The Health Care Reform Paradox

The Health Care Reform Paradox

By David Paul Kuhn - August 13, 2009

Americans are of two distinct minds on health care reform.

Most Americans continue to support major reform. But multiple polls show they are also overwhelmingly satisfied with the quality of their personal medical care, as well as their insurance coverage.

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This health care reform paradox is the core reason why Democrats are finding it increasingly difficult to rally the public behind their dramatic effort to overhaul the nation's medical system.

About three-in-four Americans believe the nation's health care system requires major reform. Most Americans view U.S. health care as flawed.

But public support for reform significantly declines when associated with taxing high-end health plans, adding to the deficit, increasing personal costs or decreasing personal flexibility.

At least a quarter of those who support fundamental reform appear unwilling to accept significant personal cost to enact that reform, or risk worsening the status quo.

Health reformers, in fact, never had a clear mandate for major reform.

In late July, a Time magazine poll found that 55 percent of Americans rate their health care system as "only fair" or "poor." Six-in-ten have a negative view of private health insurance companies' job performance. But 86 percent of Americans still said, when asked, that they were satisfied with their own health care plan.

One month earlier, an ABC News/Washington Post health care poll found that six-in-ten respondents backed reform and even the creation of a government-funded entity that would offer health insurance to the uninsured.

But the same poll also found that about eight-in-ten Americans are, again, satisfied with the quality of their care and their insurance. Fifty-five percent of Americans even expressed satisfaction with the personal costs related to health care (including 61 percent of the insured). Kaiser Family Foundation polls in 2008 and 2006 echo the same pattern.

This health care reform paradox partly explains why a strong majority of Americans remain supportive of the concept of major reform, and even the broad strokes of a likely Democratic bill, but are concurrently divided over the current legislation being negotiated in Congress.

To an extent, the paradox follows a common trend in public opinion. Americans tend to disapprove of Congress but when asked about their own congressman, they respond, "Oh, he's a good guy;" they approve. Americans want public school reform but will speak well of their child's teacher.

The extent to which personal satisfaction with health care translates into a positive sentiment has yet to be explored in depth. But in practical terms, this paradox underlies Democrats' problems.

Explaining the Paradox

About three-in-four Americans say it is "necessary to make major structural changes" to "make sure that all Americans have health insurance" or "to reduce health care costs," according to a recent CNN poll. But "Obama's plan to reform health care" won only a sliver more support than opposition, by a margin of 50 to 45 percent.

One explanation, for most of the year Obama and top Democrats advocated reform that most Americans believed would not improve their own lives.

Only about one third of adults believe health care legislation will personally "benefit" them, according to a recent CBS/New York Times poll. By a 65 to 29 percent margin, Time found, Americans believe the final legislation will make "everything more complicated," rather than "simpler."

Americans generally support the policy that supports them. It's a lesson Democrats began to learn the hard way at the apex of the Great Society.

Top Democrats have caught on this time, albeit belatedly. This summer Obama began increasingly emphasizing that the final bill will not "mess with" an American who hopes to keep her doctor or insurance.

Obama's weekly radio address at the end of July had "health insurance reform" in its title rather than "health care reform." The week before, the title used the term "heath care reform" but the address included "health insurance reform." The week before that, the phrase "health insurance reform" did not even appear in the address.

This linguistic shift signified an overdue insight. Health care reform was initially framed around a keystone reform: offering coverage to those who have none. But Time's poll, as well as others, have long found that only about one tenth of U.S. adults say they have no health care coverage.

"Health insurance reform" is meant to place the emphasis on improving everyone's experience, not simply the uninsured. But even this repackaging of message and mission are not easily reconcilable with most Americans' satisfaction with their personal experience.

The reform instinct is no less real, however. Time recently found that 55 percent of Americans favor "major reform" over "minor adjustments." The CBS/Times poll has steadily found that more then eight-in-ten Americans want "fundamental changes" or to "completely rebuild" the health care system, rather than "minor changes."

More Harm than Help?

Democrats are left with a public that supports overhauling the nation's system but they lack a public personally invested in that overhaul. The public supports reform but have come to believe reform will not support them.

This explains why the latest NBC News/Wall Street Journal Poll found that only 41 percent of Americans approve of how Obama is "handling the issue of health care reform."

But the same poll proceeded to detail a plan that Obama will likely support. Pollsters described a plan that requires: pre-existing condition coverage, most employers to cover the uninsured, tax-credits for those who cannot afford insurance and a plan that raises taxes on the wealthy. Americans supported the plan by a 56 to 35 percent margin.

Polls show a majority of the public will support raising taxes on the ultra-rich or even the wealthy to fund such reform but that is, of course, because a majority of Americans don't see themselves as wealthy or rich.

About six-in-ten Americans are, for example, against taxing expensive health care plans or "tighter restrictions on what medical procedures Medicare and Medicaid will cover," the Pew Research Center found last month, likely because enough Americans believe those measures will immediately or eventually cost them.

Perhaps more problematic for Democrats, only about a fifth of Americans believe Obama will uphold his promise to not deepen the deficit with health care reform, according to a recent Quinnipiac University poll.

The lubricant of major reform has also always been high public anxiety. But only about a third of Americans say they are worried about losing their health care coverage in the next year, according to the Time poll.

In practical terms, the health care fight has become bigger than itself. It is a proxy for a larger, and often partisan, American debate over the role of government.

The ABC/Post poll found 54 percent of Americans support a smaller government with fewer services rather than a larger government with more services. And as the poll noted, this explains why health care support plummets if private plans are threatened. Polls show Americans would still rather trust their health care to private over public plans--this, despite about a quarter of U.S. adults depending upon public plans like Medicare for insurance.

But to many Americans, and especially seniors, the current legislation is raising red flags that even their government plan is threatened.

For the wider public, there are few concerns greater than cost and liberty. Yet the Time poll found that Americans believe by about a 2 to 1 ratio that the final plan will raise their health costs, not lower them, and offer less freedom to choose doctors and coverage rather than more.

The negative views of the current legislation are partly rooted in the lack of definitive legislation. Democrats have a handful of programs cooking rather than one.

The CNN poll may ask about "Obama's plan" but, we tend to forget, he has no plan. This provides the opposition a garden of flaws to highlight, and offers Obama no one plan to defend. By early September, Obama will likely begin to promote a singular plan.

Yet the canvas of polling illustrates why even if many fears are addressed, Obama has a hard sell before him. Foremost, only so much of the electorate is open to the sale. Two-thirds of Republicans and GOP leaning independents want their representative to oppose health care reform, according to a Gallup poll. And there is no indication that there is significant room to change Republicans' minds, particularly because the defeat of this legislation would be an immense blow to Obama's presidency.

Obama's burden is ultimately dependent on his ability to unite the centrists and conservatives within his own party. And the ease of corralling those legislators will, in substance and message, depend on reconciling much of the health care reform paradox.

Democrats still must convince most Americans, independents in particular, that what is good for the nation's health care system will not be bad for them. For now, the public believes the opposite.

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David Paul Kuhn is a writer who lives in New York City. His novel, “What Makes It Worthy,” will be published in February 2015.

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