Program on International Policy

Americans on Health Care Policy

FINDINGS
August 30, 2000

4. Preferred Approaches

To address the health care needs of most of the population, the majority supports requiring employers to provide insurance to their employees. The majority then favors a variety of government programs to cover specific vulnerable populations that may lack coverage, including children, people with low incomes, those who are unemployed and looking for work and those who are approaching the eligibility age for Medicare. There is also strong support for offering financial assistance such as tax breaks to uninsured Americans.

It may seem contradictory that a strong majority of Americans believes that health care is a right that should be guaranteed by the government while there is not majority support for a government health insurance program. But this is not necessarily the case. In the focus groups, respondents explained that they saw the government as having the obligation to ensure the outcome of health care for all, but they had reservations about the government itself being directly involved in providing services or insurance.

These feelings point fairly clearly to the idea that the government should build on the system of employer-provided insurance. In the current poll, there was robust majority support for requiring businesses to extend health insurance coverage to their employees. Respondents were asked the following question:

Nearly two out of three (64%) favored such a law, while about one-third (33%) opposed the idea.

Respondents also were presented this similar question about part-time workers:

Support for this plan was even higher than for full-time workers, with 71% approving the idea and just 27% opposed.

Research by Kaiser/Harvard further demonstrates the strong public support for mandating that employers provide workers with health insurance. Since December 1998, four different surveys have shown that roughly three out of four respondents favor "requiring businesses to offer private health insurance for their employees." In the most recent poll, taken in February 2000, 77% favored that proposal, while only 21% were opposed.28

Equally important, when the employer mandate is pitted against one or more competing alternatives, it earns plurality or majority support. Asked to choose which would be a "better way to guarantee health insurance coverage for all Americans," a solid majority (54%) chose the employer mandate while 39% chose "offering uninsured Americans income tax deductions, tax credits, or other financial assistance to help them purchase private health insurance on their own" (Kaiser/NewsHour study, February 2000).29 In some polls, Kaiser also has pitted the employer mandate against tax incentives and a single-payer system, which yield a much tighter three-way split. Still – while substantial minorities prefer these other alternatives – requiring businesses to provide health insurance is always the top choice.30

The focus groups revealed strong support for some kind of reform that would require employers to cover workers. The idea that employers are responsible for providing health insurance is firmly ingrained in the public mind. However, many believed that an employer mandate should be accompanied by some government incentives, to help smaller businesses afford the insurance.

You give eight hours of your day at least to a company and I think it’s their responsibility to at least offer you the insurance. (Woman, Richmond)

I think if you are working at a full-time job, obviously you’re working and you want to make something of yourself, I think it should be required. The business should be required to give you some sort of insurance, even if it’s like a co-pay – they pay part, you pay part. But I think it should be in place to give you the opportunity. (Man, Cleveland)

As far as full-time employees, I think [businesses] should provide some kind of coverage for their employees, big companies. Maybe smaller … companies [also] should be required to legally. (Woman, Cleveland)

I think … the employer has certain responsibilities for its full-time employees … if for no other reason than an employer wants to have employees healthy to work. (Man, Richmond)

I think that employers should be mandated, maybe not completely to pay, at least have that option that insurance is there. (Woman, Cleveland)

There was also a fairly strong belief that part-time employees should be covered. Much of the support for covering part-time workers – in addition to the fundamental belief that health care should be made available to all – rests on the notion that not covering part-timers may lead businesses to avoid the mandate by reducing the number of full-time employees. Participants believed it is important that all businesses be affected in a similar way.

If you work for a company or if you work for somebody and you’re a full-time employee, even if you’re a part-time employee, you should be allowed the opportunity to have something. (Man, Richmond)

Everybody tries to work around the law … if you say 30 hours, they’ll work everybody 29.5 hours so that they don’t have to do it … If you’re going to hire somebody to work … this is going to be a cost of doing business in our culture. That’s where the government really can provide a service … (Man, Richmond)

I think that by requiring all businesses to do it then there isn’t going to be a situation where one business has a competitive advantage over another business because that business doesn’t have to provide health insurance. (Man, Richmond)

 

Extending Coverage to Specific Populations

While it appears that Americans are inclined to look to employers to cover most of the population, a majority is ready to support having the government provide coverage to specific populations. At present, of course, there is the Medicare program for the elderly and the Medicaid program for the poor. Americans show a readiness to expand this coverage to: children; those with low incomes; those who are unemployed and looking for work; and those who are approaching Medicare’s eligibility age.

