Editor’s Note: What follows is the transcript of a roundtable on public opinion and health reform that took place on October 13,  the day the Senate Finance Committee approved its version of health reform legislation. Participants included Bob Blendon, professor of health policy and political analysis at Harvard; Chad Bohnert, director of marketing and e-commerce at Zogby International; Mollyann Brodie, vice president, public opinion and survey research, at the Kaiser Family Foundation; and Bill McInturff, partner and co-founder at Public Opinion Strategies. Highlights of the roundtable are also available.

CHRIS FLEMING:  Thank you all for joining us. I’d like to address the first question to Bob Blendon. Bob, obviously this is a pretty momentous day in the health reform process.  The Senate Finance Committee is set to approve its version of the health reform bill.  Could you give us your assessment where you think things stand now in terms of public opinion?

BOB BLENDON:  My take is relatively simple.  The public expects some bill to be enacted.  There’s a real sense that something has to happen.  The problem is this: If you look at polls that were taken in the last eight days which asked about the legislation that was being considered before the Congress, or the president put forward, not one of them has majority public support. So what you have is the sense that the public wants a healthcare bill to be passed.  As a result, I can’t imagine something not coming out of this Congress.  But there’s a lot of concern about what’s included in these bills, and the concerns are around issues that are not all about if there is a public plan or employer mandate. They are about the cost of services for people, concerns about taxes, about the deficit, about Medicare cuts.  So I believe there will be a lot of public concern about the final legislation that emerges. The bottom line is we’re moving towards a final bill, but the desired content of it in the public’s mind is not settled.

FLEMING:  Chad, we recently published some findings by Zogby. There were three amendments that, if they were added to the Senate Finance bill, could take minority public support and turn it around to get majority support.  I wonder if you could briefly go through those findings, the specifics that you felt like could be added to the bill to increase public support, and then maybe folks could react to those and pick up on Bob’s point about concerns about specifics in the bill.

CHAD BOHNERT:  Sure. This polling data was from 9/28 through 9/30/09. All poll respondents before going through the survey were given the 16 points of the Baucus bill, and we made sure that they read all of those points clearly, over a page worth of information.  On our first ask, we were the same as other polls: After reading the 16 points, it was a 27 percent support, 58 so 59 percent opposed, and the 14 remaining not sure.  But then we asked, of several proposed amendments, what changes would make them support the bill if they were initially opposed to it.  And you’re right, we did have three amendments that went to the top, but there were also some others that tied in the third place.

The amendment that created the most new support for the bill was malpractice reforms:  Independent medical reviews, mediation, limits on noneconomic damages.  That was the one that spiked the highest. The next group of amendments in terms of turning opponents into supporters included replacement of the proposed cooperatives with a public option; the elimination of the individual mandate; and scrapping everything in favor of ensuring insurance portability and providing vouchers for those who are uninsured, making less than 133 percent of the federal poverty level. Also worth noting: 43 percent of opponents said none of the amendments we offered would make them support the legislation.

So I second the idea that there is a mood for change, but what change is truly going to happen is still anyone’s guess.

JOHN IGLEHART:  As professionals in the field of public opinion surveys, how do you evaluate findings like the Zogby findings, recognizing that the bills are exceedingly complex? Members of Congress don’t understand them for the most part, and yet these respondents obviously are people in all kinds of walks of life, not health policy wonks.  How much do they really know about an individual mandate, or tort reform, or whatever?

BILL McINTURFF:  John, I believe the Zogby poll was an Internet study so people could read a description of the bill?

BOHNERT:  That is correct, and it was a very detailed description. We still had about 14 percent of individuals telling us they were not sure, even after reading those points.  So you still have those who are just disengaged, or are not able to form an opinion.  But what’s important is that perception, right or wrong, equals reality to folks. 

