What Americans Want for the Future of Health Care

Co-authored by Dr. S. Ward Casscells

Health care has taken center stage in Washington, and a new poll conducted by Zogby International and commissioned by S. Ward Casscells, MD, a public policy expert at The University of Texas Health Science Center at Houston, gives unique insight into how Americans feel about this hot-button issue. This interactive survey of nearly 4,000 adults nationwide is among the largest and most comprehensive polls on health care issues in America to date. Due to the complexities of the issue, Dr. Casscells and I have decided a discussion format would help to further explore some of the survey findings and possible implications. We each have different takes on this incredibly complex issue, but agree that something must happen when it comes to health care in the U.S.

Dr. Casscells: We conducted this poll in the hopes of overcoming the problems we've had with other health care polls -- they're notoriously fickle, personal, complex, wording dependent, and often sponsored by passionate partisans. But they influence Congress and they've been volatile. In the past, such as in1993, support for health care reform waned as deadlines approached. We asked about health care reform again in this latest survey, and we decided to do it by conducting the largest poll done to date. Of 3,862 respondents we found 84% are satisfied with their health care, although 79% believe rising health care costs are hurting businesses. We also found that 53% believe health care to be a human right and 46% support President Obama's belief that you need a public plan to "keep insurance companies honest". We found that 44% believe the government should have an expanded role in health care.

John Zogby: My years of collaboration with the University of Texas Health Science Center goes back to 2003 and we're so glad to be working together on this survey at such a critical time in America. A word about the methodology, this is an online poll -- this is the wave of the future and the future is now. We invited 60,000 people at random from our panel of 500,000 adults nationwide and over the course of five days 3,862 responded, which is a good response rate. We've had 11 years of experience doing these and we've had a very good record polling Americans online.

Dr. Casscells: We also designed this survey to probe the American public on their feelings about how to best promote quality care. We gave respondents quite a few choices, and the top choice was to promote patient incentives for prevention, that is to say wellness programs such as weight control, vaccinations and cancer screenings. Number two was more government investment in basic research and among the other choices we found support for ranking doctors, more government investment in bedside research, and paying physicians for better outcomes, rather than the number of payments they see. The survey findings provided a strong indication that many Americans are willing to modify their unhealthy behaviors for the right incentive. We asked respondents if for $1,000 a year they would stop smoking or not start, lose 10 lbs., exercise 30 minutes three times per week, and get vaccinations and cancer screenings -- around 60% said yes. If they would hold to it, that would reduce health care costs.

John Zogby: These results really don't surprise me. This was an extremely comprehensive survey, there were over 100 questions. But over the years as we've been polling on health care reforms and while there has been a mandate for change -- reaching a crescendo in the 2009 campaign -- there has not been a consensus on the direction that change should take. What this poll reveals is nothing short of the complexity of the details that are involved. What we see is not only no consensus on no solutions but instead what we see when we pose those solutions is that it's virtually split right down the middle. That's the sort of thing we have seen but has never really tilted in one direction or another in terms of how to make this change.

Dr. Casscells: The poll we undertook was a little bit sobering and I feel a little bit like the designated driver at the party, but I think we need to look at the facts squarely -- President Obama's top priority now is insuring everyone and restraining the growth of health care costs. But as the August deadline approaches and legislation begins to specify who will win, who will control, and who will pay more, this survey shows most now oppose the proposed public plan released yesterday by the House of Representatives and oppose the mandates and the taxes and the individual components of the plan and the plan in aggregate. Is the air coming out of the balloon or is it just a case of cold feet before the wedding?