Children

Providing health insurance for children is arguably the public’s single most important priority for health care reform. In June 1998, an NBC News/Wall Street Journal poll found that 83% of respondents felt the fact that "too many children lack adequate health care coverage" was a "major problem" in the current health care system. Another 10% considered it a "minor problem," and just 5% deemed it "not much of a problem."31 Moreover, two surveys taken after the Clinton health plan’s demise asked respondents to choose which groups "we should try to provide with health insurance coverage first … children, working people who are currently uninsured, low-income people, or people who need long-term care." In both polls, children were chosen over the next most-cited group by more than two to one. In the December 1996 Kaiser/Harvard study, 52% gave children the top priority; 19% were most concerned about uninsured workers; 12% favored acting first for people with long-term care needs; and 11% preferred starting with low-income people in general.32

As part of the Balanced Budget Act of 1997, the Children’s Health Insurance Program (CHIP) was established as a federal-state partnership to provide uninsured children with health coverage. In some states it was established as a separate program while in others it was an extension of Medicaid. Support for this program in principle is remarkably strong. Four polls taken by Kaiser/Harvard, Harris, and Kaiser/Harvard/Washington Post between November 1996 and September 1997 revealed that an overwhelming majority – over 80% of respondents – favored the general idea of the federal government providing health insurance for uninsured children.33 As one man in COPA’s Cleveland focus group stated, "We are the wealthiest country in the world, and there’s really no reason why there should be children out there starving and going without health care."

Similar levels of support existed for more specific plans to cover children, even when respondents were asked to factor in the prospect of a higher tax burden to pay for such plans. In a December 1996 survey, the Tarrance Group and Lake Research spelled out some more detailed ideas. In one question, they asked respondents if they favored or opposed a number of proposals "… even if it meant an increase in your taxes of $100 a year." Eighty-two percent favored a proposal to "expand the Medicaid program to include all low-income children of working families who do not have health care coverage" (41% strongly favor). Just 14% opposed the idea. Also, the poll floated another proposal to "provide health insurance to every child, in which care would be provided by local pediatricians with oversight by local government and would require an extra $25 a year in new taxes." In this case, nearly three in four (74%) supported the idea (37% strongly). Only 23% were opposed.34

Recent polls have found more modest support for the government providing assistance to low- and moderate-income parents as part of a larger plan requiring all parents to buy health insurance for their children. A Kaiser/Harvard poll from December 1999 and a Kaiser/NewsHour poll from February 2000 presented this plan:

I’d like your opinion of a proposal to deal with the problem of uninsured children. ... Under this proposal, all parents would be required to buy health insurance for their children. Low- and moderate-income parents would receive some government assistance to help them pay for it. Keeping in mind that this would cost the government and taxpayers money, would you favor or oppose requiring all parents to buy health insurance for their children?

In both February and December, modest majorities (57% and 56%, respectively) favored this approach, although sizable minorities (40% and 36%) opposed it.35

Low Income

Overall, it appears there is strong support for increased government efforts to provide health insurance to those with low incomes. In three different polls since December 1999, a strong majority has favored "expanding state government programs for low-income people, such as Medicaid and the Children’s Health Insurance Program, to provide coverage for people without health insurance." Most recently, in a July 2000 Washington Post/Kaiser/Harvard study, 77% favored expansion, while only 22% opposed it.36 A December 1998 Kaiser/Harvard survey found that nearly 7 in 10 respondents (69%) favored "a new law that would offer low- and moderate-income uninsured Americans an income tax refund to help them purchase private health insurance." Twenty-seven percent opposed this idea.37

In addition, there appears to be support for a "proposal to extend [CHIP] health insurance coverage to the parents of the eligible child," though respondents were told to keep "in mind that this would cost the government and taxpayers money." Fifty-six percent favored this plan in a February 2000 Kaiser/NewsHour survey, while 41% were opposed. However, only 50% favored it in December 1999, while 37% were opposed and 13% did not know.38

A Harris poll from April 1998 found that a plurality (43%) believed the government spends "too little" on "Medicaid, the health insurance program for low-income families and children." Forty percent said the amount spent is "about right," but just 13% said government is spending "too much."39

Unemployed

Even if steps were taken to expand insurance coverage by requiring employers to cover workers, which the public seems to support readily, those who are unemployed – particularly if they are not poor – will still not have insurance coverage. Apparently Americans would be open to establishing a government program to provide health insurance for those who are out of work. In the current survey, respondents were presented with the following question:

Although support for this proposal is somewhat lower than for requiring employers to provide insurance to full-time and part-time workers, a firm majority of 58% approved this idea, while 37% were opposed. Similarly, a May 1999 poll by Belden, Russonello & Stewart found that 77% approved (44% strongly) of "setting up a new department in the federal government to provide health insurance for unemployed and low-income working people." Only 30% disapproved (21% strongly).40

Support for providing insurance for the unemployed came through in the focus groups. In addition to the general belief that everyone should have access to basic health coverage, no matter their employment status, participants also believed in the importance of having insurance during transition periods. However, support for government insuring the unemployed is tempered by skepticism about the worthiness of the potential recipients. As a result, most wanted some kind of time limit or proof that the individual was actually seeking work.

