The Commonwealth Fund, The New York Times, Harvard T.H. Chan School of Public Health, October 2019
Reforming the U.S. health insurance system has become a major issue in the upcoming presidential election, both in primaries and likely in the general election. There are a number of different health care reform proposals that have been put forth by candidates and parties, but prior studies show that voters in the general public are often not aware of the details of these plans. This suggests that the differentiation voters make between one plan and another is likely based on underlying values, beliefs, and life experiences. This report addresses specifically adultsā views in these three areas, as they relate to health insurance reform proposals supported by the public.
One of the issues that has emerged in recent polling on health insurance reform is that people often report they support more than one type of plan, even though these plans are often very different from each other from a policy perspective. This poll seeks to examine this issue by asking people who are interviewed to choose the plan that they most favor among the three major plans that are being debated currently: (1) Medicare-for-all, (2) improving the existing Affordable Care Act (Obamacare), or (3) replacing the Affordable Care Act with a new law that would give taxpayer funding to states to design their own health insurance systems with fewer federal rules.
Conclusions
This report examines Americansā current beliefs, values, and experiences, according to their preferences on three major proposals for national health reform. The results point to significant conclusions, which are timely given the importance of health care as an upcoming issue in the Democratic primaries and the 2020 presidential election.
We polled Americansā values and beliefs across seven different areas: the preferred role of government generally, the preferred role of government in health care, attitudes toward the current U.S. health care system, views on equal treatment in health care, personal experiences with health care, views on the future desired direction of health insurance reform, and public trust in groups trying to improve the U.S. health care system.
Notably, none of the three policies received a majority of Americansā support as their most-favored plan, suggesting major divisions in preferences on the future of health insurance reform. We found the greatest differences in public opinion are the preferred role of government in health care, attitudes toward the current U.S. health care system, and views on increasing taxes so everyone can have health insurance. Proponents of all three plans showed the greatest similarities in shared values for equality in health care and trust in similar groups trying to improve health care, as well as their personal experiences.
Overall, Americans who prefer Medicare-for-all and those who prefer improving the existing ACA share similar views in several areas that lie in contrast to the views of those who favor replacing the ACA with state health plans. However, proponents of Medicare- for-all and improving the existing ACA also differ in important ways. They are split in their views of the economy, where a slight majority of adults who favor improving the existing ACA have a positive image of capitalism, while a majority of adults who favor Medicare-for-all have a positive image of socialism. Meanwhile, two-thirds of Medicare- for-all proponents prefer more federal government involvement in health care, compared to only a slight majority of proponents of improving the existing ACA. In addition, about two-thirds of adults who favor improving the existing ACA hold favorable opinions about private health insurance provided by employers, compared to only about half of adults favoring Medicare-for-all who share this view.
Among all three groups, there are dramatic differences in views on the preferred role of government involvement in health care. While more than eight in ten adults who favor Medicare-for-all and more than seven in ten adults who favor improving the existing ACA say they think it is the responsibility of the government to make sure all Americans have health insurance coverage, only one in five adults who favor replacing the ACA with state health plans say this. More than seven in ten adults who favor Medicare-for-all and a majority of adults who favor improving the existing ACA prefer a health insurance system run mostly by the government, while only about one in seven adults who favor replacing the ACA with state health plans prefer this approach.
Americans are also divided in their attitudes toward the current U.S. health care system, by their preferences for health reform. While large majorities of adults who are proponents of improving the existing ACA and Medicare-for-all hold favorable opinions of the Affordable Care Act, three-quarters of adults who are proponents of replacing the ACA with state health plans hold unfavorable opinions about it. This suggests major divisions in public opinion, both in how the U.S. health care system is currently operating, as well as the path forward.
Americans also hold opposing views according to their preferences for health reform about increasing taxes so everyone can have health insurance. While large majorities of adults who favor Medicare-for-all and improving the existing ACA favor increasing taxes so everyone can have health insurance, seven in ten adults who favor replacing the ACA with state health plans oppose tax increases.
When it comes to equal treatment in U.S. health care, large majorities of adults favoring all three approaches to health reform share views that while equal treatment is not a current reality, it is an important goal. Americans generally share views on the importance of equal treatment, regardless of income or race.
When it comes to public trust in various groups trying to improve the U.S. health care system, Americans favoring all three plans generally do not trust any interest major groups, with the exception of nurses. This suggests that if outside groups are to play an important role in shaping the future of health reform, they will need to coalesce around a shared vision of what it should look like.
In addition, we found that peopleās personal experiences, though important to individuals, do not generally drive opinions about preferences for health reform. While a greater share of adults who favor Medicare-for-all express concerns about health care costs and health care access compared to those who favor improving the existing ACA and those who favor replacing the ACA with state health plans, large majorities of adults preferring all three plans say they are satisfied with their current health insurance coverage.
