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Forecast for health care reform: Fog clearing, but chilly

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Over the past 10 months we have asked 409 questions of 29,653 likely voters in ten surveys of Americans’ opinions about health care reform. Here we quantify the increasing polarization of Republicans and Democrats, and highlight the remaining common ground, and common interest.

Storm Clouds in June

In our June survey of 3862 likely voters we found fundamental differences between Democrats and Republicans, with Independents in between on almost every issue. This just preceded the release of the first health reform bill by House of Representatives Speaker Nancy Pelosi.

Asked about an expanded role for government in healthcare, 82% of Democrats were in favor, vs. 8% of Republicans and 36% of Independents.  Is health care a human right? 82% of Democrats said yes, vs. 20% of Republicans and 45% of Independents.  As to paying any increase in taxes to cover the uninsured, 15% of Democrats, 87% of Republicans, and 57% of Independents were unwilling.

They also differed in the percentage who rated it an excellent idea to require everyone to buy health insurance, with subsidies for the near-poor: D: 37%, R: 7%, I: 17%.  A single-payer plan (“like Medicare for all”) was rated excellent by 47% of Democrats, 5% of Republicans, and 19% of Independents.  Requiring insurance companies to offer everyone the same premiums regardless of age, sex, or pre-existing conditions was favored by 72% of D’s, 40% of R’s, and 54% of Independents.  Limiting care for illegal aliens was favored by 23% of Democrats, 70% of Republicans, and 53% of Independents.  Another difference was in expanding Medicaid, which was supported by71% of Democrats, 13% of Republicans, and 37% of Independents.

Areas of near agreement were: increasing anti-fraud efforts (favored by 78% of Democrats, 73% of Republicans, and 78% of Independents); eliminating Medicare’s Advantage program (thought “excellent” by 11% of D’s, 7% of R’s, and 6% of I’s); promoting the use of living wills (deemed “excellent” by 53% of D’s, 48% of R’s, and 54% of I’s.) But – presaging the August town hall outcry about “death panels”- living wills were strongly opposed by 11% of Republicans, 3% of Democrats, and 9% of Independents.

A final area of general agreement was the proposal to expand coverage by raising taxes on families making more than $250,000 per year with equal numbers rating it a good or excellent idea (though it was strongly opposed by 47% of Republicans, 33% of Democrats, and 39% of Independents.

A Blistering Summer

The summer town hall debates caused the parties to diverge further. Support for the House bill fell from 42%, then rebounded briefly to 50-50 after President Obama’s September speech to Congress. In that same September survey, we saw a fall in the percentages of people “very satisfied” with their health care, to 31%, 70%, and 49% for Democrats, Republicans, and Independents, respectively.

By September, Democrats’ support for increasing taxes on family incomes above $280,000 increased to 54% who considered it “excellent,” while support between Republicans fell to 5%, and that among Independents rose to 21%.  The parties also diverged on living wills, with “excellent” ratings increasing among Democrats from 53 to 61%, falling among Republicans from 48 to 31%, and among Independents from 54 to 41%.

In his speech, President Obama proposed to take a look at state initiatives to reform medical malpractice (“tort”) laws, but warned he would not support a cap on damages for pain and suffering. His stance was supported by 58% of Democrats; 89% of Republicans supported a cap, in addition to other reforms, as did 63% of Independents.

One proposal elicited broad support: establishing electronic insurance exchanges for individuals and small businesses to pool risks and comparison-shop. This was strongly supported by 67% of Democrats, 45% of Republicans, and 58% of Indepedents.

In our November survey of 3,706 Americans, we asked about abortion: “Do you agree or disagree that all health insurance plans subsidized by the government should be prohibited from covering abortion, except in the case of rape, incest, and to save the life of the mother?” Strong agreement was reported by 75% of Republicans, and 51% of Independents, but Democrats were sharply split: 26% strongly agreed, and 43% strongly disagreed

A Frosty Winter

In December we surveyed 1,641 Americans as to which aspects of health care reform were their top priorities. Democrats chose the proposed public option (40%), and “regulating private insurance.” Republicans chose, “how to pay for it,” as did Independents.

