Polls on the Obama health care reforms bill raised troubling questions about the validity of their results. In particular, how did the American public answer polling questions about this complex piece of legislation when, by their own admission, most said it was confusing and hard to understand? And if confused, how did polls find Americans deeply divided on the subject?
With the help of leading questions and an uncritical, self serving media, easier than you might imagine.
Social conditioning of respondents
As described in “How Polls Divided Americans on the Obama Health Care Reforms“, most polls relied on questions with preformatted responses. These responses employed wording that prompted a media conditioned response on the part of respondents in a predictable partisan direction. The conditioning was driven by a mass media bombardment of the public by highly partisan health care reform messages emanating out of the rancorous congressional debate. It was therefore not surprising that the response to many of the questions was highly correlated to respondents’ political affiliation (Republican, Democrat, or Independent).
It was a Pavlovian experiment on a national scale.
To answer the poll questions, the public did not need to know the particulars of health care reform. They simply had to connect a preformatted response with a partisan position. Bingo! Next question please. In effect, the surveys were not measuring opinion, they were creating it.
In the end, the polling results told us very little about where the public stood on the merits of the legislation, and how it would affect their lives. However, they did reveal what the large majority of Americans was certain of, namely
- the need to completely rebuild the health-care system around certain principles, and
- a profound sense of confusion as to how Obamacare was to work.
Listening to respondents
Instead of pollsters feeding Americans prepackaged responses to specific reforms about which they knew very little, it would have been much more meaningful to simply ask respondents to describe in their own words what they favored or opposed in the reforms. Instead of the pollster creating the agenda, the onus of creating the agenda would be shifted to the respondent.
This is exactly what one pollster did. In March of 2010, Gallup asked a representative national sample of over one thousand respondents to describe in their own words why they favored or opposed the health-care bill. Then Gallup laboriously coded all this information to identify the most popularly shared opinions and beliefs. The results are summarized in the tables below.
What is the main reason you favor such a health-care bill?*
Based on Americans who advised their member of Congress to vote for a health-care bill**
|People need health insurance/too many uninsured||29%|
|System is broken/needs to be fixed||18%|
|Costs are out of control/would help control costs||12%|
|Moral responsibility to provide/obligation/fair||12%|
|Would make healthcare more affordable||10%|
|Don’t trust insurance companies||5%|
|Respondent or family member currently lacks coverage||4%|
|To help senior citizens||4%|
|To help the poor||3%|
|No particular reason||1%|
What is the main reason you oppose a health-care bill?*
Based on Americans who would advise their member of Congress to vote against a health-care bill**
|Will raise costs of insurance/make it less affordable||20%|
|Does not address real problems||19%|
|Need more information/clarity on how system would work||8%|
|Against big government/too much government involvement (general)||8%|
|Government should not be involved in health care||7%|
|Healthcare is a privilege, not an entitlement||6%|
|With cost government too much/too much spending/increase the deficit||5%|
|People should not be required to buy health insurance||5%|
|Would affect respondent’s current health insurance||4%|
|Oppose the “public option” proposal||3%|
|Rushing it through process/should take more time||3%|
|Would hurt senior citizens/Medicare||3%|
|Would pay for abortions||2%|
|Has not worked in other countries||1%|
|Illegal immigrants would benefit||—|
|No reason in particular||—|
*Note the question asked respondents to describe “the main reason” for favoring or opposing the health-care bill. Many respondents had more than one reason, and provided multiple responses to this question. Unfortunately Gallup coders selected only one reason per respondent. This decision underestimated the actual totals in some response categories.
**Gallup relied on a question that used politically charged wording (“Would you advise your representative in Congress to vote for or against the health-care reform bill similar to the one proposed by President Obama?”) to categorize respondents as being in favor or opposed to the bill. If a respondent was torn between the pros and cons of healthcare reform but opposed Obama for a whole range of other reasons, that respondent would not be asked how they favored health care reform, only how they opposed it. For a respondent who supported Obama it would be the reverse scenario. A less polarizing support/oppose question would have been better as it would have more fully revealed the internal tensions stimulated by this complex legislation.
***Less than 0 .5%
The “prompting” effect
It is quite striking to see how opposition to health care reform provisions can skyrocket when it is prompted (asked as an explicit question with prepackaged response choices) versus the unprompted rate from the table above. For example, a CNN poll from March of 2010, about the same time as the Gallup poll, found that for the provision requiring “all Americans who do not have health insurance to get it”, the prompted response was 53% in opposition. Unprompted, the above table shows the opposition was only 5%. So where does the truth lie, closer to 53% or to 5%?
Abortion is another example. Unprompted, only 2% say they oppose the health-care bill because it would be used to pay for abortions. When prompted by an explicit question, the percentage who oppose jumps to 33%.
Pollsters would have you believe that prompted responses are more accurate since they simply remind respondents of forgotten but genuine, self inspired opinion. This is pure poppycock! The large majority of respondents have admitted that health care reforms are confusing. In light of this, the main function of prompts is to stimulate responses that are conditioned by a pervasive and partisan media exposure. There is very little “genuine or self inspired” about this.
