Editor’s Note: In addition to S. Ward Casscells, M.D. and Hiliary Critchley (photos and bios above), coauthors of this post include Thomas Amoroso, M.D., of the Quincy Medical Center; James Tyll of James Tyll Consulting, LLC; and John Zogby of Zogby International, Inc. The authors are also grateful for analytical advice contributed by Grace Ren of Zogby International and Stephanie Greer, Ph.d., and for helpful discussion with Larry Kaiser, M.D. Update: The methodology section of this post was updated on October 7.

Introduction. When polled at the end of September, fewer than three in ten Americans supported the health reform legislation being considered by the Senate Finance Committee. However, we also found respondents willing to engage in the health reform discussion by reading a detailed summary of the Finance Committee bill plus ten potential amendments.

In our survey, the first in which Americans were given an opportunity to “design the bill themselves,” we found that the adoption of three amendments to the Finance Committee package had the potential to significantly change public attitudes toward the bill. We found the single most decisive of the proposed amendments was reform of the medical malpractice system, which we defined as implementing independent medical reviews, mediation, and limiting non-economic damages.

A second opinion driver was the proposed elimination of the individual mandate, which would require everyone to have health insurance, with assistance for those unable to afford the premiums. The third amendment that produced major shifts in public opinion was adding a government-run “public option” to the menu of health insurance choices available under the bill. Together, the three most popular amendments would increase support from 27% to 57%, and decrease opposition from 59% to 41%, with 2% still unsure. (The questions and methodology used in the survey are in appendices A and B below.)

Background. The heated debate over health care reform has been the subject of numerous, widely divergent surveys of American public opinion. We surveyed support in June and were the first to report it had fallen below 50%, then found a rebound  — to “too close to call” — after President Obama’s speech to Congress on September 9 (submitted for publication).  Some recent polls, such as Rasmussen, have generally tracked with ours, while others (e.g., CBS/NY Times) have reported some 60-65% of Americans as being in favor of the major bill being debated today (that of the Senate Finance Committee, which is thought to have the best chance of producing a bipartisan bill and which has received most of President Obama’s attention).

Because survey results have differed substantially, some have suggested the public is unfamiliar with the bill, has been misinformed by advocates on either side, and would be more supportive if they understood the bill. Hence we set out to test two hypotheses: first, that people were interested enough and capable enough to understand a detailed description of the bill; and second, that they would be willing to choose from among ten of the most-discussed amendments, and determine which provisions would cause them to change from opposing to supporting the bill, or vice versa.

Results. During September 28-30, we polled a representative sample of 2,232 Americans to determine support of the bill in the Senate Finance Committee, which is at the center of the debate. Respondents to our poll were asked if they supported the bill currently being considered in the Senate Finance Committee (see Appendix A) and were then queried, depending on the status of their support of the bill, which of ten amendments, if accepted to the bill, would change their support status. The data are representative with regard to age, gender, geography, education, race, religious affiliation, and political party, but are slightly underrepresentative of the population on Medicare and Medicaid (23% of respondents in this survey versus 28% of Americans).

Who supports/opposes the current bill?

Overall, 27% of respondents support the bill as outlined, with 59% opposed and 14% undecided.

Among Democrats, only 49% support the bill, 32% oppose it, and 19% are unsure.  Republicans are 88% opposed, 4% in favor, and 9% unsure. Independents now oppose the bill by almost three to one (64% vs. 24%, with 21.5% unsure). Support is higher among women (33%) than men (21%), and a bit lower among seniors (22%) than younger adults (28%).

Whose support for/opposition to the bill is malleable?

While Caucasians, Hispanics, and Asians all oppose the bill  (opposition of 61% among Caucasians, 65% among Hispanics, and 69% among Asians), there is relatively more support among African Americans, who are, however, evenly split at 40% in favor, 42% in opposition, and 19% unsure.

The bill gets very low support among the poorest Americans, but that demographic also has the highest percentages of people unsure about it. Twenty-five percent of people making less than $35,000 a year answered they were not sure whether they supported the bill or not (compared to roughly 10-13% in all other income brackets).  The bill also gets little support from the middle class but growing support as yearly incomes went from $75,000 to more than $100,000. Those making less than $25,000-$35,000 had the lowest support at only 18% in favor with 57% opposed, while among those making $35,000-$50,000, support rises to 24%.

