Obama and Congress Shouldn't Let Polls Guide Health Reform

The further it progresses in Congress, the more the Democrats' push for health reform is dividing the country and dragging down President Obama's job approval ratings. Well, as Dan Rather used to tell us, "Courage." Public opinion can be fickle and contradictory and it isn't always a good predictor of how things will turn out in the end.

Big health proposals typically start out popular in polls and then plunge in a morass of details and attacks. Then political will and skill come into play. A plan either dies from lack of it or gets rammed through by leaders who hope for the best.

Former President Bill Clinton's 1993-94 health reform drive was an example of the first; former President George W. Bush's Medicare prescription drug program is an example of the second. Let's look first at the success story. Here's an abbreviated timeline derived from polling that you can find here, here and here:

May 2000: Nine in 10 people support the idea of adding drug coverage to Medicare.

November 2003: Republicans in Congress jam through a voluntary plan and Bush signs it.

December 2003: 30 percent say the program will be good for senior citizens and 31 percent say it will be bad.

December 2005: Nearly six in 10 say it's hard to understand and four in 10 say it won't reduce costs.

January 2006: The plan takes effect. Liberal writer Jacob Weisberg of Slate calls it a fiasco and says it's too complicated to work.

April 2006: 49 percent say it isn't working.

Ready for the reality check? In January 2006, 32 percent said they'd signed up or planned to, while 55 percent said they weren't going to join. Many of them have since changed their minds. As of last month, according to the Centers for Medicare and Medicaid Services, 59.5 percent of eligible seniors were enrolled.

As for political consequences, the clues were right there in the April 2006 poll. At the same time 49 percent said the program wasn't working, 57 percent said they were more likely to vote for members of Congress who had supported it. It's like the joke Woody Allen tells in the movie "Annie Hall" – the food is really terrible, "and such small portions."

Bill McInturff, a Republican strategist with extensive experience polling on health issues, says GOP lawmakers worried in 2006 that there was confusion about the program and people didn't like it. He told them it was a huge success. How did he know? Democrats weren't making it an issue in campaigns that year for House and Senate. "If it was truly unpopular, we would have heard about it," he told me.

Robert Blendon, a Harvard University authority on health care and public opinion, said one reason voters didn't rebel was that the benefit was financed with deficit spending. Unlike now, there was no talk of tax surcharges on the rich, of taxes on high-end health plans, of squeezing savings out of Medicare, hospitals and drug companies.

The prescription drug bill turned out a lot better for Republicans than a catastrophic illness benefit did for Democrats in 1988. Senior citizens reacted so vehemently against that addition to Medicare that it was repealed the next year, before it took effect. Blendon told me the backlash was warranted because the program was so badly designed. The chief problem was that every person over 65, regardless of what coverage they already had from former employers or private insurers, was going to have to pay a surcharge.

The Clinton push to reorganize the health sector in 1993-1994 was another story, one that carries eerie echoes of what's going on right now. In a 1995 study, Blendon and two co-authors wrote that support for the Clinton health plan fell from 71 percent to 43 percent in a 12-month period.

The paper attributed the slide to two bedrock attitudes: "Americans judged reform based on whether or not it was good for them personally," and "Americans were deeply cynical about government." Many individual elements of the plan, from a system of new "health alliances" to "managed care" to the drafting of the bill behind closed doors, drew attacks. Older people, fearing erosion of Medicare benefits, were a major driver of the decline.

Sound familiar? Right now, Obama and the Democrats are belatedly focusing on "what's in it for you" (as in, health reform benefits for people who already have insurance, such as not being denied a policy if you're already sick and not being dropped if you get sick). They're trying to morph cynicism about government into cynicism about insurance companies. They're trying to calm seniors who keep hearing all the talk about "squeezing savings" out of Medicare. (The idea is to cut doctor and hospital reimbursements, not services, but who can blame people for wondering?) On top of that they must convince some seniors the government is not out to euthanize them. That's the thanks a bipartisan group gets for adding a new Medicare benefit – reimbursement for conversations people might want to have about living wills and the like.

Part of the the key here is in how things are explained. But in some cases, lawmakers may have to bite the bullet. For instance, most players agree that to spread risk and bring down costs, everybody – even strapping 24-year-olds – must be required to buy health insurance. Yet people don't want to be told they must buy a policy, even if subsidies are available to help them.

Imposing the requirement regardless would reverse what McInturff says is the classic sequence: awareness leads to interest, which leads to desire, which leads to action. But in fact, McInturff told me, sometimes doing it backwards works. He personally was involved with mandatory recycling and mandatory seat belts, two initially unpopular issues. No citizens groups arose over the seat belt requirement and nobody lost an election over it, he said, and "we didn't blow up suburbia when we required recycling." The challenge on mandatory health insurance, and many other aspects of health reform, is getting lawmakers to vote yes and have faith -- in their plans and in their constituents.

Obama's political position is much stronger than Clinton's in the sense that he won 53 percent of the vote compared to Clinton's 43 percent. But big Democratic majorities and the recession have each weakened his hand. On Capitol Hill, there are dozens of conservative and moderate Democrats with ambitions of their own, who never ran on or promised major health reforms. Out in America, people are insecure about their personal situations and don't want to take any risks. Some are worried about the trillions of dollars the country is spending to recover from the economic collapse and don't want to spend anymore.

Much of the plan evolving on Capitol Hill so far would not take effect until 2013, including a new health care marketplace to compare plans, a government plan to compete with private insurance, and coverage for the uninsured. One reason for that is to allow time to set them up. Another, more relevant reason is that there's so little money available right now. McInturff says that means Democrats won't have to face the consequences of what they've done until after the next presidential election. But neither could they reap the potential rewards, as Republicans did in 2006 with the prescription benefit.

Along those lines, I asked Blendon if the country would be better off if Clinton's plan, with all its flaws, had passed. His response was a qualified yes. Health care costs and choices are an issue the world over, he said, because expectations are so high. Whatever health system they have, he said, "in no country do people say 'I don't want an MRI.'"

Still, Blendon said, the data show that "when you have everybody covered and you can't lose your coverage, it gives a sense of security and people are happier than in a country where you could lose it easily. They're less angry and concerned than in the United States. That's what we would have seen. Less anxiety."

Given the timelines, House and Senate health reform backers are likely to be running in 2010 on the promise of less anxiety in the future. But they should keep in mind that scorched-earth town halls are not real life and polls, as we are endlessly reminded, are just snapshots in time. They ought to bury their own anxieties and make it happen.

Saturday update: After sampling reader comments, I realize there is an additional point I should make: While support for health reform and Obama has been generally slipping, at least two recent polls show there are still majorities in favor of the specific plans emerging on Capitol Hill. Read about them here and here. For a broader look, here's a Gallup summary from mid-July that also shows majority support for health reform. Other Gallup findings: Seniors are most skeptical about reform, 16 percent of Americans are uninsured, and 29 percent of Americans have government health care through Medicare, Medicaid, the military or the Veterans Administration.