Americans "are deathly afraid that a government takeover will lower their quality of care." So writes Republican pollster Frank Luntz in a widely circulated set of talking points on how to stop a "government takeover" of health care.
Yet in summing up recent survey results, the Washington Post's Ceci Connolly and Jon Cohen write that poll questions "that equate the public option approach with the popular, patient-friendly Medicare system tend to get high approval, as do ones that emphasize the prospect of more choices."
Indeed, the latest ABC News/Washington Post poll found 62 percent of Americans expressing support for "having the government create a new health insurance plan to compete with private health insurance plans." Other pollsters describing the public option as "government administered" and "similar to Medicare" gauged even more positive reactions: 67 percent in a Kaiser Family Foundation poll in April and 72 percent in the most recent CBS News/New York Times poll.
So if Americans live in fear of government intrusion into health care, why does likening the public option to Medicare make reform more popular?
Consider some results obtained by the same Kaiser tracking poll. When asked how much they trust various health care players "to put your interests above their own," respondents rank doctors (78 percent trust "a lot" or "some") and nurses (74 percent) at the top of the list.
Among those insured through Medicare, however, "the Medicare program" (68 percent) scores nearly as high. Among those with private insurance, "your health insurance company" earns much less trust (48 percent).
Perhaps that result is just about perceptions of corporate interests and not about patient experience?
We can test that question with data from a set of surveys known as the Consumer Assessment of Healthcare Providers and Systems. CAHPS is an initiative of the Department of Health and Human Services that developed a standardized survey questionnaire used by virtually all health insurance plans -- public and private -- to assess patient satisfaction. Most private insurers use the CAHPS questionnaire and disclose the data to the National Committee for Quality Assurance in order to receive their accreditation. So thanks to CAHPS, we have a massive collection of data comparisons of how patients experience and rate Medicare, Medicaid and private insurance.
Those comparisons show the depth of Medicare's popularity. According to a national CAHPS survey conducted by the Centers for Medicare and Medicaid Services in 2007, 56 percent of enrollees in traditional fee-for-service Medicare give their "health plan" a rating of 9 or 10 on a 0-10 scale. Similarly, 60 percent of seniors enrolled in Medicare Managed Care rated their plans a 9 or 10. But according to the CAHPS surveys compiled by HHS, only 40 percent of Americans enrolled in private health insurance gave their plans a 9 or 10 rating.
More importantly, the higher scores for Medicare are based on perceptions of better access to care. More than two thirds (70 percent) of traditional Medicare enrollees say they "always" get access to needed care (appointments with specialists or other necessary tests and treatment), compared with 63 percent in Medicare managed care plans and only 51 percent of those with private insurance.
So let's come back to recent poll results on the "public option." Both the ABC/Post and Kaiser surveys found that while Americans react favorably to the basic concept of a public option, they are easily swayed by arguments about having an unfair advantage against private plans or being the "first step toward single-payer, government-run health care." On the latter argument, the Kaiser survey moved support from a 67-to-29 percent majority favoring the public option to a 41-to-50 percent margin opposing it.
If the Medicare experience is so positive, why are people so easily talked out of expanding on it?
First, younger Americans not enrolled in Medicare do not share the enthusiasm of seniors for the program. Six years ago, the Kaiser Foundation asked a national sample of adults to rate the Medicare program. Medicare was hugely popular among those aged 65 or greater. Eighty percent rated Medicare favorably. Similarly, more than half of seniors (62 percent) considered Medicare "well run" compared to only 28 percent willing to say the same of "private health plans such as PPOs and HMOs that people get through their jobs."
Those under 65, however, had very different views. Only 45 percent rated Medicare favorably. Only 36 percent considered it well run, as compared to 47 percent who said the same about private health plans. While 73 percent of those over 65 said Medicare allowed patients to choose any doctor, only 28 percent of those under 65 agreed.
Second, the older Americans who like Medicare see little to gain from the public option since they like the coverage they have now. Democratic pollster Stanley Greenberg finds "little support among seniors" for reform. A recent survey conducted by Greenberg's Democracy Corps found a narrow plurality among all voters favoring "President Obama's plan to change the health care system" (43 percent to 38 percent), but net opposition among seniors (34 percent to 50 percent).
So, the Americans experienced with "government-run" health insurance like what they have and don't want to change it, and younger Americans enthusiastic for change don't know what they're missing.
- Blumenthal (at Pollster): Medicare's Customer Satisfaction
So what has higher customer satisfaction. private health insurance plans or the Medicare program? The answer, revealed in my NationalJournal.com column for the week, may surprise you.
Some additional details that were a bit too wonky for the column: I cite results from surveys conducted using a standard questionnaire developed by a the Consumer Assessment of Healthcare Providers and Systems program, known better by its acronym, CAHPS (pronounced "caps"). The program is an initiative of the U.S. Agency for Healthcare Research and Quality (AHRQ) of the Department of Health and Human Services to create a standardized survey for patient satisfaction that could be used by health insurance plans and hospitals (and, full disclosure, my wife used to work at AHRQ, though she was not directly involved with the CAHPS program).
