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Health care changes can't please all

As polls show, public has mixed feelings about needs

Less than half of the public supports the health care reform legislation now taking shape in Congress, according to recent polls. But missing from that gauge is a fundamental question:

Could any legislation that significantly overhauls the health care system win broad support?

"Probably not - almost certainly not," said Charles Franklin, a professor of political science at the University of Wisconsin-Madison.

Others who follow the politics of health care reform are just as doubtful.

One reason - maybe the key reason - is that Americans have a welter of conflicting opinions about the health care system and health care reform.

Here are a few examples:

• People by sizable margins think the health care system needs to be overhauled. At the same time, most people are happy with their own health insurance.

• People think costs are too high, but by costs, they largely mean insurance premiums, not the underlying cost of health care.

• People want to control health care costs, but they don't want any changes in their own health insurance or health care.

• People are concerned about the federal budget deficit, but, at the same time, a large majority think the government spends too little on health care.

• People want to cover the uninsured, but they also are reluctant to pay higher taxes to do it.

The contradictions provide some perspective on the challenge facing Congress in the coming months - and the odds against any legislation being greeted with applause.

Even Medicare, when it was enacted in 1965, had support from only 46% of the public. That was after two decades of strong economic growth, and it provided health insurance to a segment of the population that also happened to be parents and grandparents.

Lukewarm support

The most sweeping health care legislation since then isn't faring any better.

A recent UW Badger Poll done by the University of Wisconsin Survey Center found that 44% of the state's residents favor the proposed changes in the bills before Congress, while 46% oppose them.

The poll of 507 people had a margin of error of plus or minus 4%.

Support was lower in the Kaiser Health Tracking Poll for November. That nationwide poll found that 35% of Americans are in favor of reform now and like what they are hearing about the proposals before Congress. In contrast, 33% of the people surveyed favor reform but don't like what they are hearing.

Democrats in Congress may take heart that 50% of those surveyed thought it would be better for the country as a whole if Congress passed the proposals it is considering compared with leaving the existing system in place unchanged.

None of this surprises people who track public opinion about health care reform.

After all, what's to like about legislation that raises taxes, shifts costs, takes money from the Medicare program and could add to the federal budget deficit - particularly if you are insured?

That's long been one of the obstacles to health care reform. Roughly 85% of the population has health insurance and, by and large, they are happy with their coverage. People believe the system needs significant changes. But the majority are satisfied with how it works for them.

"That creates a real opportunity for opponents for reform," said Lawrence Jacobs, a political science professor at the University of Minnesota, who has written about the politics of health care reform.

The conflict - the system needs reform but works for me - can be seen in Wisconsin.

The recent UW Badger Poll found that 72% of the public considers the health care system to be in a state of crisis or having major problems. Yet 51% of the people surveyed were extremely or very satisfied with their health plans, and an additional 13% were somewhat or slightly satisfied.

Here's another challenge: People are concerned about the uninsured, but it's not a fundamental concern.

Roughly half are willing to pay higher taxes to increase the number of Americans with insurance - and the percentage fell to 42% in the most recent Kaiser Health Tracking Poll.

"That's the fundamental reason why it seems unlikely that people will rush out into the streets to celebrate any kind of health care reform," said Franklin, the UW professor.

The majority of Americans are more concerned about rising costs. But for most people, that means the cost of health insurance - not the cost of health care. They are largely wary of proposals to spend less money on tests, procedures, drugs and other care.

"Everybody wants to bring down costs, but they don't want to cut anything," said Mark Peterson, a political science professor at UCLA and a faculty associate of its Center for Health Policy Research.

Americans just aren't too keen on being told that a referral to a specialist, a test or a procedure isn't medically necessary. And talk of making the system more efficient by reducing unneeded care inevitably invites cries of "rationing."

One Kaiser poll found that 67% of the public believes that Americans don't get the tests and treatments they need - and 55% thought an insurance company should pay for a test or procedure recommended by a doctor even if a less costly but equally effective treatment was available.

That hospitals, health insurers, drug companies and other stakeholders often are quick to contend that lower payments to them will harm patients only feeds that perception.

Not surprisingly, Congress has moved cautiously to slow the rise in health care spending. Many health care economists contend legislation doesn't do enough to control costs.

"What is going through Congress now is much weaker than many a health policy person would like to see," Peterson said.

But health policy experts aren't a large voting bloc, and people generally don't attribute rising costs to the same things that they do. People instead tend to blame malpractice insurance, insurance company profits, and fraud and abuse.

That's yet another obstacle to winning broad support for reform.

"Health care in one way or another eventually does affect everybody, so in some sense everybody has a stake in the issue," Peterson said. "But relatively very few people have much reason to be extremely well informed about the mechanics of health care - the financing of health care, the delivery system."

A pocketbook issue

The United States is on track to spend one out of every five dollars on health care. That means spending less on other public and personal goods and services. The Congressional Budget Office has said that health care costs represent the single greatest challenge to balancing the federal budget.

The catch is that people don't think of health care as a percentage of the economy; they think about it in terms of their own pocketbook.

That's in part because health care's true costs largely are hidden in lower wages and an array of taxes, such as payroll taxes, federal taxes for Medicare - most of the cost of Medicare Part B and Part D comes from general tax revenue- and state and federal taxes for Medicaid.

"If you got that on your pay stub," Peterson said, "people would have a very different view."

Here's another challenge in reining in costs: People think they spend too much on health care themselves, but not the government. One survey by the Pew Research Center for the People & the Press found that 70% of those surveyed believe that the government spends "too little" on health care, while only 11% believe it spends "too much."

There's also the sheer complexity of the bills before Congress.

"I'm a professor of medicine and have a master's degree in health policy, and it's hard for me to interpret the bills," said Susan Dorr Goold, a professor of internal medicine and director of the bioethics program at the University of Michigan, who has done research on public opinion on health care reform.

The fiercely partisan debate hasn't helped or done much to inspire confidence in the general public. Nor have the weekly if not daily changes and compromises.

"For better or worse, mostly for the worse, the public really has been exposed to the sausage-making of legislation on this bill," UW's Franklin said.

The fear is that the many compromises will mean any final legislation doesn't accomplish its goals of expanding coverage and slowing the rise in health care spending while not adding to the deficit.

But no matter what Congress does, a large segment of the public is certain to be unhappy, and a majority of those in the middle are likely to be ambivalent at best.

"There is no free lunch, and so how do you find a way to craft this plan that seems to cost citizens nothing in premiums or taxes and gives them benefits," Franklin said, "and still have some kind of effect on the cost of health care to individuals and the government?

"And that's the Gordian knot that nobody has figured out how to cut here."

© 2014, Journal Sentinel Inc. All rights reserved.

About Guy Boulton

Guy Boulton covers health policy and the business of health care.

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