Health care reform

The approaching battle over the structure of the health care system promises to hold high stakes for both political parties. While a strong majority of Americans expresses dissatisfaction with the status quo and wants fundamental changes, there is no similar consensus on the exact manner of reform, which augers well for a long, heated summer on Capitol Hill.

President Clinton and the Democrats in Congress approach this debate with high expectations -- a 53 percent majority of respondents in a late March CBS News/New York Times survey say they think Clinton will bring about significant reform -- and is under pressure to produce.

The Republicans have been reduced to sitting on the sidelines as First Lady Hillary Rodham Clinton's health care task force dominates the dialogue. The GOP's low-profile strategy runs the risk of allowing the party to continue to continue looking like bit players in this unfolding drama, and face the prospect of ceding the democrats a lock on an issue that promises to have as great a social and political influence as Social Security. Already, a majority of Americans select the Democrats over the Republicans as the party best able to deal with health care by an overwhelming 56 percent to 9 percent margin.

The GOP, on the other hand, has the initial tactical advantage of being able to poke holes in the administration's health care plan (just as they have during the ongoing budget battle), and raise the standard Republican criticism of "too much big government."

However, on an issue in which public opinion surveys document the major concerns of the American public about the present health care system, the greater sin would appear to be one of omission (not doing enough) rather than commission (going too far), and the Democratic Party's willingness to push for real reform gives it credibility during a time when voters want to do more, not less.

As politicians -- both Democrats and Republicans -- try to navigate the hazardous minefield of health care reform over the next several months, it is important to bear in mind the following key points:

1. American voters see a health care system in trouble and in need of dramatic reform. Fully 76 percent of respondents in a late March CBS News/New York Times survey said that the country was "headed toward a crisis in the health care system" because of rising costs. Similarly, in an early March NBC News/Wall Street Journal national poll, 74 percent of respondents said it would "not be possible to control health care costs and cover all Americans without a complete overhaul of our current health care system."

2. Although it is important not to overstate the case, polls show an increased willingness by Americans to pay more out of their own pockets to overhaul the present health care system. Again, the CBS/New York Times survey showed that a 58 percent majority of Americans expressed a willingness to raise taxes to bring about health care reform. And two-thirds (67 percent) believe it is not possible to provide coverage for all Americans without raising taxes. Now, handling the issue of taxes requires as much care as handling plutonium, (and its effects can be just as lethal to a politician), but Americans recognize that fundamental change requires some sacrifice. The key is to emphasize fair sacrifice for reform that provides meaningful improvement in health coverage for the public, along with a commitment to battle waste in the health care system.

3. The fundamental issue is not quality or accessibility, but affordability. Americans are happy with the quality of health care they currently receive (74 percent were satisfied in the NBC/Wall Street Journal March survey); this is not what is at issue in the health care debate. Nearly half (48 percent) of Americans, however, identify "cost" as the most important health care issue (March 1993 NBC/Wall Street Journal poll). Any reform plan that is offered to the American people must have as its fundamental premise a heavy emphasis on cost-containment without impinging on the practices and treatments that make the American system the best in the world. This is where the Republicans' free-market approach has the best chance of winning acceptance. To neutralize this advantage, Democrats need to stress the following items: (a) that runaway health care costs cannot be slowed without strong action; and (b) their plan does not limit services.

4. A single-payer, government-financed health care system wins notable support, but it is not the only alternative in voters' minds. Most national polling shows support for a single-payer system in the 50 percent to 60 percent range (depending on the exact wording of the question), but support tends to diminish when costs to the consumer (either in the form of higher taxes or change in the delivery of the health care system (78 percent of respondents in the NBC/Wall Street Journal poll say that the current system "does not meet the needs of most Americans"), but understandably have little understanding of the nuances of managed competition and other proposals for reform.

Democrats come to the table on the upcoming health care debate with tremendous credibility from the American public, and the prevailing environment certainly favors the bold action the administration is likely to offer. There is no doubt that the White House and the congressional Democrats are embarking on a path strewn with hazards and obstacles, but then, working for meaningful change is not often easy, as President Clinton has learned after six months in office. But this is an issue that holds the possibility of enormous political reward, and this should give the democrats added incentive to persevere as they work through the sticky wicket of health care reform.

