If, as the case increasingly appears to be, there will be at best modest changes to the existing health care system (modification of insurance coverage, e.g., forcing companies to cover preexisting illnesses; an increase in the number of individuals with insurance coverage; and perhaps the creation of consumer cooperatives), it will be tempting to blame President Obama for failing to achieve more sweeping change, such as the creation of a governmental insurance option or universal coverage.
That would be wrong. As I’ve tried to argue in previous blog postings, Obama has not made major mistakes in his efforts to persuade Congress to enact more sweeping health care reform. Indeed, he’s largely avoided the key errors that the Clintons made in 1994. This is not to say his performance has been flawless. His recent national television address, for example, fell short, in my view, because it lacked specifics on how he proposed to pay for health care reform, and because he sent mixed messages, by both appealing to Americans’ higher motives while also taking thinly veiled partisan jabs at opponents of his plan and setting up insurance companies as the bogeyman. Far better, I think, that he spelled out the true costs of the plan, including the almost certain necessity that taxes will need to be raised to fund it, in the context of appealing to American’s more virtuous side and bringing business, including insurance companies, on board. Businesses – particular small businesses – cannot be expected to support any initiative unless they know what the costs will be, and how they will be apportioned.
But even a perfect speech, I argue, was unlikely to significantly change the underlying dynamics of the health care reform debate. As it was, his less-than-perfect speech had at best a modest impact on public attitudes, as indicated by the national polls released in the last couple of days (see here and here).
Why, then, is broad-based health care reform so difficult to pass, if not because of Obama’s leadership failings? I’ve hinted at the answer before, but let me address it more directly. The reason has less to do with failed political strategies, and much more to do with the complexity of health care policy itself in the context of public attitudes toward reform. Simply put, there is not a lot of strong, unabashed public support for the type of sweeping reform envisioned by most advocates of health care reform. This fact is often easy to overlook in the welter of survey data that is frequently tossed around by both sides in the debate. A careful read of this data suggests two basic dimensions to public opinion on this issue – dimensions that have not changed appreciably since 1993-94. First, most Americans support reform in the abstract if it promises to control rising health care costs and prevent loss of coverage. But when they are presented the options, and competing arguments, for achieving these goals, support for reform begins to erode, and for very predictable reasons.
To see this, consider public attitudes toward the “public option” – the idea that insurance costs can be contained by providing a nonprofit government-run insurance option to compete with private insurance companies. In the abstract, most Americans by slim majorities, like this idea. Here’s a chart containing polling results from several surveys asking about the public option (see source here).
If we look at a single poll with consistent question wording, moreover, we find these numbers are pretty stable throughout this debate. For example, a recent ABC poll finds 55% support a public option, with 42% opposed. Although down from June, when it was supported 62-33, the public option still has majority approval.
However, as the chart below suggests, if you include in the question the notion that the public option would give the government an “unfair advantage” in competition with private companies, or is the first step toward a single-payer system, public support erodes. Conversely, if you present the public option as increasing insurance options, and as a means of holding down costs, support, not surprisingly, goes up. (For more on this, see source here).
The debate over the public option, I believe, mirrors Americans’ uncertainty over health reform more broadly. In the abstract, support is there for change. But when confronted with competing arguments, uncertainty grows. Over time, as the particulars of the competing viewpoints are disseminated, we see a gradual erosion in overall support. This happened in 1993-94. And it’s happening again, as indicated in the latest polls. Looking at the ABC poll, we see that a plurality of Americans think that health care reform, as outlined in the president’s speech, would make their own care worse, rather than better (32-16 percent, the rest no change); cost more, not less (40-20), and worsen their own coverage (37-11). And here’s the kicker – among the uninsured, only 51 percent think reform would improve their own coverage. Similarly, the latest CBS poll suggests that most Americans (52-42) think Obama’s health care plan will increase the deficit, and by 27-22 they believe the proposed reforms would hurt rather than help them personally.
What does this mean for fundamental health care reform? There simply is not enough political support for any proposal that would radically change the way Americans receive health care today. That means proposals including the public option, mandated universal coverage, higher taxes on “Cadillac coverage” – in short, all the core components of what most people think of when they talk about significant change – lack enough support to overcome opposition from well-entrenched and vocal minorities. Americans, as a generally risk-averse and pragmatic populace, one ideologically more conservative than the publics in other industrialized democracies, are more reluctant to sign on to major policy change in the face of these uncertainties. (This is why I am always surprised when politicians, including Obama, point out that America is the only industrialized country without universal health care coverage. For many Americans, that’s an argument against universal coverage – not in favor of it!) And our open system of shared powers at the national level, with geographical-based representation in Congress, and federalism, by affording many access points to block change, works to amplify this uncertainty. Change can occur, but not nearly on the scale envisioned by proponents of fundamental health care reform.
The bottom line is that polling data indicate that Americans want change, yes, but only in the context of maintaining the broad outlines of the private insurance/fee for services/employer-based system they know. If Obama made any mistake, it was in suggesting that anything more than incremental change was possible. In the end, I think he can get incremental changes through, with some (minimal) Republican support. But because so many portrayed this battle as the last, best chance to implement a universal health care system enjoyed by most other “western” industrialized democracies, passage of only incremental change will invariably be portrayed by some as failure. In fact, given that Obama was elected with about “average” political support, (see my numerous previous posts on this issue), even incremental change– particularly in the midst of an economic recession – of the type described above is a significant accomplishment. We ought not to lose sight of this in the midst of the inevitable wailing and gnashing of teeth that is certain to follow if more sweeping change does not occur.