As far as providing insurance to the unemployed, I think that’s definitely what I was talking about before. That the government, the country, needs to provide for its people. It needs to provide for the people that need it. People that don’t have the insurance should be able to look towards the government or someone out there that could just give them a hand. (Man, Cleveland)

I don’t know if I’d want the government to pay for it as much as I’d want them to mandate it as part of the transition system. If you let somebody go, you would be required to cover their health insurance, or part of their health insurance, for some period of time. (Man, Richmond)

As far as unemployment goes, I think everybody should have coverage, especially children, but not people that are going to be taking advantage of the situation. If they are seriously looking for employment in a serious manner then, yes, I think they should have that option. (Woman, Cleveland)

I would favor … a safety net for unemployment that would have stipulations maybe to have a certain amount of time to get a full-time job. (Woman, Cleveland)

I believe that maybe for a certain amount of time they should provide health care towards these people, only if they show proof they are really actively looking for a job … (Woman, Richmond)

Approaching Medicare Age

Another population that Americans seem ready to help cover are those who are approaching retirement age. One of the dilemmas for the current employer-provided insurance system is that people who want to retire before age 65, or who lose a job but don’t plan to return to the workforce, are often unable to afford or qualify for health insurance, leaving them vulnerable to devastating health costs. President Clinton and Democrats in Congress have proposed allowing those aged 62 and up to purchase health insurance through Medicare. Enrollees would pay substantial premiums, but the cost would be lower than private plans because the government would subsidize some of the cost. This would in turn raise the cost of the Medicare program for the taxpayers.

A September 1998 Kaiser/Harvard study presented respondents with arguments for and against allowing people 62 to 64 to buy into Medicare:

Despite the concern over future Medicare spending, some people think the program also needs to be improved and expanded. Again, I’m going to read you some arguments for and against a proposal, and then ask which point of view comes closer to your own. ... There is a proposal to expand Medicare so that people aged 62 to 64 are able to buy into the program before they turn 65, the current age of eligibility. Those who favor this change say it will give uninsured early retirees access to health insurance before they qualify for Medicare without adding substantial costs to Medicare, since those who buy in would pay the full premium. Those who oppose this change say it could add costs at a time when we need to reduce costs and limit benefits, and that it is likely to help many people. Which comes closer to your view, do you ... favor or oppose letting people aged 62 to 64 buy into Medicare?

In this case, 60% supported allowing people 62 to 64 to buy into the program, while only 37% opposed the idea.41 A January 1998 ABC News/Washington Post poll found roughly the same level of support (62%) when it included the information that buying into Medicare would cost these new participants "about $300 a month." Only 34% were opposed.42 In an NBC/Wall Street Journal poll the same month, nearly two out of three (65%) rejected the idea that those who buy in early should "have to pay a higher premium once they turn 65 to cover all the projected costs to the Medicare system."43

Other research suggests that there is substantial public support for expanding Medicare even further, to people as young as age 55. The January 1998 NBC/Wall Street Journal survey offered arguments for and against this idea. It noted that President Clinton favors "giving people as young as age 55 the right to buy Medicare coverage if they have lost their job," but that Republicans believe Medicare "is already in financial trouble and that it’s too costly to add new people to a system that can’t handle them." While support for Medicaid expansion in this case dropped to less than a majority, a 48% plurality still favored expansion, with just 39% opposed.44 Similarly, a Pew poll from the same month found 51% support for a proposal "to expand Medicare to also include younger retirees and uninsured Americans between the ages of 55 and 64 who would pay higher premiums than people 65 and older now do." Forty-one percent were opposed.45 Moreover, support actually increased to 56% when a price tag of $400 a month in premiums was suggested, though opposition remained firm at 41% (ABC/Washington Post, January 1998).46

An even stronger majority favored expanding Medicare when it was not spelled out that there would be any age requirement. A Kaiser/NewsHour study from February 2000 showed 67% in favor of "expanding Medicare to cover people under age 65 who do not have health insurance." While this represents a 10-point increase in support over a December 1999 Kaiser poll, a February 1998 Greenwald & Associates poll found a similar level of support (68%) for "allowing uninsured people to buy into Medicare." Only about one-third or less were opposed in any of these questions.47

Offering Tax Breaks

Besides targeting specific populations, Americans also support the idea that the government should offer tax breaks to help any American get health insurance. A July 2000 Washington Post/Kaiser/Harvard poll asked about the idea of "offering uninsured Americans income tax deductions, tax credits, or other financial assistance to help them purchase private health insurance on their own." A strong 69% supported such a plan, with 28% opposed. When the same question was asked in December 1999 and February 2000, 69% and 74%, respectively, favored the idea. In October 1999 Kaiser/Harvard posed a similarly worded question saying that it would entail "a new law." Seventy-one percent said they favored that idea.48

Findings Continued >>

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