Americans would embrace comprehensive healthcare reform if properly informed

26 August 2009

With polls pointing to a decline in public support for healthcare reform in the US, new research shows that getting Americans more involved in the debate is essential to swinging public opinion in its favour.

The research showed that after critically thinking through the alternatives, people were willing to make significant and surprising tradeoffs — like limiting treatments to those proven effective, expanding the role of government, and an increased role for nurses and other non-physician healthcare providers — in order to improve the healthcare system. The report offers specific insight for congressional and other leaders to help build constituent support while back in their home states.

"Major reform efforts fail either because people have been engaged and reject them, or because they were never engaged in the first place," said Daniel Yankelovich, a leader in public opinion research for more than 50 years and chair of Viewpoint Learning. "We found that when Americans are engaged and work through tradeoffs and take on board the experiences of others, they are willing to make more sacrifices than most experts give them credit for."

Published in the report Voices for Health Care, the Viewpoint research was funded by the W.K. Kellogg Foundation, which supports efforts to expand civic and philanthropic engagement across the US to improve the lives of vulnerable children and families.

Public support for any proposed healthcare plan is crucial to its approval and, ultimately, its implementation. In 1993, the Clinton Administration's health reform plan enjoyed a 71% approval rating early on, but legislation quickly stalled and that rating slipped to less than 40%, suggesting that opposition easily swayed a public that had not yet worked through the issues and reached a firm judgment.

The Voices for Health Care project took place in three very different states over the course of a year — Ohio, Mississippi and Kansas.

First, researchers engaged with healthcare, political, civic and business leaders in each state to create several healthcare reform scenarios to work through with the public. Then they engaged a random sample of participants representative of the US population (nearly 300 in total) in daylong, two-way dialogue sessions to show how everyday Americans tackled the issues.

Participants first created their vision of the healthcare system they wanted to see, and then worked through the difficult tradeoffs they would be prepared to make to realize that vision and to pay for it. Across all nine sessions (three sessions per state) participants reached a strikingly consistent set of conclusions.

Researchers quickly observed that the public approaches the issue of healthcare from a pragmatic — not a partisan — perspective and that participants were willing to change views on politically contentious issues after working through the tradeoffs of alternative potential healthcare systems and the viewpoints of other Americans. Those perspectives also made a dramatic difference in how participants felt about broad reform issues, such as universal coverage and limits on care. (Major insights are highlighted in the "key findings" section below.)

The report also showed that Americans across all demographic groups and the political spectrum might already agree on a number of important reform elements. Americans came to a quick agreement that a new system should provide greater focus on prevention and wellness, increase personal responsibility for one's own health, and ensure that all children have access to good care. They concluded that these topics could be used as an effective starting point to engage the public and open the door to addressing other more complex issues.

"For decades, lawmakers have focused primarily on the debate among vested and represented interest groups, and have not developed ways to engage in meaningful conversations with the American public," said Sterling Speirn, the president and chief executive officer of the W.K. Kellogg Foundation. "Substantive dialogue with the public about healthcare is not only feasible, it is essential if we are to advance health care that the public will embrace in the United States."

The Voices for Health Care report indicates that engaging Americans from diverse political and socioeconomic backgrounds can substantially increase public support for meaningful health care reform. It provides specific insights and a useful starting point that leaders can adopt to ensure that the thoughtful voices of everyday Americans on healthcare reform are heard in Washington.

Insights for policy makers

The Voices for Health Care report suggests a number of insights to help leaders and others build public trust and support for significant healthcare reform.

1. Start with areas where there is significant common ground. The research revealed "low-hanging fruit" that leaders can start with to begin building firmer support for change.

2. Use the public's terminology and framework. The report identifies some examples of terms where the public's assumptions and definitions differ from those of experts.

3. Sequence the conversation. People have to work through certain
questions before they are ready to consider others. The report suggests a sequence of questions that leaders and others can use to structure the conversation in a way that allows them to come to firm judgment.

4. Consider the implications of the economic downturn. The economic
downturn seems to make people more willing to consider hard choices and rethink expectations. At the same time, the abuses of public trust
uncovered by the financial collapse have added to public skepticism and cynicism. The report cites the importance of transparency and two-way conversations.

Key findings from Voices for Health Care

Americans increasingly support universal coverage once they understand that the current system already pays for the uninsured. On the issue of universal healthcare, researchers found that once participants learned that costs for covering the uninsured are already largely passed on to the public, they were more likely to see the practical and economic rationale for extending coverage to all Americans.

Americans are open to revamping the healthcare model after examining the cost structure of the private system. Initially, most participants wanted to build upon the current health care system in developing a newer model.

Many changed their position after learning the extent to which the private-insurance system diverts healthcare funding to marketing, overhead and profit and working through the complexity involved in a "shared responsibility" system.

As a result, across all research groups, participants began to explore the feasibility of a stronger role for government in a more extensively overhauled model. Most supported a two-tier system in which every citizen has publicly funded basic coverage that they could supplement with private coverage purchased individually or through their employer.

Most would pay more for a system that works better. As participants began to understand all the ways in which they pay for healthcare (taxes, wages, insurance premiums, etc.) they grew concerned over a system that they viewed as simultaneously cost intensive and largely flawed, and expressed greater openness to paying more for a system that works.

Participants shift opinion of "freeloaders" and become more supportive of healthcare benefits for all residents after learning more about the circumstances of the uninsured. Another contentious issue where perceptions shifted over the course of discussion regarded whether a public healthcare system would cover "freeloaders," including people who do not work and illegal immigrants.

However, once participants learned that most uninsured people are actually working or are members of families with workers, they began to reconsider their assumptions about the uninsured and trended toward support of all state residents (citizens or not) being covered.

In addition, all dialogue groups included a percentage of uninsured that was proportional to the percentage in the population, so participants developed a better understanding of the realities being faced by the uninsured.

Researchers also found that once participants learned that costs for covering the uninsured are already largely passed on to the public, they were more likely to see the practical and economic rationale for extending coverage to all Americans.

Language is a critical, though surmountable initial barrier. The report identified vernacular as a key barrier to engaging the public. Researchers found serious confusion over the terms "basic health care", which most participants felt should include a very broad spectrum of services, and "choice," which participants used to describe the assurance that they had a say in important decisions about their healthcare — not, as some experts believe, to have access to every provider and treatment on demand.

More information

The report can be accessed at

You can also view the project video at

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