Health Care: The Politics of Reform

June 24, 2009— -- Americans are at once supportive of health care reform yet broadly suspicious of its impact -- keeping the issue as much a political challenge as it was in the last attempt at wholesale change 16 years ago.

The chief obstacle to reform is that large majorities are satisfied with their current care and coverage; most, albeit fewer, also call their costs tolerable. Dissatisfaction with the system overall, and worry about future costs, are countered by broad concerns that change could worsen the quality, choice and coverage most Americans enjoy now.

The result: pushback works.

Click here for a PDF with charts and questionnaire.

Sixty-two percent in this new ABC News/Washington Post poll, for example, support creating a government-funded entity to offer health insurance to those who don't get it elsewhere, a cornerstone of the plans now under discussion. But if that caused many private insurers to go out of business because they couldn't compete -- as critics charge -- support plummets to 37 percent.

Among others:

- An overwhelming 70 percent oppose taxing benefits worth over $17,000 a year, a funding mechanism under discussion. (Raising income taxes on the wealthy, as usual, is far more popular.)

- Fifty-eight percent don't buy President Obama's pledge that reform can occur without forcing people to make undesired changes in their current coverage.

- The public splits about evenly, 49-47 percent, on another basic element, requiring all Americans to have health insurance. That varies widely, though -- as high as 70 percent support, as low as 44 percent -- depending on the terms of such a requirement.

- About eight in 10 are concerned that reform may reduce their quality, coverage and choice of care, and increase their costs, government bureaucracy and the federal deficit, with anywhere from 51 to 62 percent "very" worried about each of these.

While such views aren't fatal to reform, they underscore its challenges: Critical mass for change generally occurs when Americans are unhappy with current conditions, not only worried about the future. And in this poll 83 percent are very or somewhat satisfied with the quality of their care, 81 percent of insured adults are satisfied with their coverage, and 55 percent of Americans (61 percent of the insured) rate their costs positively.

This poll supports the upcoming ABC News special on health care reform, "Questions for the President: Prescription for America," anchored from the White House by Diane Sawyer and Charles Gibson, airing at 10 p.m. Eastern on Wednesday, June 24.

CHANGE -- There is countervailing impetus for change. Far fewer Americans, 43 percent, are satisfied with "the overall health care system in this country," with a mere 10 percent "very" satisfied. A whopping 85 percent are concerned about their future costs, with 59 percent "very" concerned.

Pre-Existing Conditions and Government Mandates

And there are specific measures of reform -- an employer mandate and required coverage of pre-existing conditions, for instance -- that earn broad support.

Perhaps most persuasively, the public by 58 percent to 39 percent says health care reform is "necessary to control costs and expand coverage" rather than believing it "will do more harm than good." But fewer feel "strongly" that it's necessary -- 34 percent.

Additionally, while broad numbers express concern about the impacts of reform, fewer go so far as to predict it will impact their care negatively: Thirty-one percent think that if the system is changed, their own health care will get worse.

A challenge for proponents of change is that this is nearly twice the number who think reform will improve their care, 16 percent. The rest, 50 percent, don't think it'll either help or hurt. Proponents, then, can say that a combined total of 66 percent think reform will make no difference to their care or improve it. Critics, though, can counter that this depends on what shape reform actually takes -- and on that there is broad concern.

MANDATES -- As can be expected with such a fraught issue, support for federal mandates depends to a large extent on the specifics. As noted, Americans divide evenly on a law requiring that all Americans have insurance. Support soars, however, to 70 percent if that law included aid to help low-income Americans pay for insurance, 68 percent if it required insurers to cover pre-existing conditions and 62 percent if it required employers to offer health insurance or pay into a government insurance fund.

However, support falls to 44 percent if such a system meant that working people who don't get insurance from their employer or on their own would have to pay into a government health fund -- another element of plans under discussion in Washington.

What's likely to be decisive in public attitudes is which of these elements makes it into a final plan, in what form -- and who wins the war of perceptions on the plan's impact on matters including quality, cost, coverage and choice in health care.