McINTURFF:  I agree with Bob Blendon that in the public’s mind there is something called the Obama Health Care Plan.  And so this overall read people have where you just ask whether they favor or oppose something described as the Obama Health Care Plan, — despite the fact that I have clients who feel strongly that there isn’t one and you can’t ask the question that way, the public certainly feels they can answer it.  The public can identify what they see as the key elements of the plan, and the fact that it’s got plurality or majority opposition is important.

Number two, in most of the survey work that we’ve done — with physicians, with business audiences, online, and WITH NBC and the Wall Street Journal where we’d later read some brief description – if people read the actual elements of the bill, support has gone up, not down. 

Three, the language really is important. For example, in the NBC-Wall Street Journal poll, we did what we thought was an individual mandate question, whether that was acceptable or unacceptable, and in the first month by two to one people said it was acceptable.  In the second questionnaire we did a month later, we explained that if you were above a certain income and you did not buy insurance you had to pay a penalty or fine; the numbers totally reversed.  By two to one respondents said that’s unacceptable.  A handful of very small words, introducing the concept of a penalty or fine, made that radical a difference about people’s understanding regarding an individual mandate. 

I’ve seen this in the Kaiser work. Mollyann has done some testing on how you describe the public plan.  She used the phrase “Medicare,” to see if the introduction of the word changed support.  You can see other pollsters trying alternative languages to make sure that you can look at a stable understanding.

Kaiser also in recent years has done a lot to do on both an employer and an individual mandate.  In December of ’08, they used a really powerful design where people say they support these mandates, then you present one opposition statement and watch support for both collapse.

As a pollster who has done a lot of health care polling, you learn a lot about the necessity of very precise language, testing different words and languages for reaction, and then testing some concepts that give people some of the tradeoff information they’re going to be hearing, all of which are needed to try to figure out where you think people are going to end up in this process.

The Importance Of Framing And Context

MOLLYANN BRODIE:  Thank you, Bill, for speaking on those findings because I did want to add that to this discussion. One of the things that we really do know, especially in the midst of a contentious public debate, is that it’s not just the specific language used to describe the questions, but the framing and the context of the questions, and it really matters in terms of where people ultimately come out.  On the example that Bill was just describing, on the individual mandate and on the public plan, by just doing the strongest argument for and the strongest argument against, I can move favorability from 29 percent to 76 percent. What that says to me is that while people hold core beliefs and strongly held values, and while they have an initial sense of how they feel in the abstract about a lot of these approaches and specific complex policy topics, the context in which those policy topics are discussed matters a great deal to where they’ll ultimately come out.  People’s strength of opinion on a lot of these individual items is not nearly as strong as maybe their initial starting point is. 

But that doesn’t mean, and this goes back to where Bob started this conversation, that people don’t want change.  We have to take the step back and remember that much of the reason we’re even having this debate is because people are struggling with paying the health care bills.  Even in our poll last month, a third told us they’re having problems paying bills.  Over half said that they were putting off or postponing care because of the cost of health care.

When people are trying to evaluate how these bills –- because there are still multiple proposals on the table, there still isn’t one bill to evaluate — they’re trying to evaluate how they’re going to affect them and their family.  I don’t think it’s surprising that people right now are anxious about that.  They’re anxious about how these things are going to ultimately affect them in their pocketbook, affect them as they try to seek care. I think that when we see different answers on a variety of polls, what we’re really measuring is this fundamental anxiety out there as people are trying to assess what it’s going to mean to them and their family at the end of the day. 

FLEMING:  Let me just ask you to expand on that.  As people figure out what this means, as they sort through all this different information, do you have a sense of whether one perspective, one side or another in this debate, is doing a better job of getting their context out there as the controlling framework that people are going to be looking through?  Are people moving towards the Democratic perspective that this is going to help, or towards the position that maybe this will make things even worse than they are now?

BRODIE:  What we’ve seen with our polling, and it’s not dissimilar to what we saw in ’93-94, is that we started with a big group in the middle who thought that they might not be affected by the proposals. Over time, the share saying that they and their family will be better off – the largest share, though not a majority — has remained relatively stable.  But that group in the middle, those who said that they would not be affected, has moved towards the worse off side.