"I can tell you this: I'm not going to raise taxes on middle class Americans to pay for the programs I've recommended. Read my plan." Bill Clinton, October 19, 1992 - a date that will live in television infamy.

So said the candidate. But what the president has in store for middle class America is something quite different. Health care reform is another example of a misrepresented Clinton promise.

The President's Health Care Task Force is stirring much pomp and little circumstance. Middle class voters who said that they wanted health care to be "fixed" did not expect the dynamic Clinton duo to "fix" the middle class the same way an animal shelter would "fix" a dog.

It is still far too early to claim that public opinion on health care is set in concrete. Voters will likely evaluate Clinton's plan as well as alternative plans along six criteria:

1. Does a proposal call for government to police the system (good) or does it call on government to run the system (bad)?

Like it or not, people do want a more active role for the federal government in health care. There is high support for price-setting and other regulatory reforms. At the same time, schemes that lead to the federal government actually running the system are failures.

Republicans should build the case that Clinton's reforms cross the line from the government serving in a "policing" function to government actually directing or running the health care system.

2. To gain public support for a health plan, proponents must prove that adopting the change is less risky than the status quo.

As people walk through the complexity and consequences of revising the health care system, "standing pat" might indeed be a safer option. Clinton will need to do little to convince people that the system needs to be changed, it is far more difficult to "sell" the particular changes.

3. Reforms must be explained to the public in language that's simple and easy to understand. Be careful of the words used to sell change. Bureaucratic jargon will only confuse and scare people.

"Managed competition" for some of our focus group respondents is a net loser. Who wants to be "managed?" Further, "competition" in health care at the individual consumer level is defined by many voters as "they'll squeeze and cut quality and services to save money, but this will be at my expense." Too often, the debate has been fought among health care policy elites and arguments have been designed for this audience.

People have a fuzzy notion of the current care system. They know how much they pay for insurance and out-of-pocket costs. A successfully marketed reform proposal is going to require the following elements:

* A "simple" description explaining who exactly is going to deliver care, how much it will cost, and exactly how it will work.

* An explanation of how the individual consumer will benefit, and maintain the current quality of care.

* A believable explanation of how a proposal will reduce individual health care costs.

* An answer to the question, "Does this mean that I would have to change doctors?"

4. Is the proposed health care reform structured in such a way that it solves the right problems and is directed at the right villain? A suggested Republican option: waste, fraud, abuse, and greed.

President Clinton's message will contain attacks on pharmaceutical costs, health insurance companies, etc. These provider groups are attractive targets. Republicans have lacked a villain. The only credible alternative to exclusively basking the provider community would be a clear, concise focus on "waste, fraud, abuse, and greed." Make these the "villain" and then show how the reforms would eliminate them.

5. Does a health care package address public fear and fundamental concerns?

Fear of losing insurance, not being able to get insurance if there is a major family illness, worries about the cost of catastrophic care, and dramatically increasing out-of-pocket costs. America's senior citizens will add out-of-pocket pharmaceutical costs to this list. And finally, as noted above, some attempt to "punish" those who have unfairly profited because of "waste, fraud, abuse, and greed."

6. Rhetorically, are the major goals of a health care plan being properly outlined and sold?

Clinton is an expert at selling along the following dimensions:

* It is scarier to accept the status quo than major change.

* Nitpicking my proposal means you are on the side of the "profiteers" and against real reform.

* Things are so screwed up we can't afford to not move forward implementing my very comprehensive plan.

It is important that Republican candidates not lose the forest of health care reform -- individual security; lower out-of-pocket costs, and increased access -- for the trees of individual policy points. There must be a "big idea" that animates any GOP counter proposal to neutralize the "big idea" offered by President Clinton.

Fred Yang is vice president of Garin-Hart Strategic Research Group, a Washington, D.C.-based Democratic polling firm.

Glen Bolger and Bill McInturff are partners in Public Opinion Strategies, a Virginia-based Republican polling firm.

COPYRIGHT 1993 Campaigns & Elections, Inc.
COPYRIGHT 2004 Gale Group