed by tax money, that would pay for most health care services. And about 70% of Americans continued to support the State Children's Health Insurance Program even after President George W. Bush vetoed its expansion, an action that could have polarized public opinion of the program and diminished overall support.
Decision makers and experts in health policy decry rising costs, but a cross-section of the public has apparently concluded that the government doesn't spend enough on health care. At least 61% of respondents in surveys by the Pew Research Center and by the New York Times and CBS News have indicated that they believe that the average American spends too much on health care and that their own personal health care costs are high. Large majorities look to government to reduce the burden on household budgets: 70% of Pew survey respondents believe that the government spends "too little," and only 11% think it spends "too much."
Discussion of the public's attitudes toward health care reform too often misses these contradictory strains. An accurate assessment requires recognition of Americans' multiple and competing considerations, which will affect the debate over the government's role in health care during the presidential campaign.
Republican candidate John McCain's proposals for using tax credits for health insurance and taking other incremental steps toward improving the system may convey that he understands health care's importance to Americans. Yet many Americans question whether he is adequately addressing such pragmatic concerns as the burden of paying for health insurance premiums, deductibles, and other charges. Indeed, his focus on consumer choice may actually increase the visibility and burden of costs that fall on individuals. Democratic criticism that McCain's proposals fail to alleviate the burden of price on Americans may well resonate with many Americans who believe that government should spend more to relieve the pressure on family budgets.
By contrast, Democrats Barack Obama and Hillary Clinton seek to mitigate anxiety about inadequate coverage and high costs by covering all or large segments of the uninsured population through mandates on individual taxpayers and businesses, expansions of government programs, and regulation of private insurers. Although both candidates plan to build on the employer-based system and are trying to avoid the wide scope and government visibility that characterized President Bill Clinton's 1993 plan, their plans for comprehensive change may overreach. Republican criticisms of the Democrats' "big-government" proposals could activate Americans' entrenched conservatism and uneasiness about government intrusion.
Health care reform efforts have been undermined not only by Americans' ambivalence toward government but also by the split between public dissatisfaction with the overall system's performance and patients' satisfaction with personal health care. Whereas more than 70% of Americans are quite negative about the country's coverage and costs, less than 40% are disappointed with their own circumstances. A mere 15% complain about the quality of care they receive.
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Presidential campaigns are ill-suited to the task of designing policy reforms, but they represent critical periods for setting an incoming administration's agenda. Without a dramatic change in public sentiment, Democrats and Republicans face daunting obstacles in rallying broad support for particular reforms.
Still, although public opinion influences legislators' agendas and the broad contours of policy objectives, even strong public opinion cannot unify polarized decision makers. Broad agreement by those in power on an approach to reform, as well as on critical details, is necessary. It is worth remembering that Medicare was passed in 1965 despite support from only 46% of the public.3
No potential conflict of interest relevant to this article was reported.
Source Information
Dr. Jacobs is the director of the Center for the Study of Politics and Governance at the Humphrey Institute of Public Affairs and a professor in the Political Science Department at the University of Minnesota, Minneapolis.
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