Now, the other thing you can’t remove from this discussion is that there is a real partisan divide when we look at all these data.  From the beginning of this debate Democrats have been solidly on the side of change, and solidly on the side that they and the country will be better off.  Republicans have been solidly on the side of not wanting change, and solidly on the side that they and the families will be worse off.  And its independents that have moved a little bit back and forth over the course of the debate.

FLEMING:  Bob, I wonder if we could come back to your initial comment when you talked about what the uncertainties were in people’s minds:  not the issues that have received the most attention, such as the individual mandate or the public option, but worries about Medicare, worries about the consequences of Obama Plan, if there is such a thing, on affordability for people who already have coverage.  Could you expand on that a little bit?

Looking Beyond Issues Emphasized By The Media And ‘Influentials’ To Basic Affordability Concerns

BLENDON:  The media tends to focus on three or four elements in these bills, and that’s all the “influentials” like to talk about.  But the public worries about a lot of other things. For instance, most of the components for the Clinton Plan were popular with the public when the polls said the plan was dead.  And so you’ve got to be very, very careful of just focusing on a few policy elements.

So what’s on people’s minds?  Middle class Americans have taken a terrible bashing in this recession. They want health reform, they want a change, but they do not want to be asked to pay a lot more in their premiums or taxes.  The way the five Congressional bills have been debated is they hear taxes out of every single bill, and they see rising premiums, and they’re worried about that.  That doesn’t mean that they don’t want reform, they’re just worried about their being stuck with a large bill for it.

Secondly, there’s no poll that shows that people want to pay for fixing health care by reducing health care expenditures for retirees.  That is something that came out of the   administration and Congressional budget dynamics.  Every time you ask them, especially seniors, they say don’t take funds out of Medicare, and the bills move along doing it anyhow.  That makes people anxious.  They have parents and grandparents and they’re nervous about what hundreds of billions of dollars going for something other than Medicare means.  Also, the deficit doesn’t play very well politically. It just turns out, in the Clinton years and now, it is important to people.  They’re nervous about the future of the economy.

I want to go back to the issue of the individual mandate. The individual mandate is not a matter of words.  It’s a matter of what people are learning about.  It only exists in Massachusetts.  Some polls just say we have a requirement, and that gets about 50 percent.  Then some say we’re going to make it affordable for you, and some newspapers make it sound really affordable.  That shoots the poll number right up.

Than, as Bill says, you introduce a penalty.  These are really serious words to people because when you introduce a penalty, people say, “My God, I could be caught some year and I might not be able to pay it, and now I’m in another situation.”  Therefore, the discussion about what this mandate actually is about will turn out to be very important, because millions of people are not going to have business-provided health insurance.  So they’re going to be listening not to the principle, but to how it works for people like themselves.

These are things which are driving public opinion, but the issue about it costing too much, and the sense that there actually could be restrictions – you see this quality movement — these are not things related to whether there is a “this type of element” or not.  It’s what people believe is going to happen to them, and that’s the issue they are worried about. 

Though to give credit to what we just discussed here, malpractice reform as a popular issue has been in every poll I have looked at for six months. It was not in play, and now it is a serious issue to people because they think it will lower costs.  They are obsessed with lowering their healthcare costs, and they’re listening for something that would lower it.  Malpractice liability reform didn’t come back into play — and it’s not in the bill — until the Congressional Budget Office said last week that this really could lower people’s costs.  And now you see what the polls have shown all along, it’s a very popular item and it’s something that would relate to people’s fears that they can’t afford the change that’s about to happen.

That’s what’s going through people’s minds – can I afford the change?  The President ran telling you that every American would spend $2400 less.  That was in his plan.  And so people who were answering this poll say, “How much more am I going to pay?  What happened to the $2400 that I wasn’t going to pay?”  That’s just the nature of these debates, but that’s why the anxiety leaves the poll results to be much lower than the actual polling on particular aspects of the bill.

