Articles and Analysis


Rivlin & Rivlin: Public Opinion on Health Care Reform 1993 and 2009. Is this a New Day or just Groundhog Day?

Sheri Rivlin and Allan Rivlin are the Co-Editors of CenteredPolitics.com. Allan Rivlin is a Partner at Hart Research Associates. In 1993 Allan Rivlin was a Special Assistant in the U.S. Department of Health and Human Services.

Remember 1993? Snoop Dogg was on the radio. Grunge ruled the world of fashion, and one of the top movies was "Groundhog Day" where Bill Murray had to relive the same day over again until he figured out just what he had to offer the world and finally got it right.

A charismatic young Democrat had just been elected President promising, among other things, to reform a broken health care system. Public opinion seemed to be behind him but the effort ultimately failed and a more careful reading of public opinion in those early months of the Clinton Administration reveal some of the fault lines that eventually sank the effort. Not only did reform fail to make it out of either house of Congress, but in the 1994 election voters ratified the decision and punished Democrats who supported reform rather than the Republicans who had defeated the plan.

rivlinSlide1.JPGNow a new Democrat has taken office promising healthcare reform. The question becomes; has enough changed in public opinion to offer hope that the outcome will be different this time around? A thorough review of the available polling then and now is less than encouraging for supporters of comprehensive health care reform (a category that includes the authors who should be understood to be supporters of comprehensive reform albeit sobering ones.)

Where common questions can be found in polls leading up to health reform 1993 and 2009, the public is currently less attuned to the issue, expresses less dissatisfaction with the status quo, and offers lower levels of support for the general prospect of reform. But an even greater challenge for reformers is the fact that the basic contours of public opinion that undercut the previous effort continue to be true today - perhaps even more so.

Just as in 1993, it would be easy to read current polls as highly encouraging. Many of these measures appear quite strong, it is just that they are not as strong as comparable numbers in surveys taken before the start of the 1993 effort when many pollsters, including those advising the White House were fooled into believing they had a clear mandate for major change.

Now: A 2008 Harris Interactive survey finds 29% saying so much is wrong with the current health care system that it needs to be completely rebuilt, and an additional 53% says that while there are some good aspects the system needs fundamental changes. That adds up to 82% calling for fundamental change. Just 13% say the system works pretty well and only needs minor changes.

Then: The problem is, these results were typical, though a little stronger in the period before the failed effort. As early as 1991, the same pollsters (then Lou Harris and Associates, the word "Interactive" as we know it today had not yet been coined) using the same question recorded 42% saying so much is wrong with the current health care system that it needs to be completely rebuilt, and an additional 50% said that while there are some good aspects the system needs fundamental changes - for a total of 92% calling for fundamental change and just 6% said the system worked well and only needed minor changes.

Now: A 2008 Harvard School of Public Health survey found a 55% majority in support of "national health insurance" with 35% opposed. While this is unlikely to be a phrase that this round of reformers will find useful or descriptive of their proposals, the term that was in common use in 1993 does allow for an apples to apples comparison.

Then: The same researchers using the same phrase in 1993 found 63% supporting "national health insurance" and just 26% were opposed.

rivlinSlide2.JPGThen as now the real problems facing health care reformers were structural and clearly visible in the polls. As the nation reached near consensus that there was a problem, there was never any such agreement on the specific solution. While many people agreed then as they do now that it is wrong that so many Americans are either uninsured or underinsured, the priority then, as now, for most people was on finding ways to lower their own health insurance cost. Then as now most people had health insurance that they judged to be pretty good.

Then: In 1993 a 77% majority told Martilla and Kiley that they were at least somewhat satisfied with their own health care coverage.

Now: For comparison, 82% expressed a similar level of satisfaction with their own insurance in a 2007 Greenberg Quinlan Rosner Poll.

Then: A 1993 Gallup Poll asked people about their priorities for reform and 38% said they wanted health insurance that included all Americans. The bare majority, 51% wanted to control costs, and 10% volunteered that they want reform that did both.

Now: The comparison here is a little less direct, but in 2008 the Harvard School of Public and the Kaiser Family Foundation found similar results with 45% saying they want to make health care insurance more affordable and 22% saying their goal for reform would be to expand insurance to the uninsured.

Then: An NBC News Wall Street Journal Poll in March 1993 found 66% agreeing with the statement "I would be willing to pay higher taxes so that everyone can have health insurance." Just 30% were opposed. A Martilla and Kiley poll found a similar result but in a clear sign of the problems that would emerge, among their 65% willing to pay higher taxes, just 25% said in a follow up question that they would be willing to pay as much as $50 more a month, 40% said they would pay $30, and the majority 62% were only willing got go as high as $10 per month more in order to give coverage to everyone.

Now: In the most recent NBC News Wall Street Journal Poll conducted February 26 to March 1, 2009 the public is now split with just 49% agreeing with the statement "I would be willing to pay higher taxes so that everyone can have health insurance" and nearly as many 45% do not agree.

rivlinSlide3.JPGDoes all of this mean that the Obama plan is doomed before it has even begun? Of course not, but putting the apparently positive number from many of today's poll questions in the context of even more positive numbers from polls taken before the previous failed effort should serve to underscore the difficulty of the challenge ahead.

It is clear that the new team will benefit from lessons learned in the earlier health care reform effort. Reflecting a hard won understanding that most Americans are fairly satisfied with their current coverage, the first words out of any Administration spokesperson, including President Obama, on the subject of health care reform is that if you like what you have now you will be able to keep it. Also reflecting the priorities expressed in public opinion polls today (and back then), far greater emphasis is now being placed on cost containment than on extending coverage.

The real question will of course come in the details of the proposal. If Obama can come up with a plan that extends coverage to more Americans without a major increase in the burdens it places on the individuals and businesses who pay for it, then it will be difficult for those who want to see this effort fail to generate much public opposition. Naturally this is a tall order, but we would not want to be among the legions of commentators who have had to swallow their doubts that Barack Obama can achieve the difficult.

The only thing we will predict is that there will be a lot of articles written looking at statistics like some of the ones mentioned here (in fact they are likely to grow stronger as the heat is turned up on the issue) to make the case that this time around the public strongly supports reform. We hope this little bit of context will help keep these articles in perspective.

The authors wish to thank Julia Kurnik for Research Assistance and Robert Blendon of the Harvard School of Public Health for invaluable assistance. Would anyone try to write this article without first calling Bob Blendon?