Robert Blendon on Health Policy and Public Opinion

Interviewed by Doug Gavel Sept. 22, 2009

Lawmakers in Washington are considering some of the most far-reaching reforms to the nation’s health care system in decades. President Obama is lobbying for a reform package designed to extend coverage while proposing a series of measures to try to control costs. Opponents have managed to swing popular opinion against the so-called “public option,” but other elements of the plan remain popular with the American people. Robert Blendon, professor of health policy and analysis, examines how public opinion affects and influences the design and execution of health policy.

Q. The current debate over health care reform has proven quite a challenge for lawmakers who are trying to frame the issues in terms that people can understand. Has the president and his supporters succeeded or failed in efforts to convince the voters that reform is necessary now and that their plan is the best way to achieve it?

Blendon:No. The president has started to run into the problems that President and Mrs. Clinton did with the American public. Many people have become worried that the plans being discussed will not benefit them and their families and will actually threaten the economic situation in the country rather than fix the healthcare problem that just a year ago showed up in every single poll as a very high priority.

The summer was not particularly good for reform proponents with the town hall meetings. They are facing a situation now in which most of the polls show about half the population supports the general idea of reform while half are opposed. At the moment, however, more Americans oppose what the president is trying to do on health care than strongly favor it.

In a sense, the debate has been shortened in the Obama administration. The plans in the Congress took off quickly and there was a lot of initial public enthusiasm, but since this summer polls have cooled, doubts have risen, and there’s a real question as to whether or not the plans as they are understood are really good for the country and particularly whether they are good for middle income American families.

Q. What does the American public want to hear, and need to hear in order to support a reform plan?

Blendon:Health care is an issue very similar to schools and social security. The debate usually starts talking about a broad national problem that has to be solved and everybody agrees that it can’t go on the way it is and that we’re worse compared to other countries. And then in the middle of the debate it shifts with people starting to think about how it affects their own families, their own situations.

What they become focused on are just simple questions – would our family be better off or worse off if this bill passed? In general, the cost of our health insurance, the security of our coverage, our taxes, the quality of care that our family receives – they want to be reassured that things will actually be better. At the current moment, what the polls show is that on every issue I just mentioned, the majority of Americans do not believe they will be better off any of these bills pass, and more worrisome for the president, of those who think something would change, on every measure I mentioned, more think they would be worse off than better off. Taxes, quality of care, costs they pay.

So what political leaders have to do is, they have to talk to people the way you would parents about changing their schools for their children: how would this actually function in a way that would make things less expensive for you, and that would improve the quality of care, and convince them their taxes are not going up. Instead, what politicians tend to talk about are the mechanisms of the bills. Individual mandates, public plans versus private plans, employer mandates – they talk about the mechanisms, and then pollsters ask you if you like this mechanism. In reality what counts to people is how it works in practice. The political leaders have not been particularly good in discussing it in a way that reassures people that things would get better.

At the moment, the biggest threat has to do with older Americans – who have Medicare, an all-government plan – which you would naturally think would lead them to be very supportive of the president and Congressional efforts. Instead the majority are currently opposed. Why? Because they’ve heard these discussions about big cuts to Medicare and they think the services they get will deteriorate. Physicians will not spend as much time with them; their benefits will be cut back; some are afraid there will be rationing. These are the issues that have to be addressed by the president and other health reform advocates. Until now they have failed to talk directly to seniors, to address their questions and concerns in a thoughtful and persuasive way.

Q. You have discussed how Massachusetts’ health care program is actually quite popular amongst citizens here. Can the program and its success be leveraged by the president and his supporters in this national campaign?

Blendon:Americans, in practical matters always do better if there’s a real-life example: How you change schools, how you might change social security, and truly how you change health care? So the fact that there is a state, Massachusetts, in which 97% of people have health insurance, things go on. The polls have shown considerable support for the bill. There are problems -- there are cost problems in the future that have to be addressed -- but all in all the state has gotten most of the people covered, they’ve offered people who purchase their own insurance a much better deal than they had before, they’ve eliminated the worst of medical underwriting that people are so worried about across the country, and it actually functions.

So the president absolutely can use Massachusetts’ model. The dilemma being faced is that Massachusetts has a moderate plan. The political leaders in the state did not address all the problems that are being addressed nationally, and the sense on Beacon Hill was that you cover people, you offer people alternative policies, and then you go back and try to deal with the tough issues of cost and use of services.

The bills currently before the Congress not only try to emulate the Massachusetts plan, they try to solve a lot of other problems to reduce costs right away, and that ambition has made it tougher to use Massachusetts as an example because the state has not solved every problem facing American health care. It has increased the number of people with health insurance, eliminated the pre-existing conditions, and awaits another legislative round to see if they can deal with longer term issues. So it is an excellent model in one sense, but not the model the president wants to follow, which is one bill, one time, which fixes everything that we’ve been unable to fix since the first proposals for national health insurance were proposed.

Q. You’ve been looking at public opinion on health care for a very long time. Based on your experience, are you surprised that public opinion remains so fractured, and yet the debate rages on?

Blendon:For someone who has studied this for a long time, you really hope that the next wave of political leaders learns from the others experiences. And I think President Obama and the leaders of the Congress actually tried to do a number of things very different than President Clinton. I think they drew a number of lessons. But even with all their insight and wisdom they ran into the problem that our research has indicated for decades, which is that Americans want change and are really quite concerned about how that change comes out.

But the middle class in this country is risk averse. They have something to lose, and if you’re not extraordinarily careful, our work suggests that you can lose people very quickly, people who just a few months ago were in favor for the biggest-scale change that anyone could imagine.

So, in a sense, our research would suggest that even greater caution is essential for advocates to distill the key ideas necessary to convince the American people to support reforming the system. Look at the confusion created by having five congressional committees debating the same set of issues simultaneously, and coming up with different solutions. This had the effect of scaring and confusing people.

The fact that the president has lost control of the issue has led people to be uniquely worried about things that may in fact never affect their health care. So I think the mismanagement of this process, and the lack of recognition about how easy the public can turn on political leaders if they feel threatened by change has been a bit of a disappointment. We had hoped that you could draw enough from the prior experience, that there would be more caution in how both the president and congressional leaders went about trying to enact reform, and how they would describe the changes they were going to make. People are very protective of their own schools and their own health care arrangements, and in a sense advocates lost control of the message that things would improve for average families in the process. For someone who has studied this for a long time, I was very sorry to see that outcome.

Q. So what are the most salient lessons you take from this current health care debate?

Blendon:I think the broadest thing is that people in public life are going to increasingly have to confront is that the changes they seek in public and social policy have to be acceptable to populations in their country. Regardless of how expert we are in solving these issues, people are increasingly resistant to having their lives change by just the experts or reform laws. We have to bring them along if we’re going to have, in democratic societies, support for the changes that need to be done, and the people in political life really have to work at being effective at that.
A lesson to be learned from health care is that convincing people to vote for you as a candidate, as a leader for change, is not the same as convincing them to support you in changing their health care system, their Medicare system, their social security or their schools. It’s a different set of processes that affect the way people think about this, and the next generation of public leaders has to be more effective in dealing with a very diverse public, with issues about change in their lives.

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