FLEMING:  Chad, your polling found, as you mentioned, that malpractice liability reform was perhaps the biggest changer or game changer in terms of public support.  Did your poll have other questions that would pick up on why that was the case,, that would pick up the kind of worries that Bob Blendon was just talking about in terms of affordability, and do you have the same sense that he does of what’s moving through people’s minds on this?

BOHNERT:  Yes. One interesting point: We found that 30 percent of those opposed to the bill would support it if malpractice reforms were added. But on the flip side, for those supporting the bill, what would make them oppose it?  You get 11 percent saying that if we add malpractice reform they would oppose it.  So you get partisanship on both sides.

Now talking about what’s it going to cost.  When we asked supporters what would make them oppose it, 12 percent said they would oppose the bill if increased taxes on high earners were added.  But on the flip side, if you take the the folks that said they were opposed, 16 percent said they would support it if higher taxes on high earners were added.  So because of the partisanship on both sides, the net change from a lot of these changes can be very small.

Trends In Polling Data

IGLEHART:  Bill, how has the polling of Republicans changed, if it has, in recent months, in relation to reform?

McINTURFF:  I think there’s been only a modest change.  Republicans moved very quickly against something called the Obama Health Care Bill, and we need to put this bill into context.  There are concerns in the public about spending, and the role of government.  Those feelings were ruptured because of the February stimulus, purchasing General Motors in March, and the health reform bill has the misfortunate of following these other very large events.  As a result, we’re having a public discussion of what it means to have an Obama administration that deals with the role of government and spending. This bill has become a surrogate measure for an enormous amount of emotion around those issues, and certainly among Republican core opponents. Bob’s point –- and I think it’s a good one – is that you need to take a step back and look at the macro-picture, and it’s not each individual element.  It’s a broader concern.

Republicans by August were very strongly opposed.  They are a little more opposed today.  The difference between our August and October polling — and our stuff in this respect differs from Kaiser’s — has been a shift among Democrats.  Independents have not moved much – there is still a plurality against the Obama plan for the most part.  It’s the Democrats that have moved a lot from August to October. The reason that the numbers are, I think today marginally better than they were in August for something called the Obama Plan is because these last six weeks have seen a marked increase in the level of Democratic support. So today we’re watching a very bifurcated public, with once again Republican and Democrats in very sharply different camps, and what Bob describes as the overall bill being a little bit under water because of plurality or a slight majority of independents leaning against the Obama Plan.

IGLEHART: Does anybody have survey data on voters in those districts represented today by Democrats that previously were represented by Republicans, what the attitudes are in those districts?

McINTURFF: Not in the public domain.  But I can say that if you’re a blue dog Democrat, between the stimulus vote, the health care vote, the climate change vote, and the President saying that he wanted to get on to immigration when all that was done, there’s a reason those men and women are very, very cautious.  In our last track in September among white voters, we asked this very simple question: Is the Obama Plan a good idea, a bad idea, or don’t know? (Don’t know is a read option, so that when you say good or bad idea, you really kind of mean it.)  Among white Southerners, the good idea/bad idea was 21-61.  If you look at where current Democratic/previously Republican seats are in the South and in the Mountain West, there’s a reason you are seeing this kind of caution among Blue Dog Democrats.

CHAD BOHNERT:  We took those districts that the Cook Report identified as potentially vulnerable in 2010. We compared those districts against all the other safe districts, and we saw almost equal support and oppose in districts that were up for grabs and those that were safe.

IGLEHART: How about Senators? What are the attitudes in states where it’s close to a tossup between the R’s and the D’s?

McINTURFF:  Senator Olympia Snowe (R-ME) just voted for the Senate Finance Bill today; she’s in a 60-plus Obama state.  There’s a very interesting factoid: If you look at the initial votes on the public plan in the Senate Finance Committee, in the states represented by Democratic senators who voted against it, Obama’s average vote was 49 percent. In the states of Democrats who voted for it, the Obama average vote was 56 percent.  So it’s not hard to look at the way public opinion influences behavior, because that one little factoid says a lot about the nature of the Democrats in the Senate Finance Committee who voted against the public plan versus those who voted for it.