Tort reform (as the sole amendment to the bill) would turn 399 of 1,315 opponents into supporters, of whom 199 are Republicans, 137 Independents, 52 Democrats, and the rest uncharacterized. It would also turn 65 of 603 supporters into opponents. Of the 65, 50 are Democrats, 12 are Independents, three are Republicans, and the rest uncharacterized.

Eliminating the individual mandate with no other amendments would win over 350 supporters, (155 Republicans, 120 Independents, and 58 Democrats, and the rest uncharacterized) but drive off 70 supporters (45 Democrats, 21 Independents, and four Republicans).

Adding a public option (as the sole amendment) would win 308 new supporters (171 Democrats, 87 Independents, 37 Republicans, and the rest uncharacterized) but turn 106 supporters into opponents (75 Democrats, 23 Independents, 9 Republicans. (The subtotals sum to one more than the total because the data set is slightly weighted by key demographics. Any slight discrepancy is due to rounding.)

What amendments might “lead Congress to a ‘YES’ from the American people?”

For those who opposed the bill, we asked which of ten proposed amendments “would change your opinion to supporting the bill, if any?” For those in support of the bill, we asked which of the ten proposed amendments “change your opinion to opposing the bill, if any?” They were each allowed to choose three of the ten amendments.

The figures in the table below show how each of the ten amendments changed support and opposition to the bill. For example, with medical malpractice liability reform added, support for the bill rose from the baseline 27% to 44%, while opposition dropped from 59% to 46%. In order to assess the impact of each amendment, the number of people who became supportive of the bill was assessed by adding to these initial figures those who were initially unsure but changed to being supportive with those who were initially opposed and became supportive minus those who were originally supportive but changed to being opposed due to each amendment. In order to assess the number of people who became opposed to the bill based on each new amendment, we added to these initial figures those who were initially unsure but changed to being opposed with those who were initially supportive and became opposed minus those who were originally opposed but changed to being supportive due to each amendment.

Table 1: Impact of Individual Health Care Reform Amendment on Public Support

  % Support % Opposed
Malpractice reform 44% 46%
Eliminate individual mandate 42% 48%
Add public option 40% 53%
Increase taxes on high earners 36% 55%
Make insurance portable only 33% 56%
Close doughnut hole in Medicare Rx coverage 32% 57%
Reduce penalty on non-insured 31% 57%
Eliminate comparative effectiveness research 31% 56%
Add trigger option 28% 63%
Cut payments to MDs if a top 10% spender 27% 60%

In analyzing the responses in groups of amendments, in order to assess the overall impact of two or more amendments on overall support or disapproval of the bill, we assumed that our survey respondents would change their opinion to support/opposition of the bill if any of the analyzed amendments above were implemented, and also assumed that only the analyzed amendments above were actually implemented.

In assessing the impact of the top three most popular amendments, (1) implementing malpractice reforms, which would include independent medical reviews, mediation, and limits on non-economic damages; (2) eliminating the “individual mandate,” which makes everyone buy insurance, with assistance for those who can not afford the premiums; and (3) replacing the proposed cooperatives with a “public option” (government-run health insurance for those without other coverage) would most significantly tip the balance in support of the health care reform bill. If these three amendments were implemented, we found support for the bill would rise to 57% and opposition would fall to 41%.

If only two amendments were implemented, the combination of malpractice reform and elimination of the individual mandate would lead to support rising to 49% and opposition dropping to 44%. When both malpractice reform and adding a public option were implemented, support would rise to 55% and opposition would drop to 41%. If adding a public option and eliminating the individual mandate were implemented, support would rise to 51% and opposition would drop to 44%.

To determine how one particular subset of responses are correlated with or clustered to one another, an exploratory factor analysis was performed. Correlations for respondents’ opinions of two or more amendments of various strengths were found, but in no case were they correlated across different subgroups of respondents, indicating the heterogeneity of responses that are rarely linked to political affiliations. However, these rare instances of correlation along political spectrum are elucidated here.