As we look ahead to the debate over national health insurance reform, it is clear that Americansā viewpoints on health care issues are heavily driven by their basic beliefs and values. Medicare-for-all is a powerful issue in the Democratic primary, but for Americans who are Republicans or Independents, this approach to health insurance reform does not resonate the same way. These Americans are split in preferences between improving the existing ACA and developing other alternatives.
The following responses are grouped based on the plan most preferred by individual respondents:
- Plan A: Medicare for All
- Plan B: Improving the Affordable Care Act
- Plan C: Give taxpayer funding to states to design their own health insurance systems
Q12. In the future, how involved do you think the federal government should be in health care? Should it be (more involved), (less involved), or about as involved as it is now?
- Plan A: 67% MORE involved
- Plan B: 54% MORE involved
- Plan C: 65% LESS involved
Q13. Do you think it is the responsibility of the government to make sure all Americans have health insurance coverage, or is that not the responsibility of the government?
- Plan A: 85% Responsibility
- Plan B: 73% Responsibility
- Plan C: 76% NOT responsibility
Q14. Do you favor or oppose increasing taxes on higher income people so everyone can have health insurance?
- Plan A: 84% Favor
- Plan B: 76% Favor
- Plan C: 70% OPPOSE
Q15. Would you personally be willing or unwilling to pay more in taxes so that everyone can have health insurance in the U.S.?
- Plan A: 79% Willing
- Plan B: 67% Willing
- Plan C: 74% UNWILLING
Q16. Which of the following approaches for providing health insurance in the United States would you prefer–a health insurance system (run mostly by the government), or a system (based mostly on private health insurance)?
- Plan A: 73% Run mostly by the government
- Plan B: 55% Run mostly by the government
- Plan C: 84% Mostly PRIVATE HEALTH INSURANCE
Q27. Do you think all Americans should have a right to health care regardless of ability to pay, or not?
- Plan A: 94% Should have right
- Plan B: 91% Should have right
- Plan C: 60% Should have right
Q29. How important is it to you that all Americans be treated equally in terms of the health care they receive? Very important, somewhat important, not too important, not important at all?
- Plan A: 97% Very or somewhat important
- Plan B: 98% Very or somewhat important
- Plan C: 88% Very or somewhat important
Q30. How important do you think it is that poor American families receive the same quality of health care as rich American families? Is it very important, somewhat important, not too important, or not at all important?
- Plan A: 98% Very or somewhat important
- Plan B: 98% Very or somewhat important
- Plan C: 90% Very or somewhat important
Q31. How important do you think it is that African Americans receive the same quality of health care as white Americans? Is it very important, somewhat important, not too important, or not at all important?
- Plan A: 99% Very or somewhat important
- Plan B: 99% Very or somewhat important
- Plan C: 92% Very or somewhat important
Q32. How much do you trust each of the following groups when it comes to trying to improve the U.S. health care system? How about (INSERT ITEM)? Do you trust them a great deal, a fair amount, not very much, or not at all?
- g. Pharmaceutical companies
-
- Plan A: 70% Not very much or not at all
- Plan B: 72% Not very much or not at all
- Plan C: 78% Not very much or not at all
- h. Health insurance companies
-
- Plan A: 67% Not very much or not at all
- Plan B: 64% Not very much or not at all
- Plan C: 53% Not very much or not at all
- i. The federal government
-
- Plan A: 48% Not very much or not at all
- Plan B: 47% Not very much or not at all
- Plan C: 70% Not very much or not at all
Comment:
By Don McCanne, M.D.
This survey confirms, once again, that Americans are divided over the role that government should play in financing our health care system. Those favoring a greater role for government are divided between improving the Affordable Care Act or replacing it with Medicare for All. Those opposing government involvement would prefer that states design their own systems, and they are unwilling to pay more taxes to fund health care.
What is interesting is that those opposed to a greater government role nevertheless do support health care justice in that they agree that health care should be a right regardless of ability to pay, that all Americans be treated equally in terms of the health care that they receive, that poor American families receive the same quality of health care as rich American families, and that African Americans receive the same quality of health care as white Americans.
The report confirms that Democrats are split between the two options of Medicare for All or expanding the Affordable Care Act, Republicans favor turning health care over to the states, and Independents are divided between the three options.
Thus there is a conflict between concepts of health care justice which are supported by all and the three options for reforming health care. Only a single payer Medicare for All program would accomplish the listed goals of social justice. The Republicans have been stumbling around with proposals that would actually further suppress health care justice, while Independents and moderate Democrats support the model we already have that still falls far short of health care justice for all.
Which really is more important? Health care justice for all? Or holding fort in your ideological camp? We are accomplishing the latter but not the former. Shouldn’t we reverse our priorities?
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