In our February survey of 2,525 Americans, Democrats prioritized “covering the uninsured” ahead of “cutting costs,” with “improving the quality of care” in third place. Republicans ranked “cutting costs” as the top priority, and put “expanding coverage” last. Independents rated “cutting costs” as the top priority, followed by “expanding coverage,” then “improving quality.”

As to specific provisions, eight provisions had more than 50% support among Democrats, vs. two among Republicans and four among Independents. A ban on excluding those with pre-existing conditions was favored by 85% of Democrats and 67% of Independents, but only 46% of Republicans.

Democrats’ second priority (82%) – “insuring the uninsured” – was supported by only 46% of Independents and 12% of Re[publicans. The third priority (for 77% of D’s) was equal premiums for men and women, which drew support from 59% of Independents and 39% of Republicans.

Democrats’ fourth priority (at 75%) was ensuring coverage for children, a priority for 48% of Independents and 27% of Republicans; followed by expanding Medicaid eligibility( D: 70%; R: 13%; I: 35%), and capping out-of-pocket expenditures (D: 70%; R: 25%; I: 44%).

Seventh on the list for Democrats (66% support) – but #2 for Republicans (at 60%) and Independents (at 66%) is the proposed health insurance exchange.  This was tied with subsidizing premiums for low and middle-income Americans, and the creation of a Medicare-like “public option” for those without other health insurance.

Support was expressed by a majority of Republicans for just two proposals: tort reform, and exchanges. As usual, independents split the difference, favoring insurance without regard to pre-existing conditions, exchanges, elimination of gender-based premiums, and tort reform, in that order.

For all three groups there was a fall (compared to our summer and fall surveys) in support for requiring everyone to buy insurance (D: 30%; R: 5%; I: 18%).

As for abortion, when compared with other priorities, a ban on federal funds for abortions other than for incest, rape, or to save the mother’s life, was a priority for 42% of Republicans, 6% of Democrats, and 18% of Indpendents.

Compared to our summer and fall surveys, less priority was given to efforts to fight fraud (D: 20%; R: 38%; I: 26%), wellness incentives (D: 19%; R: 11%; I: 20%), incentives for quality of care by physicians (D: 22%; R: 8%; I: 10%), efforts to decrease needless tests and treatments (D: 12%; R: 8%; I: 14%), or medical errors (D: 7%; R: 5%; I: 6%).

Asked if Congress should “start over” on healthcare reform, 18% of Democrats strongly agreed, vs. 81% of Republicans and 56% of Independents.

Yet another growing divide was revealed by asking, “are you more or less supportive of healthcare reform than a year ago?” Fifty-six percent of Democrats were more supportive (43% much more so), vs. 9% of Republicans, and 30% of Independents.

Willingness to pay more taxes also diverged: only 16% of Democrats now oppose any increase, whereas 74% of Republicans now oppose any tax increase, as do 44% of independents.

Sixty-one percent of Republicans thought it very important to have some Republicans in favor of any successful bill, vs. 26% of Democrats and 49% of Independents.

Democratic leaders were called “out in front” by 60% of Democrats but “out of touch” by 91% of Republicans and 69% of Independents.

As to the nation’s overall priorities, 54% of Democrats chose unemployment as the most important issue, followed by health care reform (31%). Republicans chose “excess government spending” (46%), followed by unemployment (37%), then homeland security (13%), and healthcare reform (2%).  Forty-six percent of Independents were most concerned about unemployment, followed by excess government spending (29%), and health care reform (17%). Education and the environment were selected by less than 2% of each group.

We again surveyed Americans just before and a week after Obama’s all-day Feb 25 Health Care Summit. The summit produced subtle changes: an increase in Democrats’ support of the Obama plan (from 68 to 82%), with little change among Republicans (5% to 4%), but Independents trended up (to 35%, from 32%).

In keeping with this, 33% of Democrats said the summit had strongly increased their support of Obama’s plan, while 46% of Republicans said it had strongly decreased their interest. Strongly decreased support was also expressed by 21% of independents, vs. 9% with strongly increased support.