For those who were initially supportive of the health reform bill, malpractice reform and the elimination of comparative effectiveness research are correlated, which are both Republican issues. This suggests that Democrats or liberals would lose interest in the bill should these amendments pass. Within those who were initially unsupportive of the bill, the segments that become supportive with the addition of a public option and the increase of taxes on high earners are correlated. This suggests that there is a bloc of Democratic respondents whose reactions to specific amendments are based on party line. Likewise, among those who were initially unsupportive, the Republican-backed amendments of malpractice reform and the elimination of comparative effectiveness research (as above) are also correlated. Among those who were initially unsure of their support of the bill, those who chose the public option are correlated with those who chose to increase taxes on high earners.

Discussion.  Our a one-of-a-kind survey of American opinions on health care reform was an attempt to learn if Americans would in fact read a detailed summary of the bill that is the current focus of the national debate, plus ten amendments, and be willing and able to identify the provisions that would, if enacted, switch their stance from support to opposition (or vice versa), or from unsure to pro or con. We found that the response rate, at 9% (versus the usual 10% for our health polls) was sufficient to reject the null hypothesis that people would not participate in a detailed survey of health legislation.

Second, we found support for the health care reform bill, as outlined, to be only 27% (with 59% opposed). This is a lower level of support than in our previous surveys, or those of others.

Third, because this study is the first in which Americans were given the opportunity to “design the bill” themselves, we were able to identify those issues that are critical to Americans’ support of the bill, or lack thereof.  We found the single most decisive of the proposed amendments was reform of the medical malpractice system, which we defined as implementing independent medical reviews, mediation, and limiting non-economic damages. Adding this amendment by itself would raise support of the bill from 27% to 44%, with 46% opposed.

A second opinion driver was the proposed elimination of the individual mandate, which would require everyone to have health insurance and provide federal subsidies for those who could not afford the premiums.

Support for the public option, which has become central to the public debate, is also significant: it would lift support of the bill to 40%. Quite a few oppose the bill only because it lacks a public option. Most supporters of the current bill can live with replacing the cooperatives with a new government-run Medicare-like option.

Fourth, we found significant heterogeneity in responses. Some amendments are clearly correlated (e.g., support of malpractice reform and the individual mandate), but we did not find that responses to proposed amendments fell solely along party lines. Rather, people identified the issues they care about most and fell into numerous clusters.

Thus, we were able to identify combinations of two or three amendments, which would net significant increased support for the bill. Stepwise and multivariate analyses were done to determine the degree of independence of the variables, which yielded the following findings. Together, the three most popular amendments would increase support from 27% to 57%, and decrease opposition from 59% to 41%, with 2% still unsure.  The combination of tort reform and a public option yields 55% support, with 41% opposed, while the combination of tort reform and elimination of the individual mandate yields 49% support, 44% opposition.

We also calculated the impact of (1) just eliminating the individual mandate (ignoring the fact that this would require an employer mandate and/or inducements to purchase insurance, which would inflate the Congressional Budget Office’s estimate of the bill’s cost); and (2) adding  the public option. This yielded 51% pro, 44% con.  

In summary, the American public’s support for the major health reform legislation being debated in recent weeks has fallen to 27%, with 59% opposed. Yet just one proposed amendment, tort reform, raises support for the bill to “too close to call” (44% for, 46% against). The second biggest boost would come from eliminating the individual mandate, and the third from adding a public option. Several combinations of two amendments would yield plurality or majority support.

These data may prove helpful if legislators wish to craft a bipartisan bill with support from a majority of Americans. On October 2, the Senate Finance Committee completed its amendments, and will vote on the bill by mid-October. It will then be blended with the more liberal bill passed several months ago by the Senate Health, Education, Labor, and Pensions Committee, a bill that is largely similar (e.g., in barring exclusions based on pre-existing conditions ) but has a public option, and higher costs. If a bill passes the Senate and one passes the House of Representatives, these bills will then have to be reconciled before the legislation could be sent to the president and signed into law.

During the Senate Finance Committee’s consideration of its bill, it adopted several changes to the original legislation proposed by Chairman Max Baucus (D-MT). Key amendments to the Finance Committee’s bill were (1) the easing of the individual mandate to buy insurance (exempting those for whom the least expensive policy would exceed 8% of adjusted gross income, and delaying the penalty and cutting it in half); and (2) allowing states to use federal subsidies to initiate public options.