FLEMING:  On the atmospherics of this, it seems to me that some of the things that might scare people — like some of the savings in Medicare, the “MedPAC on steroids” idea, and outside of Medicare something like the Cadillac health plan tax –- are the very things that might be considered actual reforms in terms of possibly cutting costs as we move down the road, actually “bending the cost curve,” as they say.  Is there a way get the public to view these things as positive reforms rather than threats?

Public Worries About Personal Costs, Not National Costs

BRODIE:  We have known for years and years through all of our polling that the public is not exactly willing to give up much in order to get all the things that they want.  In fact, even in some of our recent polls, the majority believe that reform can be done without spending any more money, and they believe it can be done without changing people’s health care arrangements.  I think that goes directly to the fact that people don’t think that patients are necessarily to blame for the problems in our health care system.  We talk to them about what’s driving rising costs:  They think it’s malpractice, they think it’s high profits.  They think it’s fraud and abuse — if we just solved all the fraud and abuse and waste in the system, we could pay for everything. 

As Chad said before, perceptions are a reality for people.  They’re not economists, they’re not political, they don’t necessarily understand this concept of bending the curve because they don’t attribute the rising costs to the same things economists attribute the rising costs to.

And, again, we think about what’s on people’s minds.  People are worried about the costs they pay, not necessarily the cost the nation pays.  And in fact we’ve asked them plenty of different ways what worries you most, the overall cost to the nation or the cost of your out-of-pocket payments, and it’s always the individual costs.  It’s never what’s going on in the nation.  In fact, people say as a nation we spend too little on health care, which certainly goes against what most experts would say at this point.

So I think that it’s important to recognize that it’s going to be hard to educate the public.  We’ve been trying for 15 years to get the public to understand who the uninsured are and they still don’t understand that one factoid.  So I think trying to get a sense of bending the cost curve might be more than we can expect.

But that doesn’t mean that we can’t get people on board, and again, it comes down to framing.  So take the Medicare provider cuts as an example.  When we talk to seniors about cuts to the Medicare program or Medicare providers to pay for health reform, of course they are completely against it.  They don’t want to see cuts to the program. But if instead you talk to them about a way to help keep Medicare financially sound for the future, a majority favors it. 

I think it would be too much to expect the public to come on board for big changes that they think will hurt them and their family.  That’s just not the way the American psyche works.  On the other hand, there are things that can happen and ways to frame it that can help bring people closer to the views of the experts.

FLEMING:  Bob Blendon, do you agree with Mollyann?  How optimistic are you that you could take for instance the Medicare cuts and frame them in a way that is going to make people less nervous?

Wording Or Substance?

BLENDON:   I always get concerned that it sounds like it’s wording rather than substance.  Republicans are repeating over and over again that the money that’s being saved is going out of the Medicare program.  It’s not going to make the Medicare program more solvent.  If some of the money that was being reduced went to make it more solvent, it would take Molly’s point and make it more of a reality.  But I’ve actually seen in newspaper stories about how billions are going out of their Medicare program to somebody else.  So one of the real issues for the public has to be how many billions of dollars you can take out of Medicare to spend on other groups before care deteriorates.  That was the central issue for seniors in the 1994 debate.  Their support for the Clinton Plan dropped by 25 percent, and they were not likely to be impacted by the Harry and Louise ads.  They were people who heard their Medicare funds were going to another place.

I think there’s some real substantive issues here for the public.  The Baucus bill moves less money away from older people.  AARP can say you’re not going to lose that.  But it’s really important that some of the changes there really will be seen as very threatening to people, and the wording changes will only matter if somebody validates it as being real.  If there’s a $2,000 penalty for a 30-year old who doesn’t buy insurance, a lot of 30-year old Democrats are not going to like that plan.  And I can’t rewrite the phrasing to get it right. 