Not surprisingly, Democrats’ interest in a fresh start fell from 28 to 15%, while that of Republicans increased a bit (from 87 to 90%) and Independents dropped a bit, from 57 to 54%.

Finally, we found one area of agreement: an increase in “the chances health reform will pass this year.” The percent of Democrats who gave the Obama plan a 75% or greater chance was 53% (up from 37% pre-summit), vs. the Republicans’ 19% (up from 10%) and Independents’ 29% (up from 15%).

A Spring Without Sunshine

In short, these data show a continued divergence of Republican and Democratic attitudes toward the healthcare reform bills. Over the past year they have increasingly disagreed on most provisions, and have generally moved from “supportive” to “very supportive”, or “opposed” to “strongly opposed”. Republicans, in particular, increasingly feel “very” (as opposed to “somewhat”) opposed to many aspects of the Obama plan. Indeed, the only provision that is strongly endorsed by both Republicans and Democrats is the health insurance exchange(s).

Proposals that drew strong bipartisan support six months ago now are less of a priority for members of both parties: fighting fraud, reducing waste and medical errors, promoting wellness and prevention, and paying doctors for quality not quantity of care.

Compared to Democrats, for whom healthcare reform is priority #2 (after unemployment), Republicans are more concerned about deficit spending, unemployment and homeland security than about healthcare reform.  Nine of ten Republicans want changes made in the US health system, but they believe only a few changes are essential: tort reform, creation of insurance exchanges, reducing costs (and the deficit), and barring federal payments for elective abortion. Other provisions such as health savings accounts, “portability” (keeping the same insurance despite changing jobs), permitting health insurance to be sold across state lines, are considered less essential.

In contrast, more than half of Democrats support nine major changes. Independents, too, have recently separated into camps, supporting either the Obama plan, or the Republican House plan (or no plan), increasingly strongly.

Some of this divergence is probably the inevitable partitioning of opinion that results as the vote approaches, though it is hard to doubt that Congressional leaders and partisans in the media have fanned the flames.

This is not to say that the increasing divergence is all a matter of passion, or anger. 52% of Democrats and 66% of independents feel it is somewhat or very important that healthcare reform have Republican support. And when asked, “Do you believe newly-elected Massachusetts Senator Scott Brown should join fellow Republicans in opposing broad healthcare reform legislation, or should he try to work with Republicans and Democrats to find a compromise”, 28% of Republicans urged compromise, as did 61% of independents and 87% of Democrats. Interestingly, over the past year we have noted a small but steady increase in the percentage of voters who call themselves independents, from 28 to 30%, perhaps reflecting discontent with the extremes of each party.

The Forecast: Partly Sunny

There is no avoiding the fact that the health care debate has divided the country.  Whether the Obama plan passes or not, either party’s bitterness in defeat could obstruct progress in other areas such as reform of financial markets, homeland security, immigration, education, and the environment.

Add to the list: health care reform; if the Obama plan fails it will be followed by his Plan B (expansion of Medicaid and state Children’s Health Insurance Programs), with Republicans sure to propose a small, market-oriented, personal responsibility-oriented bill to demonstrate that they are the “Party of Now,” and not the “Party of “No!”

If the Obama plan becomes law, it will be followed by intense rulemaking within the Department of Health and Human Services, and by legislative proposals to modify the new law.  Ideally, these will be bipartisan.

Minimizing bitterness and regaining trust will require more than Obama’s Lincoln-esque oratorical skill. The president will have to meet with Congressional leaders more often, and not just in the Oval Office but in open meetings like the healthcare summit, and in hospitals and factories and schools, and over sandwiches on the bus, and drinks after work. Win or lose, they are still in a three-legged sack race. If they don’t learn to work together, they will fall and be out of the running, come November.

S.Ward Casscells, MD is the Tyson Distinguished Professor of Medicine and Public Health, and VP for Public Policy, at the University of Texas at Houston

James Tyll is with Tyll Consulting, LLC

John Zogby, the Chairman of Zogby International, is the author of “The Way We’ll Be”