If we assume that these two steps are half as successful in winning back public support as the two amendments we polled, we would project that the bill would be supported by 40% of Americans, but still opposed by 53%.  Majority support is attainable, according to our survey, by reforming the adversarial malpractice system — a reform that, according to the U.S. Department of Health and Human Services, would yield savings of at least $60B/year and which President Obama is investigating through an HHS initiative. Such amendments may yet be added by the Senate Judiciary Committee or by the full Senate, but would pose a difficult choice for Democratic leaders who have  staunch allies in the tort bar, yet are keen to see health reform pass.

What is clear is that Americans remain interested in health reform, and their views suggest several possible paths to passage of health reform.

Appendix A: Zogby Interactive Poll Script

We invite you to share your opinion on the national healthcare reform debate. As the bill is complex, we ask you to read the summary closely and decide if you support or oppose this bill.

 Broadly, The bill would….

1.  Require everyone have health insurance, with credits and subsidies for those who make less than 3 times the poverty level, or whose premium and deductible would exceed 2-11% of income (2% for family of 4 making $22,000/yr; 11% for $88,000/yr); choosing not to buy insurance would incur a penalty of $1500-$3800/family/yr

2.  Set up insurance exchanges and co-ops, rather than a public-option

3.  Cover those with pre-existing conditions

4.  Require all but the smallest companies to provide health insurance or pay into a pool for employees who use the federal subsidies

5.  Expand Medicaid eligibility to 133% of the federal poverty level (FPL)

6.  Eliminate lifetime limits and forbid the dropping of insured patients who become ill.

7.  Fill the Medicare Part D “doughnut hole, expanding coverage of medications

8. Limiting annual medical out of pocket expenses to $5,950 for individuals and $11,900 for families

9. Require Medicare and Medicaid to cover an annual exam and wellness plan

10.    Eliminate co-payments and deductibles for preventive services

11.    Set incentives for healthy lifestyles

12.    Set incentives for electronic records

13.    Set incentives for data reporting and bonus hospitals for risk-adjusted good outcomes (in surgery, care of heart attack and heart failure, pneumonia, and patient satisfaction), and penalize hospitals for infections, avoidable re-admissions or other preventable complications

14. Require transparency as to hospital volumes, outcomes, and prices 

15. Encourage states to develop alternatives to the present civil litigation system

16. The expanded services are estimated by the independent Congressional Budget Office (CBO) to cost $774B (over 10 years), which would be paid by: 1) savings from Medicare quality initiatives, ($409B over 10 years); 2) new taxes:  a 35-40% excise tax on “gold-plated” company plans above $8000 for individuals and $22,000 for families; plus fees on pharmaceutical, medical device, insurance, and lab companies, proportional to their market share, and fees from nonparticipating employers and individuals. The CBO estimates the legislation would generate net savings of $25B, and more in subsequent decades, but cites uncertainties as to savings from efforts to promote prevention, performance, and reduce waste and fraud. 

300. Do you support or oppose this bill?

1. Support

2. Oppose

3. Not sure  

(Q301 only if Q300=1)

301. Which of the following proposed amendments would change your opinion to opposing the bill, if any? (choose up to three)

1. Replacement of the proposed cooperatives by a “public option” (government-run health insurance for those without other coverage)

2. Inclusion of a “trigger option,” that would establish a public option only if private insurers do not offer affordable coverage

3. Malpractice reforms (independent medical reviews; mediation; limits on non-economic damages) .

4. Elimination of the “individual mandate” which makes every employee buy insurance, with assistance for those who cannot afford the premiums

5. Reduce the penalty for not having insurance by up to half

6. Increase taxes on high earners

7. Eliminate proposed funding for a comparative-effectiveness research institute

8. Cut by 5% payments to doctors who end the year in the top 10% for Medicare and Medicaid expense per patient

9. Closure of the Medicare Part D doughnut hole, which would expand the prescription drug coverage for seniors

10. Scrap everything but make insurance portable and offer vouchers to the uninsured who make less than 133% of the poverty level, so they can buy insurance, paid by increase in income and cigarette taxes

11. None of the above

12. Not sure

(Q302 only if Q300=2)

302. Which of the following proposed amendments would change your opinion to supporting the bill? (choose up to three)

1. Replacement of the proposed cooperatives by a “public option” (government-run health insurance for those without other coverage)

2. Inclusion of a “trigger option,” that would establish a public option only if private insurers do not offer affordable coverage

