FINDING 1: Americans of all political affiliations are calling for substantial changes to the health care system, including those who are satisfied with their current insurance.
A clear majority of Americans want to see significant changes to the American health care system: 40 percent want to see major changes and another 22 percent want to redesign it completely. Only 7 percent of Americans think the system should be left the way it is; see Figure 1.
This desire for change is shared across the political spectrum. Among Republicans, Democrats, Independents and people who are apolitical, around 6 in 10 say the system needs major changes or a complete redesign. However, retirees and people over 55 are significantly less likely to seek a complete redesign.
In the focus groups conducted for this research, participants expressed outrage and frustration regarding the health care system and made clear their strong desire for change.
“It is an urgent problem and it’s getting worse.” – Earth City, MO; in his 70s; White; Republican
“There’s so many parts to the system that are broken.” – Dallas, TX; in her 30s; White; Republican
“Why don’t we just knock it down and start over?” – Dallas, TX; in her 30s; Black; Independent
“If you make minor changes you only get minor improvements. I think we as Americans just need to be open to the idea that we might have to break down the system to see improvement.” – Dallas, TX; in his 30s; Asian; Independent
Even people who are satisfied with their current insurance want the health care system to change.
People’s stated satisfaction with their own insurance coverage belies opinions about the nation’s health care system as a whole. Among the nearly half of Americans who describe their current health insurance as excellent or very good, just over half (54 percent) nonetheless believe the health care system needs major changes or a complete redesign. This includes nearly equal proportions of Republicans, Democrats, Independents and apolitical individuals who describe their insurance as excellent or very good but nonetheless believe the system needs to change substantially.
Focus group participants often expressed their feelings of insecurity with the health care system, particularly regarding the financial toll it exacts on them and their families.
“The system works to some degree. But the system picks and chooses who it works for. I thought at one point that I had very good health care. But the rug gets pulled out from under you and then you’re struggling.” – Baltimore, MD; in his 60s; White; Republican
“The opportunities and the good fortune that some of us have been given are not available to everybody out there. Not everybody has insurance through a job.” – New Rochelle, NY; in his 50s; White; Republican
“People are tied to jobs they can’t leave. They can’t divorce. If someone is diagnosed with a condition, then a pre-existing condition will prevent them from being covered in the future. I think there should be some basic level of health care provided to everybody regardless of employment. Because you can easily become unemployed.” – Baltimore, MD; in her 40s; Asian; Democrat
“There are people who have access to health care but then they don’t have the means to afford care.” – Earth City, MO; in his 30s; Asian; Independent
“I have little kids. My deductible is like $6,000 or $7,000. A couple of clinics that pop up are nice but when they can’t do x-rays then you’re paying for this place and you have to go over here and pay for that place, I mean those costs are adding up. Why do they have this stuff if you can’t really benefit from it?” – Earth City, MO; in her 30s; Latina; Republican
FINDING 2: Americans across the political spectrum share many of the same goals for health care, beginning with making it more affordable for ordinary people — perhaps because half of Americans have experienced serious financial difficulties due to health care or know someone who has. Other important shared goals include covering pre-existing conditions and covering long-term care.
Of the nine goals for improving health care tested in this survey, 85 percent or more of Americans say that each is very or somewhat important to them. In fact, there are five goals that over 90 percent of Americans rate as very or somewhat important: making health care more affordable for ordinary Americans, lowering the cost of prescription drugs, making sure people with pre-existing medical conditions can get affordable health insurance, covering long-term care for the elderly and disabled, and making sure all communities have access to enough doctors and hospitals; see Figure 2.
While these goals are widely shared across the American public, Democrats express particularly high concern about affordability, improving access and getting everyone covered.
While vast majorities across all political affiliations rated every goal as at least somewhat important, substantially more Democrats than Republicans rated all of them as very important. Independents and apolitical individuals fall between the two major parties, leaning slightly towards the Democratic perspective.
