Decision Day For Democrats: Poll Shows Path to Healthcare Reform

By S. Ward Casscells, MD and John Zogby

As regular chroniclers of American opinion on health care reform, we got a shock, and then a surprise, from our Sept. 28-30 poll (for details see today's issue of the Health Affairs blog). Support for the health care reform bill that has been most discussed and praised by President Obama -- the moderate bill being debated this week and next in the Senate Finance Committee, chaired by Max Baucus (D, MT) -- is only 27%, with 59% opposed and 14% undecided.

Even among Democrats, only half support, and a third oppose. Only one in 25 Republicans, and a quarter of independents, support the bill. Support is higher among women than men, and a bit lower among seniors.

Now the surprise: We asked which of 10 proposed amendments would change people's minds: "replacement of the proposed cooperatives by a 'public option' (government-run health insurance for those without other coverage); "inclusion of a 'trigger option' that would establish a public option only if private insurers do not offer affordable coverage"; "malpractice reforms (independent medical reviews, mediation; limits on non-economic damages); "elimination of the 'individual mandate' which makes every employee buy insurance, with assistance for those who cannot afford the premiums."

And so on. Despite suggestions that Americans were either tired of the health care issue or did not consider it to be enough of a priority, we found that people would read the long description of the bill, then wade through 10 amendments. Even after months of off-putting rhetoric by an over-heated, over-publicized few on both sides, Americans do indeed care about this health care debate.

Moreover, they sent a clear message: Only one proposed amendment raises support for the bill to even: malpractice reform. The second biggest boost was from eliminating the individual mandate, and third: adding a public option. 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.

(Another surprise: Americans did not just vote the party ticket: Some responses were clustered, but there were many clusters and combinations. Americans are not so much polarized as arrayed in numerous camps.)

Together, the three amendments would increase support to the mid-50s, as would the combination of tort reform and a public option, while tort reform and elimination of the individual mandate yields a slim plurality of support.

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 a slim majority.

Earlier this week the Senate Finance Committee moved in two half-steps: easing the individual mandate (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 allowing states to use federal subsidies to initiate public options.

If we guesstimate that these steps are half as successful in winning back public support as the two amendments we polled, we now estimate the bill is supported by only in two in five Americans.

But tort reform alone -- which would be a big concession to Republicans -- yields essentially equal numbers of supporters and opponents, and majority support could be earned by adding to tort reform either a Democratic amendment -- the public option -- or a second (largely Republican) amendment: eliminating the individual mandate (which would increase costs).

This is the fork in the road for the Senate's Democratic leaders: they must choose between the tort lawyers and a health care bill that could re-unite a country that has turned against the present bill.

It appears the President Obama got the same message from his private polling when he offered a modest test of tort reform in his address before Congress. But the biggest lesson from the long, arduous debate in Congress and town halls is this: the public is the adult in the room and are pointing the way to consensus on health care reform.

John Zogby is President and CEO of Zogby International, and most recently the author of "The Way We'll Be: The Zogby Report on the Transformation of the American Dream (Random House). 

S. Ward Casscells, MD is the Tyson Distinguished Professor of Medicine and Public Health, V P for External Affairs and Public Policy at the University of Texas Health Science Center at Houston, Senior Scholar at the Texas Heart Institute, and from April 2007 to May 2009 served as Assistant Secretary of Defense for Health Affairs.