If you actually watch what Senator Olympia Snowe has done, she’s taken things that really bother average people and she’s moderated them, so it will not solve as many health care problems as experts want, but if you actually looked at the proposed legislation, they are more moderate in their threat to middle income people and the seniors, and I think that’s what’s going to help get these bills over the home plate. It will not do as much the public would like, but it will be less threatening to people in this environment.

Changing The Focus From The Uninsured To The Insured

McINTURFF:  In a survey we did, we presented people with trade-offs: whether they thought this was something you needed to do, and was it acceptable or not acceptable.  Echoing Molly’s point, when we’ve asked people if they would be ok with a little less care so that everybody gets something, that’s been an unacceptable trade-off. 

We asked people an open-ended question from around April to August: What is the Obama plan, what does he want to do?  The answer tended to be that Obama’s plan was to cover all the uninsured and to have a government plan to compete with insurers.  Those were the two elements, and I think people reacted by thinking, “I betcha I’m going to end up paying more, and I’m not sure I’m going to get anything.”

And so both in ’93 and ’94 and then today, every time we’ve had an incredibly long focus about covering the uninsured, there has been a counter-reaction that has made passing health care harder.  So starting in August, the President started in August changing the language to health insurance reform.  I think that they are trying to change the focus, to try to convince the majority of Americans who have stable coverage that there is a benefit for them.  They are locked into trying to convince enough people that there’s enough in there for me to put up with for the trade-offs.        

I’d say lastly that in a common sense way, when we’re doing focus groups, when you talk about the shift in Medicare, people are really confused and they say, “What?  So in other words, we’re going to take money away from the one public program that we’ve got that’s working for seniors, and we’re taking money away from them to start another big public program?”  There might be lots of ways from a policy perspective you can explain what they’re doing; I’m just saying that with real people sitting in a room reading and learning about this, it comes down to something that seems very confusing.  Why would you take money away from something that’s working, that already has money troubles, to start a huge new program?  To Bob’s point, however it is worded on the survey, that’s kind of a fundamental disconnect that has been a little confusing for the American public.

FLEMING: Chad, does that jibe with your sense as well?  And if that’s the way people are viewing it, are we heading down a road where we end up with something which, because of these apprehensions, may not end up sort of doing nearly as much as maybe some of the people in the health policy world had hoped going in, in terms of decreasing the number of uninsured or bending the cost curve by as much as people want it? 

BOHNERT:  I think you’re exactly right, that is where we’re headed. But what’s interesting is that we asked these same questions of both the insured and the uninsured, and the numbers weren’t that far off. You had 27 perecent support overall and 32 percent approval among the uninsured. You’re not moving it much there.

On the other hand, in focus groups, we also asked two groups — the currently uninsured and those who had been recently uninsured but were now covered — “Whose responsibility is it for you to have health insurance?” Virtually all the currently uninsured said it was a government responsibility, whereas those who had found a way to obtain insurance said it was their responsibility. Across partisan lines, the attitude of this second group was “O.K., I found a way to get coverage, why can’t others do it? “

We’re going to get a bill that’s in the middle of all of this in some form.

Stakeholder Concerns

McINTURFF:  There is, of course, the other issue of the stakeholders.  The pharmaceutical folks thought they were settled and supportive, then oops, now they’ve got some stuff they’re unhappy with.  I read about Chip Kahn from the Federation of American Hospitals who said, “Hey, we agreed to those Medicare cuts because you promised 94 percent coverage rate.  Now we’re at 91.” The health insurers said “Look, we promised billions of dollars in savings, but we  need a large insurance pool full of healthy folks, and that weak individual mandate won’t do it.”  

So we don’t know what’s going to happen yet.  There’s been so much attention focused on how different this time around is than ’93-94 because these major players have come to the table, but they came to the table in return for incredibly explicit guarantees. 

