by Ruy Teixeira

Last week, in the context of discussing public opinion on health care costs, I offered a few brief observations about public opinion on universal health care. Here’s a more extensive treatment of public opinion on universal health care–both what we know and what we don’t know, based on available data.

What We Know

1. Rising health care costs, not health coverage, is people’s chief health care concern. For example, in a June, 2005 Kaiser Family Foundation survey, the top worry was “having to pay more for your health care or health insurance” (45 percent said they were very worried), followed by “not being able to pay medical costs when you are elderly” (42 percent), “your income not keeping up with rising prices” (40 percent), not being able to afford the health care you think you need (34 percent), losing your health insurance (30 percent) and not being able to change jobs because you’re afraid of losing your health insurance (18 percent)

2. The public wants the government to play a leading role in providing health care for all. For example, in an October, 2003 Washington Post/ABC poll, by almost a two-to-one margin (62 percent to 33 percent), Americans said that they preferred a universal system that would provide coverage to everyone under a government program, as opposed to the current employer-based system. Similarly, in Kaiser polls from 1992 to 2000, a large majority of the public agreed that the federal government should guarantee medical care for people who don’t have health insurance. In a slightly different question asked more recently by Kaiser in June 2003, more than seven in ten adults (72 percent) agreed that the government should guarantee health insurance for all citizens, even if it means repealing most of the tax cuts passed under President George W. Bush, while less than one-quarter (24 percent) disagreed with this statement. Finally, the last time Gallup asked whether the federal government should make sure all Americans have health coverage, they agreed that was a federal government responsibility by 62-35 (November, 2002).

3. American overwhelmingly agree that access to health care should be a right. In 2000 just as in 1993, eight in ten agreed that health care should be provided equally to everyone, and over half agreed “strongly” or “completely”. In addition, in 2004, about three-quarters (76%) agreed strongly or somewhat that access health care should be a right.

4. The public says it is willing to pay more in taxes to provide every American with health care coverage. In August, 2003, Pew found Americans favoring, by 67-26, the US government guaranteeing “health insurance for all citizens”, even if that meant repealing most of “recent tax cuts”. And the majority was scarcely diminished (67-29) by referring not to repealing tax cuts but more directly to “raising taxes”. Similarly, Greenberg Quinlan Rosner/Public Opinion Strategies (GQR/POS) found, in January, 2004, a 69-28 majority saying they would be willing to pay more per year in federal taxes to assure every American citizen received health care coverage.

4. But support for universal coverage drops significantly if such a program would mean limitations on access to medical care. For example, while 62 percent in the October, 2003 WP/ABC poll said they wanted universal health care system run by the government, rather than the current system, that support dropped to 35 percent if that limited choice of doctors and to 38 percent if that meant longer waits for nonemergency treatment.

5. Moreover, willingness to pay more in taxes for universal coverage is a “soft” commitment. For example, when phrased as whether the respondent would be “willing to pay more–either in higher insurance premiums or higher taxes--in order to increase the number of insured Americans”, 51 percent say they would not, compared to 45 percent who say they would. And, in the GQR/POS survey, when asked how much they’d be willing to pay in additional taxes to assure universal coverage for American citizens, 40 percent would not name a dollar figure at all and 16 percent named a figure under $100.

6. The public is also not completely clear on whether the federal government actually has to lead the way on universal coverage. When asked specifically about responsibility for covering the uninsured, four in ten people (43 percent) do say that the federal government should have the most responsibility for providing health insurance coverage to the uninsured, but two in ten (20 percent) say that state governments should be most responsible, and about one in ten (11 percent) say that employers should be most responsible. Another two in ten (18 percent) think that the responsibility belongs to none of these or to another group. (June 2003 Kaiser poll)

7. And the public is not sure whether the government should make a major or a limited effort to provide health insurance to the uninsured. The last time this question was asked by Kaiser in May 2003, 42 percent said that there should be a major effort, 37 percent said there should be a limited effort, and 13 percent said that things should be kept the way they are.

8. The public generally wants to build on, rather than eliminate, the current employer-based private health insurance system. In a January, 2000 Kaiser poll, they preferred building on the current system to switching to a system of individual responsibility (54-39) and in a November, 2003 Kaiser poll, they preferred keeping the current system to replacing it with a government-run system (57-38).

9. In that context, the public supports a wide variety of options for expanding health insurance to cover more Americans. In a June, 2005 Kaiser poll, the public said they favored tax deductions or credits for businesses (88 percent); expanding state government programs like Medicaid (80 percent); expanding Medicare to cover people ages 55-64 (74 percent); tax credits for uninsured individuals (73 percent); and requiring business to offer employees health insurance (70 percent). In a December, 2003 Harvard School of Public Health/Robert Wood Johnson/ICR poll, 80 percent supported expanding Medicaid/SCHIP; 76 percent supported employers being required to offer a health plan; and 71 percent supported a tax credit plan. Trailing these options, but still garnering majority support, were a universal Medicare plan (55 percent) and an individual coverage mandate plan (54 percent). Finally, the 2004 GQR/POS poll found 74 percent favoring guaranteed health care coverage for all American children under 18 and 62 percent favoring catastrophic health insurance coverage for all Americans. (Note: one of the only options that didn’t garner majority support in these polls was a single or national health plan financed by tax payers that would provide insurance for all Americans (37-47 percent)).

What We Don’t Know

So, it appears that public is very open to a government-supported system of universal coverage, but not sure about how (and how fast) to get there and what kind of system it really wants. This is a challenging environment for advocates of universal coverage. To be effective, they will need to resolve a number of unanswered questions about public responsiveness to a universal coverage message.

1. Does the public see a connection between universal coverage and containing health care costs? If so, what kind and how can that connection be strengthened? If not, what can be done to create that connection?

2. The public says it favors a government role in guaranteeing health insurance coverage for all. But how does the public envision that role? And what does the public really hear when terms like “universal coverage” and “guaranteed health insurance” are used? Do advocates know what kind of terminology would actually work the best when talking about these goals with the public?

3. If the public believes access health care is a “right”, is that the best way to talk about the goal of universal coverage? If not, what is the best way to connect to Americans’ values in and around the health care issue?

4. We need to know much more about the sensitivity of the American public to the costs involved in extending health insurance coverage. How seriously should we take the surface commitment to pay more in taxes? How would the issue have to be framed to make that surface commitment into a more durable one? How important might the issue of containing health care costs be to getting the public to accept the costs of universal coverage?

5. How can advocates avoid the restricted choice counterattack that will inevitably be raised to any universal coverage plan? Should consumer choice be a central element of any universal coverage plan? If so, what is the best way to frame that?

6. The public appears to support the general goal of universal coverage but seems shaky on the scale of the effort need to meet that goal. What is the best and most effective way of making clear the scale of effort needed to actually attain universal coverage?

7. The public appears to support a wide range of possible ways to increase coverage, but it is unclear which, if any, of these approaches the public identifies as particularly effective. Can the public be led to identify progress toward universal coverage with a few key reforms that would stand out from the rest? If so, which ones and how should advocates talk about them?