For example, 89 percent of Democrats rate making health care more affordable for ordinary Americans as very important compared to 65 percent of Republicans who say that goal is very important. Similarly, 84 percent of Democrats rate making sure that lower-income people have about the same quality of basic health care as higher-income people as very important, but less than half, 48 percent, of Republicans say that goal is very important.
More starkly, 84 percent of Democrats rate making sure all Americans have health insurance coverage as very important but only 35 percent of Republicans say that goal is very important.
Besides these differences by political affiliation, some other demographic groups view certain goals as particularly important. For example, African Americans and Hispanic Americans are more likely than white Americans to say that improving quality of care, making sure all Americans have coverage, covering treatment for mental health and addiction services, and ensuring lower-income Americans receive the same quality of care are very important. People who have had a lot or some contact with the health care system are more likely to say that making health care more affordable is very important, both for ordinary Americans and for people with pre-existing conditions.
Affordability is job one.
The survey asked respondents to prioritize two goals from those they rated as very important. Affordability emerged clearly as one of Americans’ biggest priorities. Forty percent say making health care more affordable for ordinary Americans should be one of the two top priorities, which is more than any other goal that this survey asked people to consider; see Figure 3.
Lowering the cost of prescription drugs — which also involves affordability — and making sure all Americans have health insurance coverage are the next two priorities that Americans most commonly ranked among their top two issues.
About half of Americans say that they or someone they know has experienced serious financial difficulties due to health care costs.
One potential factor driving people’s desire to make health care more affordable: 53 percent of Americans have personally experienced or know someone who has experienced serious financial difficulties due to health care costs.
About 60 percent of households earning less than $100,000 report experiencing serious financial difficulties due to health care costs or knowing someone who has. But even among those with household incomes of $100,000 and more, 42 percent report direct experience with financial difficulties from health care or know someone who has. Several other groups are more likely to experience those financial difficulties or to know someone who has: younger Americans (ages 18 to 34) (61 percent) and part-time workers (65 percent).
Focus group participants spoke about the financial burdens that health care costs have placed on them and the people they know:
“I worked for thirty years until last year when I retired. Getting on Medicare and all the supplemental packages was a serious wakeup call. Because now I’m paying for it.” – Baltimore, MD; in his 60s; White; Republican
“The thing that sticks out for me is the cost of medications. It’s just ridiculous. I know that a lot of research goes into it. But people are struggling these days. There are things that you need, sometimes people go without because they just can’t afford it.” – Baltimore, MD; in his 50s; White; Independent
“I have a granddaughter that’s totally disabled and she gets Medicaid. I think Medicaid is a great thing. My problem is it’s just over-administered. If you look at the administration cost for the program and you would just take some of that money and put it back into taking care of the people that need it, it would be a lot less expensive on us taxpayers. I’d like to see that money given to the people that need it.” – Earth City, MO; in his 70s; White; Republican
FINDING 3: The survey asked people to consider four approaches to health care reform. Of those, a public option-type plan is supported by a majority of Democrats while Republicans are split on it. A Medicare for All-type plan is also popular with Democrats but opposed by most Republicans. A market-based approach appeals to about half of Republicans and a plurality of Democrats. Giving states more responsibility for health care garners the least support overall.
The survey presented people with four plans for improving the nation’s health care system. In describing the plans to respondents, the survey avoided politicization or trigger words in order to understand Americans’ views on the plans’ substance. Each plan is roughly analogous to policy ideas currently being debated: a public option, Medicare for All, a market-based approach and shifting more responsibility for health care to state governments.
Almost half of Americans support three of those plans — the public option-type plan, Medicare for All-type plan and a market-based approach. Only about a third of Americans support a plan that would shift more responsibility for health care to state governments. For each, about a quarter of Americans do not know whether they support it or not, suggesting a substantial opportunity for people’s opinions about improving health care to evolve as they learn more.