FLEMING: Mollyann, I wonder if you could pick up on that a little bit. I’d be curious to hear your sense of a couple of things. First, every year in Health Affairs, researchers from Kaiser and the Health Research and Educational Trust examine the state of employer coverage, and every year that deteriorates.  So I wonder if there is a way to capitalize on that and say to people who are insured, look, this is not all about helping the people who are uninsured now.  This is about creating a situation so that if you don’t have your employer coverage tomorrow, you won’t be out in the cold.”

Second, I wonder if people think that the issues in terms of public opinion, and the issues that Bill McInturff just talked about with the stakeholders, are so severe that at the end of the day that this could all fall apart.  What the chances that at the end of the day we don’t get a bill?

BRODIE:   Let me start with what Bill just raised regarding the stakeholders, it’s a really important point for this conversation. Even though the conversation is focused on public opinion, public opinion is just one of many, many factors in any kind of public policy debate, and particularly one that is as massive as something like trying to reform the U.S. health care system.

Public opinion tells us where the public is at any given point in time, but it doesn’t necessarily tell us the right thing to do, or necessarily tell us what’s going to happen.  I’ll use Medicare part D as a case in point. None of the public opinion data leading up to the passage of the drug benefit would have predicted that it would used private companies as a means to deliver the drug benefit.  All the seniors wanted to just have another prescription drug benefit added to the Medicare program.  But that’s not what happened because of politics, stakeholders, and ideology. 

If you remember the data at the time, there was alot of anxiety and worry about the plan as it passed, lots of concern about how implementation would work.  Implementation took a really long time.  Nobody really bore great costs right away.  At the end of the day, though, most people I think, would come away saying that — the doughnut-hole issue and a few individual problems set aside — for the most part it was a successful implementation.  Seniors got a new benefit that they wanted and needed, but it went through a policy process very different from what the public wanted.

What we can say about public opinion now is back to the basics: People are concerned about costs, they’re anxious about it.  At some levels some things haven’t ever changed in this debate, going back as far as you want.  At this point the Hill is really where it’s going to be happening, and ultimately the public is going to come down on this.  Let’s say there is a bill: It will be perceived and judged on what happens with the implementation time line.

When you start hearing about some of these time lines, it’s a long time, and for the most part nobody sees any radical change early on, and I think that in effect will reduce anxiety and fears.  As we talked about, it seems like the expectations on neither side will be met.  The pro-reformers are not going to get the nirvana that they had hoped for, but it’s unlikely that the opponents are going to see something that’s as horrible as they had been fearful of either. 

So I think that there is still a long way to go, and that right now the real action is going to be in the Washington, DC area between the stakeholders and the legislators, as they keep working out the details of these proposals to try to get something to a vote.

IGLEHART: How does the average member of Congress — say a Democrat from a conservative district – how does he or she factor public opinion into the calculus when it comes to voting yes or no on an amendment or on a reform bill?  Molly points out that public opinion is only one factor in the equation.  How big a factor is it for the average member of Congress, if there is such a thing?

McINTURFF: Well, that’s a constituency I’ve worked with for a long time directly.  I think there are two classes of bills.  There’s the Clinton impeachment, there’s the go-to- war vote, there are a handful of times members will tell me, “This is the vote of my career. This is one of the handful of votes that will decide how history judges me, and I want to do what I think is right.”  For Democratic legislators, this is probably close to rising to that level.

The second class of vote is everything else. Everything else is this complex mish-mash of public opinion, donors, parties, constituencies, and committee assignments. 

As part of this mishmash, the prospects for health reform are in my mind going to be influenced by New Jersey and Virginia election results.  If the Democrats lose both governors races and if Virginia gets ugly in terms of margin, I think that we’ll have a very chilling result, and I think one of the reasons that we are in this legislative calendar is they are desperately trying to get these votes done before those elections. Conversely, if the Democrats win both races, that would be used as a powerful signal in the Democratic caucus: ”The American public knew we inherited a difficult time, they want change, they’re still with us our agenda.” 

