Americans would embrace comprehensive healthcare reform if properly
26 August 2009
With polls pointing to a decline in public support for healthcare
reform in the US, new research shows that getting Americans more
involved in the debate is essential to swinging public opinion in its
The research showed that after critically thinking through the
alternatives, people were willing to make significant and surprising
tradeoffs — like limiting treatments to those proven effective,
expanding the role of government, and an increased role for nurses and
other non-physician healthcare providers — in order to improve the
healthcare system. The report offers specific insight for congressional
and other leaders to help build constituent support while back in their
"Major reform efforts fail either because people have been engaged and
reject them, or because they were never engaged in the first place,"
said Daniel Yankelovich, a leader in public opinion research for more
than 50 years and chair of Viewpoint Learning. "We found that when
Americans are engaged and work through tradeoffs and take on board the
experiences of others, they are willing to make more sacrifices than
most experts give them credit for."
Published in the report Voices for Health Care, the Viewpoint
research was funded by the W.K. Kellogg Foundation, which supports
efforts to expand civic and philanthropic engagement across the US to
improve the lives of vulnerable children and families.
Public support for any proposed healthcare plan is crucial to its
approval and, ultimately, its implementation. In 1993, the Clinton
Administration's health reform plan enjoyed a 71% approval rating early
on, but legislation quickly stalled and that rating slipped to less than
40%, suggesting that opposition easily swayed a public that had not yet
worked through the issues and reached a firm judgment.
The Voices for Health Care project took place in three very different
states over the course of a year — Ohio, Mississippi and Kansas.
First, researchers engaged with healthcare, political, civic and
business leaders in each state to create several healthcare reform
scenarios to work through with the public. Then they engaged a random
sample of participants representative of the US population (nearly 300
in total) in daylong, two-way dialogue sessions to show how everyday
Americans tackled the issues.
Participants first created their vision of the healthcare system they
wanted to see, and then worked through the difficult tradeoffs they
would be prepared to make to realize that vision and to pay for it.
Across all nine sessions (three sessions per state) participants reached
a strikingly consistent set of conclusions.
Researchers quickly observed that the public approaches the issue of
healthcare from a pragmatic — not a partisan — perspective and that
participants were willing to change views on politically contentious
issues after working through the tradeoffs of alternative potential
healthcare systems and the viewpoints of other Americans. Those
perspectives also made a dramatic difference in how participants felt
about broad reform issues, such as universal coverage and limits on
care. (Major insights are highlighted in the "key findings" section
The report also showed that Americans across all demographic groups and
the political spectrum might already agree on a number of important
reform elements. Americans came to a quick agreement that a new system
should provide greater focus on prevention and wellness, increase
personal responsibility for one's own health, and ensure that all
children have access to good care. They concluded that these topics
could be used as an effective starting point to engage the public and
open the door to addressing other more complex issues.
"For decades, lawmakers have focused primarily on the debate among
vested and represented interest groups, and have not developed ways to
engage in meaningful conversations with the American public," said
Sterling Speirn, the president and chief executive officer of the W.K.
Kellogg Foundation. "Substantive dialogue with the public about
healthcare is not only feasible, it is essential if we are to advance
health care that the public will embrace in the United States."
The Voices for Health Care report indicates that engaging Americans from
diverse political and socioeconomic backgrounds can substantially
increase public support for meaningful health care reform. It provides
specific insights and a useful starting point that leaders can adopt to
ensure that the thoughtful voices of everyday Americans on healthcare
reform are heard in Washington.
Insights for policy makers
The Voices for Health Care report suggests a number of insights to help
leaders and others build public trust and support for significant
1. Start with areas where there is significant common ground. The
research revealed "low-hanging fruit" that leaders can start with to
begin building firmer support for change.
2. Use the public's terminology and framework. The report identifies
some examples of terms where the public's assumptions and definitions
differ from those of experts.
3. Sequence the conversation. People have to work through certain
questions before they are ready to consider others. The report suggests
a sequence of questions that leaders and others can use to structure the
conversation in a way that allows them to come to firm judgment.
4. Consider the implications of the economic downturn. The economic
downturn seems to make people more willing to consider hard choices and
rethink expectations. At the same time, the abuses of public trust
uncovered by the financial collapse have added to public skepticism and
cynicism. The report cites the importance of transparency and two-way
Key findings from Voices for Health Care
Americans increasingly support universal coverage once they
understand that the current system already pays for the uninsured. On
the issue of universal healthcare, researchers found that once
participants learned that costs for covering the uninsured are already
largely passed on to the public, they were more likely to see the
practical and economic rationale for extending coverage to all
Americans are open to revamping the healthcare model after examining
the cost structure of the private system. Initially, most participants
wanted to build upon the current health care system in developing a
Many changed their position after learning the extent to which the
private-insurance system diverts healthcare funding to marketing,
overhead and profit and working through the complexity involved in a
"shared responsibility" system.
As a result, across all research groups, participants began to
explore the feasibility of a stronger role for government in a more
extensively overhauled model. Most supported a two-tier system in which
every citizen has publicly funded basic coverage that they could
supplement with private coverage purchased individually or through their
Most would pay more for a system that works better. As participants
began to understand all the ways in which they pay for healthcare
(taxes, wages, insurance premiums, etc.) they grew concerned over a
system that they viewed as simultaneously cost intensive and largely
flawed, and expressed greater openness to paying more for a system that
Participants shift opinion of "freeloaders" and become more
supportive of healthcare benefits for all residents after learning more
about the circumstances of the uninsured. Another contentious issue
where perceptions shifted over the course of discussion regarded whether
a public healthcare system would cover "freeloaders," including people
who do not work and illegal immigrants.
However, once participants learned that most uninsured people are
actually working or are members of families with workers, they began to
reconsider their assumptions about the uninsured and trended toward
support of all state residents (citizens or not) being covered.
In addition, all dialogue groups included a percentage of uninsured
that was proportional to the percentage in the population, so
participants developed a better understanding of the realities being
faced by the uninsured.
Researchers also found that once participants learned that costs for
covering the uninsured are already largely passed on to the public, they
were more likely to see the practical and economic rationale for
extending coverage to all Americans.
Language is a critical, though surmountable initial barrier. The report
identified vernacular as a key barrier to engaging the public.
Researchers found serious confusion over the terms "basic health care",
which most participants felt should include a very broad spectrum of
services, and "choice," which participants used to describe the
assurance that they had a say in important decisions about their
healthcare — not, as some experts believe, to have access to every
provider and treatment on demand.
The report can be accessed at
You can also view the project video at
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