The four plans people responded to in the survey are:
- Public option-type plan: 48 percent of Americans say they would support a plan that the survey described as follows: “One idea would create a new federal health insurance program that gives people a new option beyond what’s currently available in the private insurance marketplace. Any adult could buy into the program on a sliding scale (those with less money pay less, those with more money pay more).”
- Market-based plan: 46 percent of Americans say they would support a plan that the survey described as follows: “One idea would use tax incentives to encourage people to save money for their health needs. It would also require doctors and hospitals to post prices clearly so people can shop for the best deal, and it would deregulate insurance companies to spur development of new, low-cost options like short-term, minimal-coverage, or high-deductible policies.”
- Medicare for All-type plan: 45 percent of Americans say they would support a plan that the survey described as follows: “One idea would create a single federal health insurance program that automatically covers all Americans, replacing all private and employer-provided insurance. This program would be completely free for individuals and families; instead, it would be paid for through taxes.”
- State-based plan: 36 percent of Americans say they would support a plan that the survey described as follows: “One idea would shift more responsibility, resources and authority for health care reform from the federal government to the states. State policymakers could then decide on the reforms that would make the most sense for their residents.”
Just under half of Americans support a public option-type plan. Democrats support it more strongly than Independents and apoliticals, while Republicans are divided over it.
The public option-type plan is fairly popular with Democrats — 61 percent of them would support or probably support it. Republicans are almost evenly split between whether to support it, aside from the quarter of Republicans who say they do not have enough information to say. Somewhat more Independents support a public option-type plan than oppose it. A narrow plurality of apoliticals also support this plan, but an almost equal share of them say they do not have enough information to give an opinion; see Figure 4.
A market-based plan attracts support from 46 percent of Americans, including slim majorities of Republicans and Independents and a plurality of Democrats.
A market-based plan — including tax incentives for health savings accounts, transparent pricing and deregulation of insurance plans — attracts modest support from just over half of Republicans and Independents, although their support for this plan does not rise to the level of Democrats’ support for either the public option-type or Medicare for All-type plans. A plurality of Democrats also supports a market-based plan; see Figure 5.
Beyond political affiliation, those with a household income below $50,000 are less likely to support this plan (37 percent support) compared to wealthier people (53 percent support it among those with household incomes at or above $100,000). Americans with a college degree are more likely to support it (54 percent) than those without a degree (43 percent).
Overall, 45 percent of Americans support a Medicare for All-type plan, including most Democrats and a plurality of apoliticals. Most Republicans and a plurality of Independents are not supportive.
A Medicare for all-type plan is popular with Democrats – 65 percent of them say they would support or probably support it, as would a plurality of apolitical people. But this approach does not sit well with a majority of Republicans, 61 percent of whom say they would not support it. Half of Independents also would not support it; see Figure 6.
Younger and middle-aged Americans ages 18 to 54 (51 percent) support a Medicare for all-type plan than those older than 55 (35 percent). African Americans (54 percent) and Hispanic Americans (60 percent) are more likely to support a Medicare for All-type plan than white Americans (39 percent). There is more support for it among those living in urban (48 percent) and suburban (46 percent) areas compared to those living in rural areas (33 percent).
A Medicare for all-type plan is especially popular among people who think the health care system needs major changes or a complete redesign (54 percent of them support it) while only 30 percent support it among those who think the system needs only minor or no changes.
Medicare for All was a subject of lively conversation in the focus groups, where participants wrestled with the implications and tradeoffs of that idea, including its potential to get more people covered, its impact on people’s finances, and concerns about choice, freeloaders and fairness.