But imagine the dialogue with those Blue Dog democrats if the party has just lost New Jersey and Virginia as they get to the final vote on health reform: That would be a very chilling input.  If they do pass health reform, I have a feeling that between the stimulus and that, members are going to start telling their leadership, ”That’s it.  I’ve done my “Profiles in Courage” votes until I get re-elected.”  And it’s going to make the rest of 2010 very difficult on a lot of the major elements of the Obama agenda if they get a very substantial health bill passed.

BOHNERT:  That is right along the lines of what I am hearing members saying, particularly the Blue Dogs: “I don’t want to spend the next 12 months defending a vote, but I also don’t want public opinion to necessarily influence my vote.”  So they’re very torn, and that goes exactly to what you’re saying.

BLENDON: The other side of this coin is that this issue is unbelievably important to the Democratic voter base.  If it were to die and nothing were to pass, in many areas you will have trouble mobilizing Democrats when you’re running for re-election.  They’re just not going to show up in 2010.  My view is that not acting on health care would be to Democrats what raising taxes would be to conservative Republicans:  If you do it, they will not even support their own party.  They just won’t show up.      

My belief is that Democrats need a bill to pass, but it does not have to be that huge.  They need to show that they did something that was significant, and it wasn’t that threatening.  But I think having no bill, even for most Blue Dog Democrats will be a serious problem among the Democratic base.  They care a lot about this issue.  But what’s in it could be more modest than some of the current bills.

The Aftermath Of Passing A Bill

FLEMING:      We’ve talked about public opinion around the initial passage, or at least the initial attempt to pass the bill.  One thing that people don’t talk about as much is that there are all sorts of things that a bill like this will assume will happen: continuing restraints in provider payment updates, the Medicare commission – if there is one — making decisions that the Congress doesn’t interfere with.  What are the chances that you pass of a bill and then, once the spotlight is off a little bit, we go back to business as usual so that a lot of what happens in the bill gradually gets overturned and we end up with a lot less change than we thought we had?

McINTURFF:  Well, that’s the other “genius.”  This thing doesn’t even happen until 2013.  So we need to understand that, on purpose, that we have this “major reform” but the major reform is meant to happen after Obama’s re-election. This means he gets to run on “We passed a major reform and boy, it’s coming soon,” and not “Oh my God, this whole thing is collapsing and it’s my fault,” if that’s what happens.  Who knows, maybe it will be successful, but the point is that no one has seemed to want to gamble his or her own re-election on that outcome.  So it’s more likely, whatever happens, to be stuck in a drawer to wait until the next time, which is after the re-election campaign.

BLENDON:  There are just two models historically: Medicare and Medicare Catastrophic.  In Medicare they gave the insurance cards out on day one and you paid for it years later.  In Medicare Catastrophic you paid for it for two years, and they never got around to giving the cards out.  If there’s no pain I’m completely with Bill, but if there is anything in this legislation that has people suffering pain for the first four years, it will have a different political impact than if nothing happens and then cards are given out four years from now. 

I’m not sure if there will be parts of these bills that will lead to pain for the public. If there is, people are going to try to move away from that pain over the next four years.  If nothing threatening happens in the short term, then I think it waits to a future election.

BOHNERT:  90 percent of folks that we polled said that they wanted to make sure that all bills were posted for 72 hours online before any votes were taken.  In the past, you couldn’t find 90 percent to support anything, let alone that, four years ago.  So this debate has definitely crossed the line: The public wants to be informed, and that’s likely to persist.

BRODIE:  If you look at the history of health care reform, no bill has ever gotten passed.  If a bill passes, there is something symbolic about that; it will have meaning in and of itself politically moving forward.  Medicare has had many, many legislative changes and modifications in the 40 years after it was passed, so I think that a health reform bill may be a first step.  It may be a much more modest step than proponents would like, and a much bigger step than opponents want.  But if a bill actually passes, that’s an historic achievement in and of itself.

FLEMING:  Thank you all.

This entry was posted on Friday, November 6th, 2009 at 11:44 am and is filed under All Categories, Health Reform, Medicare, Public Opinion. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.