John Zogby: Democrats are from one planet and Republicans are from another planet, not only on health care reform but on a variety of issues. The critical mass is created generally by independents and moderates and in this instance we see a split among moderates and independents that further complicates this matter. Americans do believe in fairness, no doubt about it. They do believe in universal coverage, though they in no way agree on how to achieve it. I think you can say justifiably that five or six months into the Obama administration that perhaps Americans feel a "stimulus overload" -- a stimulus package, a TARP package from the previous administration, a bank bailout, and a new unit of measurement called trillions, instead of the modest billions many of us grew up with. There's a sense that the sacrifices are taking place up front, but that there hasn't been a return yet to justify more sacrifices so Americans, I think, are in a very, very cautious mood. Interestingly, my personal interpretation it that it's wise that this legislation is before Congress -- this is the time to implement health care reform. Some of the specifics here may not be popular, but President Obama is popular. If Americans do want change than something or someone is going to have to tip the scale and Obama is the person to raise the issue and somehow get it done in the first year of his first term.

Dr. Casscells: The survey also sheds light on how divided Americans are when it comes to health care reform proposals. Forty-two percent agree that we should require everyone in this country to have health insurance and offer federal help for those who cannot afford the premium, but slightly more -- 48% -- are opposed. But the big question of course is how to pay for it -- nearly everyone agrees we need to eliminate fraud, and there is strong support for standardize forms, simplify billing and reduce medical. The survey shows people are willing to have high premiums for those who participate in unhealthy behaviors, such as smoking or gaining weight, not exercising or not getting their cancer screenings -- they think that's fair. They don't think it's fair to have higher premiums for preexisting illnesses. Taxing alcohol is not very popular, but is more popular than taxing high income earners or sugary drinks or increasing the Medicare age to 66. Rationing is very unpopular as is decreasing home care.

John Zogby: There are a lot of complexities here, Democrats and Republicans are both positioning themselves on the basis of going back to their base, so I think that for the President and for Democrats, the moment is absolutely right because this will generate enthusiasm among the Democratic base going into 2010. By the same token this issue will be very appealing for Republicans to take to their base as they try to rally support. In terms of the whole populous though, no one was really polling like this in 1933, but as a historian, I can tell you that FDR, while he was pushing the Keynesian New Deal, was also going before the American people saying "my goal is to balance the budget". I think there was a sense by perhaps by the greatest politician of the 20th century that even the New Deal wouldn't have been terribly popular among all segments of the American people, Franklin Roosevelt re-defined presidential leadership. On balance I think it's a plus for Obama and the Democrats to pursue this, the risk is he certainly can't get this done during an election year, it's too hot of a potato, if he doesn't know where his numbers are going to be in 2010 or 2011 for that matter.

Dr. Casscells: Looking back, we were surprised by these findings. There's less support for sweeping health care reform than we had expected so we began to look at the past several months of health care polls and we found that despite the headlines support has been declining for the proposal to tax the "Cadillac" of public health care plans. The same for public options, support seems to be trending down. Support for the public option seems to be drifting down since early June, and we found the same for support for taxing high-income families to support the uninsured. There is strong support for providing insurance for all Americans, none for rationing care or increasing taxes. There is strong support for simplified billing, decreasing fraud, medical errors and unnecessary care, and particularly incentivizing doctors and patients for performance, especially disease prevention and good health outcomes. Overall, Americans are in favor of improving care and generating economic savings by incentivizing best practices. They want the system put on a diet and an exercise regime before resorting to surgery.

John Zogby: I believe health care reform will pass and it will not be sufficiently bipartisan, but there will be a few Republicans jumping in.

Dr. Casscells: It looks like there is some consensus and I think something will pass, but it looks like more of an engine tune-up than an engine overhaul. I think what we're seeing now is akin to wedding bell cold feet that will resolve once something is passed. This will be just another round in this fight. I think we'll have the biggest legislation since 1965, but I don't think it will be as sweeping as the House bill. I think this 42% support will be a little sobering and will embolden the Senate Finance Committee to find a middle ground. As a patient and a doctor I hope so.

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 (Cardiology) and Public Health, Vice President for External Affairs and Public Policy at the University of Texas Health Science Center at Houston; Senior Scholar, Texas Heart Institute; and until May 2009 served Presidents Bush and Obama as Assistant Secretary of Defense (Health Affairs).

To view a webcast discussion of the survey results with John Zogby, Dr. Casscells, and leaders of the health care, business, academic, medical and policy community, please visit

The survey results are available at and