“If you make it Medicare for everyone? I don’t know. Maybe everything will change because everyone’s on the same plan.” – Dallas, TX; in her 30s; Black; Independent
“Forcing everyone into a program? It’s a terrible idea. I would not want to be forced into a government program. I would have no choice. I think there would have to be some rationing just because of the number of people that are in the system. I do think we would have less options.” – Baltimore, MD; in his 60s; White; Independent
“I do think it would be more beneficial for our country to have universal insurance because we would be more productive. We would make more money.” – Dallas, TX; in her 30s; White; Republican
“I’m a capitalist at heart. I’m conflicted on this because I believe if everybody could have insurance, we would save so much money from an employer’s standpoint. I’m not going to sit here and say I wish all medicine was socialized. But, when you really look at it, Medicare is socialized. I really don’t know how we’re going to get there but, we need to figure it out real fast.” – Dallas, TX; in her 70s; White; Republican
“I definitely want everybody to have health care. But I don’t think that the people who have worked and managed their money well should have to support the people who choose not to. There are people who can’t work. But there are people who just work the system and it’s not fair for the ones of us who have worked to have to take care of the ones who choose not to.” – Dallas, TX; in her 70s; White; Republican
Participants also expressed a sentiment that Public Agenda researchers routinely hear in focus groups on health care: that politicians have better insurance than ordinary people and that politicians should be forced to experience the same frustrating, expensive insurance coverage that their constituents do.
“I’m in favor of Medicare for All if the senators and all the big shots get on Medicare also. They are saying Medicare for All but they have their own thing. They should be on it and experience what it’s like.” – Earth City, MO; in his 70s; White; Republican
The idea of shifting more responsibility for health care to states does not attract majority support from any political affiliation.
People’s views are tepid on the idea of shifting more responsibility, resources and authority for health care reform from the federal government to the states. Overall, only a third of Americans support it. While just under half of Republicans support this idea, a plurality of Independents would not support it. Democrats are more divided, with around a third saying they would support it and slightly more saying they would not; see Figure 7.
A quarter of Americans say they do not know enough to express an opinion about each plan, meaning that there is room for people to learn more about health care reform.
Around a quarter of Americans do not know how they feel about each of the four plans that the survey posed; see Figure 8. This suggests that their opinions could evolve, especially if they have opportunities to learn about these and other options for improving health care, emphasizing the importance of public engagement that builds on the places where common ground on health care exists.
Finding 4: As people grapple with the four approaches, common ground on protecting people with pre-existing conditions emerges strongly. Democrats are more comfortable with using tax increases to fund health care and with a larger role for the federal government than republicans are, while republicans particularly value consumer choice.
As people weigh the potential implications of four plans for improving health care, their responses reinforce the importance of protecting people with pre-existing conditions. Any approach to health care reform that fails to protect pre-existing conditions may face popular backlash.
There are some partisan differences regarding the role of taxation and the size of the federal government in addressing perceived problems, suggesting that national conversations about improving health care will need to address this disparity in opinion. Tradeoffs between choice and complexity may also shape partisan differences of opinion on how to improve health care. Most Americans value preserving or increasing consumer choice, but Republicans especially value it, while Democrats may be more willing to sacrifice a degree of consumer choice if it means reducing complexity. Working through these differences could help cut through conflict over how to achieve Americans’ goals for health care.
Americans agree across parties on protecting people with pre-existing conditions.
The survey finds several examples of the importance people place on making sure those with pre-existing conditions are not disadvantaged. For example, pluralities of Republicans and apolitical individuals, and majorities of Democrats and Independents would be more likely to support a public option-type plan if they knew it protected pre-existing conditions, regardless of their initial support for a public-option; see Figure 9.
We saw the same pattern in relation to the other three plans: if a plan would protect people with pre-existing conditions, pluralities across parties are more likely to support it. If a plan would not protect those with pre-existing conditions, pluralities across parties are less likely to support it.
Democrats are more comfortable than Republicans with using tax increases to fund health care.
Democrats do not appear to be enthusiastic about tax increases or larger government. For instance, pluralities of Democrats, as well as majorities of Republicans and Independents, say that they are more likely to support the market-based plan if it would not affect anyone’s taxes or increase the size of a federal agency.