3. Malpractice reforms (independent medical reviews; mediation; limits on non-economic damages) .

4. Elimination of the “individual mandate” which makes every employee buy insurance, with assistance for those who cannot afford the premiums

5. Reduce the penalty for not having insurance by up to half

6. Increase taxes on high earners

7. Eliminate proposed funding for a comparative-effectiveness research institute

8. Cut by 5% payments to doctors who end the year in the top 10% for Medicare and Medicaid expense per patient

9. Closure of the Medicare Part D doughnut hole, which would expand the prescription drug coverage for seniors

10. Scrap everything but make insurance portable and offer vouchers to the uninsured who make less than 133% of the poverty level, so they can buy insurance, paid by increase in income and cigarette taxes

11. None of the above

12. Not sure

(Q303 only if Q300=3)

303. Which of the following proposed amendments would change your opinion to opposing the bill, if any? (choose up to three)

1. Replacement of the proposed cooperatives by a “public option” (government-run health insurance for those without other coverage)

2. Inclusion of a “trigger option,” that would establish a public option only if private insurers do not offer affordable coverage

3. Malpractice reforms (independent medical reviews; mediation; limits on non-economic damages) .

4. Elimination of the “individual mandate” which makes every employee buy insurance, with assistance for those who cannot afford the premiums

5. Reduce the penalty for not having insurance by up to half

6. Increase taxes on high earners

7. Eliminate proposed funding for a comparative-effectiveness research institute

8. Cut by 5% payments to doctors who end the year in the top 10% for Medicare and Medicaid expense per patient

9. Closure of the Medicare Part D doughnut hole, which would expand the prescription drug coverage for seniors

10. Scrap everything but make insurance portable and offer vouchers to the uninsured who make less than 133% of the poverty level, so they can buy insurance, paid by increase in income and cigarette taxes

11. None of the above

12. Not sure

(Q303 only if Q300=3)

303. Which of the following proposed amendments would change your opinion to supporting the bill, if any? (choose up to three)

1. Replacement of the proposed cooperatives by a “public option” (government-run health insurance for those without other coverage)

2. Inclusion of a “trigger option,” that would establish a public option only if private insurers do not offer affordable coverage

3. Malpractice reforms (independent medical reviews; mediation; limits on non-economic damages) .

4. Elimination of the “individual mandate” which makes every employee buy insurance, with assistance for those who cannot afford the premiums

5. Reduce the penalty for not having insurance by up to half

6. Increase taxes on high earners

7. Eliminate proposed funding for a comparative-effectiveness research institute

8. Cut by 5% payments to doctors who end the year in the top 10% for Medicare and Medicaid expense per patient

9. Closure of the Medicare Part D doughnut hole, which would expand the prescription drug coverage for seniors

10. Scrap everything but make insurance portable and offer vouchers to the uninsured who make less than 133% of the poverty level, so they can buy insurance, paid by increase in income and cigarette taxes

11. None of the above

12. Not sure

6. What kind of health insurance do you have, if any?

    1. HMO, such as Kaiser, MVP, etc.

    2. PPO, such as Blue Cross-Blue Shield, Cigna, United Health Care

    3  Medicare

    4. Medicare with part D

    5. Medicaid

    6. Tricare, military veteran insurance

    7. Other

    8. None

    9. Not sure

Appendix B: Methodology

With the approval of the Institutional Review Board of the University of Texas Health Science Center at Houston, a sampling of adults from Zogby International’s online panel, which is representative of the United States adult population, were surveyed to assess attitudes concerning health care reform utilizing both standard and novel questions. From September 28 through 30 of 2009, 2,232 Americans over the age of 18 were sampled, and slight weights were added to region, party, age, race, religion, gender, education to more accurately reflect the population. The margin of error is +/- 2.1 percentage points. Margins of error are higher in sub-groups.

Methodology used by Zogby International is discussed in the below articles

1. Currall SC, King EB, Lane N, Madera J, Turner S. What drives public acceptance of nanotechnology? Nature Nanotech. 2006 Dec; 1:153-5.

2. Ren G, Buturovic-Bradaric Z, Schwalbe K. Challenges and benefits of interactive online surveys: a case survey of youth political ideology. American Association of Public Opinion Research Annual Conference, 2009 May.

3. Sack K, Connelly M. In poll, wide support for government-run health. N Y Times, 20 June 2009.

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