GOV'T ROLE -- The broader question of creating a government-supported health insurance alternative also produces divergent views, not least because of general skepticism about the role of government in society. Fifty-four percent of Americans say that overall they prefer smaller government with fewer services to larger government with more services, an attitude that weighs heavily in views on health care reform.

Given that sentiment about the role of government, support for a government-funded plan, as noted, dives from 62 percent to 37 percent if it would put many private plans out of business. And in another result, Americans who support a government-run alternative say by a 2-1 margin that it should be run by an independent organization with government funding and oversight, rather than by the federal government itself.

The Politics and Partisanship of Health Reform

Interestingly, there's another area for reform that a majority supports, but where Obama himself has been unwilling to go. Fifty-seven percent of Americans say they'd support limiting medical malpractice awards; 53 percent say they'd support it even if it meant limiting the amount they themselves could collect in such cases.

POLITICS -- The push-and-pull nature of views on health reform are what make it so tricky politically, as well as the fact that negative arguments retain particular resonance. No wonder the president heads into this debate with a fairly tepid 53 percent approval rating for handling health care, including just 50 percent from independents, the indispensable political center. That's 15 points below approval among independents for his job performance overall.

At the same time, as on other issues, Obama retains a strong upper hand over the Republicans in Congress: Asked whom they trust more to handle health care reform, 55 percent pick Obama, just 27 percent the Republicans. The question is whether the president can turn that advantage into positive persuasion on an issue on which so many Americans are so conflicted.

PARTISANSHIP -- One thing that's unlikely is broad consensus, given the very sharp partisan, ideological and philosophical lines that define attitudes on health care reform. Republicans, conservatives and advocates of smaller government -- all related groups, with the latter the largest -- are far more skeptical; Democrats, liberals and backers of larger government, more supportive.

The differences are striking. Among the majority of Americans who prefer smaller government, 62 percent think health care reform will bring more harm than good; among those who prefer larger government, just 13 percent agree. Similarly, the "more harm than good" range goes from 67 percent of Republicans (peaking at 79 percent of conservative Republicans) to 40 percent of independents and on to just 19 percent of Democrats (bottoming out at 6 percent of liberal Democrats).

In another metric, 55 percent of Republicans think reform would worsen their own health care; that drops to three in 10 independents and just 14 percent of Democrats. And while 61 percent of Democrats support requiring health care for all (without specifying the terms); that drops to 48 percent of independents and 39 percent of Republicans.

Three-quarters of Democrats and about two-thirds of independents support creating a government-run plan, compared with 40 percent of Republicans. But there's a similar effect of pushback: Support falls almost equally across these groups, by 23 to 26 points, if it meant private insurers couldn't compete.

OTHER GROUPS -- There are differences among other groups. For example seniors, protective of Medicare, are much more satisfied with their current care and costs (indeed, 71 percent are "very" satisfied with their quality of care, compared with 44 percent of adults under age 65) and are more skeptical of reform.

Women are more worried than men about their future health care costs. But women also are more apt than men to express concern that reform will reduce the quality of their health care. And women are particularly responsive to pushback on a government-financed plan; if it would kill off private insurers their support for the idea drops by 30 points, vs. a 19-point drop among men.

Naturally, uninsured adults are three times as apt as those with insurance to think reform will improve their quality of care -- but still just 37 percent of uninsureds think so, vs. 12 percent of insureds.

In the end, though, the biggest barrier to change remains the fact that so many Americans are satisfied with their current care and coverage. Support for reform is lower among people who think it will require coverage changes they don't want to make. And, most strikingly, people who are satisfied with their current care and coverage -- especially those who are "very" satisfied -- are far more resistant to reform. Therein lies the challenge in the debate ahead.

METHODOLOGY -- This ABC News/Washington Post poll was conducted by telephone June 18-21, 2009, among a random national sample of 1,001 adults, including landline and cell-phone-only respondents. Results for the full sample have a 3.5-point error margin; click here for a detailed description of sampling error. Sampling, data collection and tabulation by TNS of Horsham, Pa.