But Democrats do seem to be more comfortable than other political affiliations with using tax increases, particularly on high-income people, to fund health care reforms. For example, 57 percent of Democrats say they would be more likely to support the public option-type plan if it increased taxes for high-income people but only 19 percent of Republicans would be more likely to support it if it had those tax implications; see Figure 10.
Democrats are even somewhat comfortable with increasing taxes for both high-income and middle-class Americans if it will get them the kind of health care they want. A plurality of Republicans and Independents would be less likely to support a Medicare for All-type plan if it has those tax implications, but that tradeoff does not dissuade a plurality of Democrats; see Figure 11.
Democrats are more comfortable than Republicans with a larger role for the federal government in health care.
In considering the implications of the four plans, Republicans clearly express their preferences for smaller federal government. Democrats do not favor increases to the size of the federal government per se; rather, they seem indifferent to them, while Independents are generally split.
For example, if the public option type-plan would “somewhat increase” the size of a federal agency, 45 percent of Republicans say they would be less likely to support it. Meanwhile, 48 percent of Democrats indicate that an increase in the size of the federal government would have no impact on their views of the public option-type plan; see Figure 12.
Similarly, if the Medicare for All-type plan would “significantly increase” the size of an existing federal agency, most Republicans and a plurality of Independents would be less likely to support it. Again, however, a plurality of Democrats say their support would be unchanged.
While the survey focused especially on the size of the federal government, focus group participants also raised a variety of other concerns as they considered the implications of a larger role for the federal government in delivering health care.
“The government’s already deeply in debt. There is so much government waste. And that just really irks me. If we didn’t have so much government and waste, so much needless spending, we could afford to implement a new government plan similar to Medicare.” – New Rochelle, NY; in his 60s; White; Independent
“This is a great option in theory but there’s a lack of transparency in how our money is being spent. We would love for everybody to have health care. But what does that mean for the rest of us? What are we sacrificing as a whole? When you’re putting a lot of money into one pot like this, everybody should have a chance to understand what they’re paying for.” – Baltimore, MD; in her 30s; Asian; Independent
“I think the government would help to just kind of level-set what procedures and things should be costing. Why can’t it be standardized? I feel like if the government does step in, it would be helpful if they at least made it a standard of care and standard price for things.” – Dallas, TX; in her 30s; White; Republican
“The only thing I would be afraid of is that the government has religious or moral reasons to hold back care, like in the AIDS crisis. In that sense, I’m not comfortable with government. At the same time, I’m not sure if there’s a better system.” – Dallas, TX; in his 20s; Latino; Democrat
Most people value preserving or increasing consumer choice in health care — particularly Republicans. Democrats seem more willing to sacrifice consumer choice if it means reducing the complexity of the system.
Across partisan affiliations, most Americans appreciate consumer choice in health care (e.g., being able to keep their doctors and to choose among providers). For example, when considering the public option-type plan, nearly two-thirds say they would be more likely to support it if they could have the same choice of doctors as they have today, including two-thirds of Republicans, Democrats, Independents and half of apoliticals; see Figure 13.
Under the market-based plan, partisan differences are more apparent when respondents consider if people could decide for themselves whether to get health insurance, what kind of insurance to buy and how much coverage they need. Majorities or pluralities across political affiliations would be more likely to support the market-based plan if it allowed for that kind of consumer choice. But that degree of choice is significantly more appealing to Republicans than it is to Democrats, Independents, and apoliticals; see Figure 14.
The strength of Republicans’ desire for choice is particularly apparent when people consider a tradeoff between choice and complexity. A majority of Democrats and pluralities of Independents and apoliticals would be more likely to support the Medicare for All-type plan if it would make the health care system simpler by creating a single insurance provider. But a plurality of Republicans indicates that they would be less likely to support the Medicare for All-type plan if it limited consumer choice; see Figure 15.