From the perspective of the press, prompted responses deliver headline fodder. “Americans Oppose Forced Purchase of Health Care Insurance” would be a legitimate headline in the above example. But if it were explained to respondents that forced purchase is a necessary condition to realize a bunch of other reform goodies they strongly support, the degree of opposition to it may diminish dramatically. With something as complex as health care reform, it is important that polls explore the consequences of such tradeoffs, particularly if the public admits to being ill-informed on the subject.
But trying to understand such complexities does not sell papers. Feeding a conflict driven, adversarial, partisan narrative, however, does. This, more than anything, accounts for the deep public divisions on health care reform reported by the press.
The priorities in respondents’ own words
The other noteworthy observation about the tables is the diversity of reasons — 10 in the favor group and 17 in the oppose group. Some in the latter read like they came straight out of the GOP playbook, and to be fair, some in the former read like they came straight out of the Democratic playbook.
That said, we find that these diverse reasons fall into three broad categories for both groups. They are:
1. The healthcare system is broken. Those in favor (18%) believe Mr. Obama’s plan fixes it. Those opposed believe it doesn’t (19%) or require more information (8%) and time (3%) to understand how it works.
2. Ideological differences. Those in favor believe it is a moral responsibility for the nation to care for those who succumb to disease and illness (52%). Those opposed disagree and are extremely concerned about the encroachment of big government in the lives of its citizens (33%).
3. Economic concerns. Many who are opposed believe that the fix would be economically disastrous for the country (32%). Those in favor believe Mr. Obama’s claim that his fix will reduce health costs in the long term (22%).
Economic uncertainties of the bill
The 32% figure for those who oppose health-care reforms because they would be disastrous for the economy is an underestimate since, as noted earlier, Gallup did not count multiple responses. A closer examination of the multiple responses in the verbatim comments provided by Gallup suggests the correct figure is 39%, about four of every 10 naysayers. Given all the uncertainty as to how the health-care bill will work as well as the economic crisis in which the country finds itself, it is perhaps not surprising that so many respondents who oppose the reforms question it on economic grounds.
Some examples of comments related to economic concerns are listed below:
- “We cannot afford it.”
- “It’s a trillion dollars. It’s too much. I’m not paying for anybody else’s healthcare”
- “I just think it’s going to cost too much for what we’re going to get for it”
- “Expensive. The deficit’s going to go through the roof”
- “I feel like my taxes will increase to support those who do not have health care”
- “Too expensive and the United States can’t afford it. We’re broke.”
- “Because it is going to screw everybody, everyone that has insurance now, their costs are going to skyrocket.”
- “We’re in debt, and he wants to spend another trillion dollars, and it’s not gonna to work.”
- “The unknown costs, everything that is buried in there that is going to increase taxes or deficit.”
With all the political wrangling in Congress, it is unlikely the ideological divide will be breached between the two sides. If however Mr. Obama can show the reforms deliver significant health savings, there is a chance to reduce public resistance to his reforms. At the risk of sounding pessimistic, there is little likelihood for this providential outcome. In his New York Times column, David Brooks addresses some of the key economic projections of the health-care reform bill and notes that economists predict that projected costs would underestimate real costs by almost $1 trillion by 2019.
Insurance company profits
It seems the fly in the ointment in all this are the private health insurance companies and the wretched deal Mr. Obama made with them to gain their support. Reforming the system to provide adequate but less costly health care fundamentally conflicts with what is best for the patient versus what is best for the insurance company. The primary purpose of a private health insurance company, like any other company, is to earn profits for its shareholders. The primary purpose of a doctor or hospital ministering to a person who is ill is to bring them back to health. One of the major complaints of many doctors today is the amount of time they need to haggle with insurance companies to insure their patients get the necessary medical treatment. In effect insurance adjusters try to override medical decisions for which they have no qualifications to ensure that company profits are protected.
Even with millions of new clients seeking health care insurance, this conflict is inherently impossible to resolve. That is why most other industrially advanced democracies have taken financial profits out of the health-care cost equation and have designated health care as a responsibility of the state. Some may argue that this step is tantamount to godless socialism. Others might argue that this is simply an act of Christian charity conducted on a grand scale.
The bankruptcy cliff
But whether one sees this as godless socialism or Christian charity, the fact remains that the government cannot allow costs to escalate to the point where it bankrupts the nation. If nothing is done to remedy the costs, they will climb to about one fifth of total GDP by 2017. At present about 40% of all Americans have either no health insurance or are inadequately insured. Yet the per capita cost of US health care for Americans is about two times that of Canadians.
The single-payer alternative
In Canada there is a single-payer system where costs are regulated by the government but where doctors and hospitals are free to run their own medical businesses. Public health care in Canada has become part of what it means to be Canadian. It is a social compact where all Canadians agree that if one of them is ill, that person is cared for through their illness by all Canadians Like in The Three Musketeers, it’s all for one and one for all. Secondly, no queue jumping is allowed. Priority is determined by medical urgency, not by size of wallet. Public health care has been in operation for decades and contrary to what is heard on Fox News, the system works fairly efficiently with most Canadians regarding it as a sacrosanct institution.
One final note. With a conservative Canadian government far more right-wing than the Obama administration, there is no talk of repealing Canada’s health care legislation, and so far as I know, little danger Canada going Communist in the foreseeable future.
Oleh Iwanyshyn is a Canadian pollster with over 30 years of experience in the profession. In the spirit of full disclosure, he has used the Canadian health care system and is still alive to tell the tale.