Battleground or Common Ground? American Public Opinion on Health Care Reform

William A. Galston,
Bill Galston
William A. Galston Ezra K. Zilkha Chair and Senior Fellow - Governance Studies

Steven Kull, and
Steven Kull
Steven Kull Senior Research Fellow and Director, Program for Public Consultation, School of Public Policy - University of Maryland
Clay Ramsay

October 8, 2009


The health care debate in the United States needs no introduction. It has been an ongoing background debate for decades and periodically comes to the fore when an administration seeks to institute reforms. The effort at reform in the early 1990s produced a frenzy of political activity and the current one is proving to be similar.

Behind much of the debate is the question of whether the United States is exceptional. No other highly developed country in the world has a health care system similar to that in the United States. While the United States excels in advanced medical technology, it leaves the largest percentage of its population uninsured. Questions about how much responsibility the government has for its citizens’ health care go to the core of an ongoing debate in American culture about the role of government and the responsibility of citizens for their own welfare.

In 2008 conducted a poll of 21 nations from around the world, asking people whether they believe that their government is responsible for ensuring access to health care. Americans registered the second lowest number saying that the government is responsible. And yet three quarters said it was. Seven in 10 Americans also said that their government was not doing a good job in ensuring access–the fourth highest of all countries polled in a list that included many developing countries.

One of the key purposes of this study has been to dig deeper into these beliefs. What do Americans mean when they say the government is responsible for ensuring access and why are they dissatisfied with what the government is doing? What would they like the government to do?

The current environment for conducting surveys is unusual if not unique. There has been no shortage of shrill rhetoric about the role of the government in health care, much of it in highly partisan contexts. Has this had an impact on how people view these fundamental questions?

Much polling has been conducted in recent months as the health care debate has heated up. However, a large portion of it has focused on the political dynamics. Support for reform has eroded. Views of the administration have cooled, but views of the Republicans are worse. It is not clear whether these tepid responses are to the actual content of reforms proposed or if they are a reaction to the highly partisan character of the debate. Numerous studies have shown that when the parties fight about possible changes, the public tends to ‘turn off’ and lose confidence in the any of the ideas.

A major factor affecting responses to any government initiative is the general lack of trust in the government, which is at historical lows. When the public does not trust the government it is not always clear whether their lack of enthusiasm for new initiatives reflects a lack of support for the specifics of the initiative or rather a general lack of confidence about the government in general.

A central goal of this study has been to go beyond the responses to the politics and to the government as an institution and to find out more about how people think about the actual proposals.

Some, though not all, of the key reform proposals have been tested in other polls. Often they have been mentioned in cryptic phrases that are clearly understandable only to people who have been following the debate closely. As a result, it is not always clear what less attentive people are assuming when they respond. Some may argue that this does not matter; that the views of the attentive public are all that matters politically.

We have sought to find out more about the values of the public as a whole. In many questions we have made a point of providing clear information about possible reforms, and have presented respondents with the dominant pro and con arguments. Even if many people do not fully understand the debate now, its consequences will become clearer to them if reforms are instituted. Thus it behooves policymakers to seek to understand in advance how Americans really think about these issues when they are clearly presented and better understood.

Existing poll questions based on cryptic but varied descriptions of reform proposals have elicited highly different responses. This suggests that people are trying to use the descriptions of proposals as a way of trying to understand them more fully. Looking at the variance based on wording can be illuminating, but another method, used here, is to provide fuller information explicitly. We have also sought to extend the range of reforms that can be explored.

To begin with, on the controversial public option, little is known about the public’s views on the actual versions circulating in Congress which would make it available, not to all, but only to those who cannot obtain employer-based insurance. How does the public evaluate both a general, and a more limited public option?

The idea of a national health exchange, and also ideas for a national insurance market that Republicans have proposed (including Senator McCain during his presidential campaign), would all require changes in the rules against purchasing insurance across state lines, which are justified by the state’s role as primary regulator of its health insurance industry. When these factors are laid out to the public in pro and con arguments, do they view changing these rules as a good idea?

With the increasing polarization of the debate, has there been an effect on levels of support for placing further regulation on health insurance companies? Are there meaningful divergences on this issue now among Republicans, Democrats and Independents?

Tort reform is a longstanding Republican cause that yet rarely enters the mainstream of debate. But when the public evaluates the arguments, does it think tort reform could make a worthwhile contribution or not? How partisanized is this issue, so long inscribed on the Republican banner?

The idea of an employer mandate—making all but the smallest employers’ provision of health care a requirement, with the choice of contributing to a public fund instead—has been tested with the public many times and benefits from an underlying value that employers have a responsibility where their employees’ health insurance is concerned. However, 2009 is the worst economic year for decades, and many employers are hard-pressed to hold down layoffs, much less increase benefits. Does the economic crisis play into the public’s attitudes—and if so, what is its judgment, all things considered, on an employer mandate?

An element that was already known to be problematic for the public is the individual mandate, which would require everyone to have health insurance—with financial help if necessary, but spurred by a penalty for those who do not comply. While the element of compulsion is known to be unpopular, how does the public respond to the argument that those without insurance use hospitals anyway and their costs are passed through to the whole population?

The idea that savings can be found in the health care system–and especially in Medicare– through streamlining, cutting waste and tracking down fraud and abuse, has given rise to a forceful reply that the health of senior citizens would be endangered by any process of looking for cost savings in Medicare. Does the public think this is true? Do older people? Do people think that Medicare has distinctly more or less waste than private health care?