Why would the government care about creating a standardized "customer satisfaction" questionnaire for health care? In the late 1990s, Congress allowed states to enroll Medicaid recipients into managed care plans run by private insurance companies, but the states had to offer multiple plans. One of the reasons for the CAHPS initiative was to create a standard for providing uniform quality information to Medicaid recipients.
The non-profit National Committee for Quality Assurance (NCQA) also played a significant role in the CAHPS' creation. NCQA uses CAHPS data to evaluate and accredit private health plans, so those companies that wish to receive NCQA's seal of approval or rank high in the U.S. News & World Report annual feature on "America's Best Health Insurance Plans" have an incentive to participate. As a result, roughly 90 percent of private insurers conduct CAHPS surveys and provide the data to NCQA.
Survey reachers of all stripes can learn from the extensive research and development that went into the creation of CAHPS program. One of its goals was to create a survey questionnaire based on the "best science...the state-of-the-art in survey and report design," and there are few precedents for what they achieved. In its first phase, the CAHPS program spent over $5 million on cognitive pre-testing and other pilot studies of a questionnaire developed jointly by RTI, RAND, Harvard Medical School & Westat. The lessons they learned should be of interest to anyone conducting a customer satisfaction survey.
Most of the CAHPS data I cited in the column come from a Health Plan Survey Chartbook published by AHRQ that includes compilations of data culled from over hundreds of individual surveys and literally hundreds of thousands of interviews conducted with patients in private insurance plans and managed care plans that enroll Medicare and Medicaid beneficiaries. The comparison data for those in traditional, fee-for-service Medicare comes from a spokesperson for the Centers for Medicare & Medicaid Services (CMS). Note that although the AHRQ chart book includes more recent data, I cited data from 2007 that would be comparable to the survey data on fee-for-service Medicare recipients that I received from CMS.
The old rule of thumb in journalism is that it takes three to make a trend. So I think we have a trend here in the question being raised by Jonathan Cohn, E.J. Dionne, and, today, David Brooks. Brooks concludes:
The great paradox of the age is that Barack Obama, the most riveting of recent presidents, is leading us into an era of Congressional dominance. And Congressional governance is a haven for special interest pleading and venal logrolling.
When the executive branch is dominant you often get coherent proposals that may not pass. When Congress is dominant, as now, you get politically viable mishmashes that don't necessarily make sense.
It's also important to remember that a bill--if it passes--is only the beginning of the process. Implementing any kind of far-reaching health reform is going to take years, maybe decades. And that is an argument for making sure that it starts with both a broad base of support, as well as with its gain and pain in balance. Congress, with its two-year election cycles, is not exactly known for taking the long view. As Cohn notes, in looking at where the Senate Finance Committee appears to be headed:
Consider the proposed reduction in subsidies. In the original schemes, families of four making up to $88,000 a year would get at least some assistance; under the alternatives under discussion, only families making up to $66,000 could get subsidies. Yet families making between $66,000 and $88,000 are precisely the sort of families who could use help--not a lot of help, but a little--paying for insurance. And that's assuming subsidies really end up at $66,000. Lawmakers could easily bid the number down more before reaching a final compromise.
Put aside, for a moment, the policy merits of these moves. The politics are lousy. Obama would be in danger of producing legislation that seems to offer little up-front benefit, particularly for the electorally vital middle class. And if some of these people end up paying even modestly higher taxes to help finance reform they're not likely to be happy about it. It's hard to imagine such legislation provoking a backlash that could produce total repeal. It's not so hard to imagine such legislation creating bad political feelings, the kind that linger around until the next Election Day and pave the way for legislative retrenchment later on.
Late last week, I was summoned to a windowed meeting room overlooking the White House to sit with members of one of Washington's nimbler, smarter think tanks. The assembled thinkers tried to convince me that Barack Obama was missing a historic opportunity: The legislation that was traveling under his name was increasingly unlikely to bind the middle class to his presidency or party. Cap-and-trade was a mess. Health reform was going to fail on cost control. And what of jobs? Obama, they said, had to take a firmer hand with the Congress. His hands-off approach was a fiasco. Leadership matters. It's important. It's needed.
Of course, as David Brooks points out, a firm hand with Congress is remembered as the defining mistake of the Bill Clinton's first-term. As you can read in detail here, there was no mistake more consequential than the president's decision to dictate every jit and tot of his health reform plan to the legislature. Obama's congressionalist approach is an effort to avoid the mistakes of the Clinton years. Predictably enough, that's led to a growing chorus flaying him for making the opposite mistakes.
And maybe that chorus is right. But the implicit assumption of these arguments about strategy is that there is, somewhere out there, a workable strategy. That there is some way to navigate our political system such that you enact wise legislation solving pressing problems. But that's an increasingly uncertain assumption, I think.
Imagine a group of men sitting in a dim prison cell. One of the walls has a window. Beyond that wall, they know they'll find freedom. One of the men spends years picking away at it with a small knife. The others eventually tire of him. That's an idiotic approach, they say. You need more force. So one of the other men spends his days ramming the bed frame into the wall. Eventually, he exhausts himself. The others mock his hubris. Another tries to light the wall of fire. That fails as well. The assembled prisoners laugh at the attempt. And so it goes. But the problem is that there is no answer to their dilemma. The problem is not their strategy. It's the wall.
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