Editor’s Note: In addition to S. Ward Casscells, M.D. and Hiliary Critchley (photos and bios above), contributors to this post include Larry Kaiser, M.D of the University of Texas, John Zogby of Zogby International, Inc.; Grace Ren of Zogby International; and Stephanie Greer of the University of Texas.
On November 7, 2009, the U.S. House of Representatives passed the Affordable Health Care for America Act (H.R. 3962) by a vote of 220-215. On November 21, 2009, the U.S. Senate voted to invoke cloture and proceed with consideration of the Patient Protection Affordable Care Act (H.R. 3590) by a vote of 60-39. The Senate is currently considering that legislation.
The two bills are similar in many ways. But they also differ on several hot-button issues. To gauge public preferences on these issues, after the Senate invoked cloture, members of Zogby International’s online panel were asked a series of questions; 3,706 members of the panel completed the survey. (More information on the methodology and the precise questions asked, as well as demographic information on respondents, are available from the authors.) After reading a summary of similarities between the House and Senate bills, respondents were asked their preferences on several of the areas where the two bills differ. (Respondents were not told which position represented the Senate approach and which represented the House approach.)
(1) Financing. To help pay for expanding coverage, the House bill would impose a 5.4% income tax surcharge on individuals making more than $500,000 and couples earning more than $1 million. The Senate bill would impose a 40 percent tax on expensive health plans (defined as over $8,500 for individuals and $23,000 for families) and increase the Medicare payroll tax on individuals earning $200,000 per year and couples earning $250,000 per year. The Senate bill also includes a 5 percent tax on elective cosmetic surgery and fees on insurance companies, drug makers, and medical device manufacturers.
The House revenue approach was more popular than the Senate’s: 33 percent favored the House’s approach, while only 10 percent favored the Senate’s. However, over half of all respondents favored neither approach, consistent with a general reluctance to pay for health reform even among many who favor reform.
(2) Employer Mandate. The House bill requires employers to provide health coverage to their employees. Businesses with payrolls above $750,000 that did not offer coverage would have to pay a penalty equal to 8 percent of payroll; the penalty would be lower for smaller businesses, and employers with payrolls below $500,000 would be exempt entirely from the mandate. The Senate bill does not contain a mandate that employers provide coverage; however, any business with more than 50 workers where at least one employee qualifies for government coverage subsidies would face a penalty of $750 for every full-time employee if it did not offer health care coverage.
A significant majority of respondents, 59 percent, either strongly or somewhat agreed that employers should be required to provide coverage, while only 38 percent strongly or somewhat disagreed. However, when respondents were asked if employers that did not provide coverage should be fined, only 40 percent of respondents strongly or somewhat agreed, while 55 percent strongly or somewhat disagreed – almost the reverse of the results for the employer mandate in the abstract.
(3) Illegal Immigrants. The Senate bill bars illegal immigrants from purchasing coverage on a new health insurance exchange – and consequently from participating in any new public health insurance option sold on the exchange — even if they purchase the coverage entirely with their own money. The House bill does not allow illegal immigrants to receive subsidies to help them purchase coverage, but it does not prohibit them from using their own money to purchase coverage on the exchange.
Most respondents agreed with the Senate position; 66 percent either strongly or somewhat disagreed with allowing illegal immigrants to participate in the exchange or public option, while only 28 percent either strongly or somewhat agreed with allowing them to do so.
(4) Abortion Coverage. Through the provisions of the “Stupak amendment,” the House bill prohibits coverage of abortion by the new public health insurance option, except in the cases of rape, incest, or danger to the life of the mother. With the same exceptions, the House bill also prohibits coverage of abortion in policies purchased by people receiving government subsidies, although people receiving subsidies may purchase supplemental abortion coverage, if it is available, with their own money.
By contrast, the Senate bill allows abortion to be covered by the public option and other policies purchased in the exchange with the aid of government subsidies, but insurers must segregate public and private funds to ensure that only private premium payments are used to fund abortion benefits. The Senate defeated an attempt to add the tougher Stupak restrictions to its bill.
Most respondents agreed with the House approach to abortion coverage; 61 percent either strongly or somewhat agreed that insurance policies purchased with the aid of government subsidies should be prohibited from covering abortion, while 32 percent either strongly or somewhat disagreed. In contrast, 47 percent either strongly or somewhat disagreed with the Senate approach of allowing insurers to cover abortion using segregated private funds, while 42 percent either strongly or somewhat agreed with this approach.
Respondents were also asked whether they preferred the House or the Senate position on providing a new public health insurance option, but the provisions of the Senate bill in this area have been undergoing substantial change.