President Obama has made a commitment that a health care reform package he would sign will not have the long-term effect of adding to the budget deficit. Past polling has shown that majorities believes health care reform will increase the deficit, and also their taxes (which is not the same thing). But what is the real relationship between these beliefs and support or opposition to health care reform? Do most of those who expect a rise in their taxes oppose reform?

One of the familiar battle cries in this and past health care debates is that the US health care system is the best in the world. How many Americans think this is true? Do they think this is true about all, some, or few aspects of their health care system?

To probe for answers to these and other questions about how Americans view health care, and the Brookings Institution conducted a poll among 1400 Americans. The size of the sample answering each question varied, though all had over 800 respondents. The margin of error varied from +/- 2.6 to 3.5 percentage points.

The survey was fielded September 26-October 5, 2009 by Knowledge Networks, a polling, social science, and market research firm in Menlo Park, California, with a stratified random sample of its large-scale nationwide research panel. This panel itself has been randomly recruited from the national population of households having telephones; households without internet access are subsequently provided with free web access and an internet appliance. Thus the panel is not limited to those who already have home internet access. The distribution of the sample in the Web-enabled panel closely tracks the distribution of United States Census counts for the US population on age, race, Hispanic ethnicity, geographical region, employment status, income, education, etc. Upon survey completion, the data were weighted by gender, age, education, and ethnicity. For more information about the online survey methodology, please go to:

Key findings were:

1. The Role of Government in Health Care

Three in five Americans believe that the government has the responsibility to ensure that citizens can meet their basic need for health care; however, this number has declined significantly over the last year, and is no longer bipartisan, presumably in response to the current debate. Three in five also see health care as a right, not a privilege. Views are roughly divided as to whether the government should generally provide health care services directly.

2. Assessments of Current Situation

Two out of three Americans, including clear majorities of all parties, believe that the US government is doing a poor job of ensuring that people can meet their basic needs for health care. A majority thinks that the present health care system is not viable because costs are rising while more people are going onto Medicare. Large majorities are concerned about whether they and Americans in general will be able to get health insurance at a price they can afford. However, there is less concern about the quality of health care: views are divided as to whether, on its present trajectory, health care will worsen.

3. Reaction to Health Care Debate

As the partisan debate has grown more intense, far more people have become less supportive of both parties’ ideas than have become more supportive of the ideas of one party. People express substantial levels of anxiety about the subject of health care. More express fear that the government action will make the health care system worse than express confidence that government action will help. People are divided as to whether the government can afford to reform health care in the current economic environment.

4. Specific proposals

Nearly all of the specific proposals for health care reform are endorsed by a majority. Large majorities favor a public option limited to those who are not receiving insurance through their employer, cross-state purchasing and requiring insurance companies to accept every applicant and to not drop sick people for making a mistake in their original application form. More modest majorities favor tort reform, a public option for all who wish it, an employer mandate, and an individual mandate. A modest majority opposes the government directly providing health care.

4a. Public Option

A majority favors a public option available to all, while three-quarters favor one limited to those who cannot get insurance through their employers. Interestingly, a modest majority of Republicans, as well as large majorities of Democrats and Independents, favors a limited public option.

4b. Cross-State Purchasing

Two-thirds favor the idea of cross-state purchasing, including large majorities of all parties. A large majority finds the argument in favor of cross-state purchasing convincing, while a substantial majority finds the argument against it unconvincing.

4c. Insurance Company Regulation

Overwhelming majorities of all parties favor the government requiring insurance companies to accept every applicant for coverage and prohibiting insurance companies from dropping a sick person because of a minor mistake in his or her application form.

4d. Tort Reform

A modest majority favors the idea of tort reform, including a plurality of Democrats. The argument in favor of tort reform is found convincing by a large majority, while the argument against it elicits a divided response.

4e. Employer mandate

A large majority is convinced by the argument against a proposed requirement that all but the smallest businesses either provide health insurance to all their workers or pay into a public fund to cover the uninsured, but a strong majority also finds the argument for such a requirement convincing. A modest majority favors such a requirement.

4f. Individual Mandate

A modest majority favors requiring all people to have health insurance for themselves and their children, with a subsidy for those who could not afford it and a penalty for those who refuse. Views break along party lines. Interestingly, majorities of both parties find convincing arguments both for and against an individual mandate.

5. Cutting Health Care Costs

An overwhelming majority thinks that it is possible to cut waste, fraud and abuse in the health care system without denying people the treatment they need. Estimates of the magnitude of waste, fraud, and abuse are substantial and approximately equal for private and public health care.

6. Impact of Health Care Reform on Taxes and the Deficit

Six in ten believe that health care reform will lead to at least somewhat higher taxes and that the deficit will increase at least somewhat. Those who believe that taxes and the deficit will go up are less supportive of reform, but only those who believe that their taxes and the deficit will become a lot greater depart from majority positions in support of major health care reforms.

7. Perceptions of US Health Care System

Contrary to frequent assertions in the health care debate that the American health care system is the best in the world, most Americans have more modest and realistic assumptions about how the American health care system compares to other highly developed countries. Most Americans have a good understanding about which health care programs are government sponsored and which are private.

8. Older Americans

Older Americans are generally less supportive than younger people of the government taking on new obligations (obligations that could potentially compete with Medicare). However a majority, albeit a relatively smaller one, does support the idea that the government is responsible for ensuring access to health care, a slight majority favors a generally available public option, and a large majority supports a limited public option. Older Americans report that they are following the health care debate more closely than do persons of other ages; they also express more worry about the issues of health care.