As health care reform enters the phase of serious legislation, it becomes vital to understand what the American people expect and believe … and how the forthcoming debate is likely to affect their views. Because no one has tracked these matters more carefully and professionally than the Kaiser Family Foundation, I reviewed a number of documents they’ve published during the past eight months and supplemented their findings with other credible sources. What I found suggests that little happened, during either the campaign or the first four months of the Obama administration, to educate the people about the real choices their elected representatives now face. As the discussion of legislative options becomes more precise, the people will be in for some rude surprises—and advocates of fundamental reform will have a harder time making their case than they now believe.
I take as my point of departure a survey Kaiser conducted in October of 2008, on the threshold of the presidential election. It shows that twice as many voters cared about making health care and health insurance more affordable as about expanding coverage for the uninsured, and that only one in ten gave high priority to improving the quality of care and reducing medical errors. Not surprisingly, voters were very concerned about increases in their health insurance premiums and other out-of-pocket costs—indeed, more concerned about this than about increasing employer, government, and national spending combined. It is hard to avoid the conclusion that in evaluating proposed health reform legislation, voters will be looking first and foremost at its impact on their own pocketbooks, with broader issues trailing well behind.
I looked next at Kaiser’s first 2009 health care tracking survey, issued in February 2009. It found that while 59 percent of respondents thought that reform would make the country as a whole better off, only 38 percent believed that they and their families would benefit. To be sure, a plurality thought that they wouldn’t be affected much, one way or the other. Still, “it won’t hurt you” is not exactly a ringing reform slogan, especially in the context of the survey’s other striking finding: 58 percent believed that “if policymakers made the right changes, they could reform the health care system without spending more money to do it.” If the people mean what they say, they are likely to regard requests for additional funds as evidence that Congress has made the wrong changes—that is, unless President Obama and congressional leaders explain why health reform cannot succeed without substantial upfront investments.
This brings me to the April tracking survey. It showed that respondents think reforming health care is only the fourth most important priority (on a list of eight), behind improving the economy, stabilizing Medicare and Social Security, and reducing the federal budget deficit. It is hardly surprising that partisans divide sharply: Democrats rank health reform second from the top, Republicans second from the bottom. Independents, whose ranks have swelled since the election, place it fifth.
As for financing options, majorities support increasing taxes on cigarettes, alcohol, and “unhealthy snack foods” but not soda and soft drinks, which experts regard as major contributors to the rising tide of obesity. (When those who favored this approach heard the argument that so-called “sin taxes” would hit low-income people the hardest, however, six in ten changed their minds and opposed it.) As for taxing employer-provided benefits, a solid majority are opposed, even when they are told that only the “most generous” benefits would be affected.