Current Trends in Public Opinions on Single-Payer Healthcare

Mr. Nacinovich:
By its very nature, health care is a deeply personal and pressing topic for the American public, especially when it comes to addressing costs and coverage, but it’s also a highly polarizing topic for those same reasons. As the concept of a single-payer national health insurance program has swung back into the limelight this election year, questions surface as to what’s shifted in the court of public opinion, how this may affect voter attitudes, and whether there’s a common understanding of the proposals being made.

Welcome to Voices from American Medicine on ReachMD. I’m Mario Nacinovich, and joining our program to discuss current trends in public opinions around single-payer health care is Liz Hamel, Vice President and Director of Public Opinion and Survey Research at the Kaiser Family Foundation. Liz directs KFF’s polling work, including the monthly Health Tracking Poll, and collaborates with various news media on survey partnerships. Thank you for collaborating with us today, Liz.

Ms. Hamel:
Thanks for having me.

Mr. Nacinovich:
So to start, can you walk us through the research being conducted at your institution and what you’re looking to find?

Ms. Hamel:
So, we have been tracking here at the Kaiser Family Foundation public opinion on the idea of a national single-payer health plan dating all the way back to the late 1990s, and what we found is that while support for this type of plan never really reached a majority up through around 2009-2010, once Bernie Sanders really began to talk a lot about it in the 2016 presidential campaign and sort of branded it as Medicare for All, since that time we’ve seen a majority of people in favor of the idea of this type of plan, a slim majority, usually just somewhere above 50 percent that says they would support this type of plan when you initially ask the question.

Mr. Nacinovich:
So, from your research, which populations have you found to be in favor of the federal government doing more to expand health insurance for more Americans, and which have remained or have become opposed?

Ms. Hamel:
Well, I should start by saying that most people overall are in favor of doing something more, but when you ask about what specific plan they support and you ask about a plan like single-payer or Medicare for All, as you can imagine, you get a very divided partisan response, so we’ve found that a majority of Democrats are in favor of this type of plan, independents are a little bit split on it, but Republicans are largely opposed to this type of plan.

Mr. Nacinovich:
So, it does seem like attitudes align more generally with political identification, but is it more complex than that?

Ms. Hamel:
It certainly is more complex than that. One thing that we say about public opinion on a complex idea like single-payer or Medicare for All is that public opinion is very malleable. So, you can ask people if you support this type of plan, and you get one answer, but if you start reading people some of the arguments that people have made, either supporters of this kind of plan or opponents, you can really push public opinion in one direction or the other. So, for example, if we say to people, “What if you hear that this plan would guarantee health insurance as a right for all Americans?” - you can push support up to 71 percent. On the other hand, if you say, “What if it would eliminate private health insurance companies, threaten the current Medicare program, or lead to delays in people getting medical tests and treatment?” - you can push opposition as high as 70 percent, and so depending on which aspects or potential implications of a plan that you emphasize, you really can see large swings in public opinion.

Mr. Nacinovich:
How have these opinions shifted over the course of your research efforts?

Ms. Hamel:
We’ve been tracking since about 2017, and we haven’t seen major shifts over time. Support has sort of bounced around between 51 percent and 57 percent, but there hasn’t been a big shift in general support for Medicare for All. Another thing that we’ve seen through the course of the Democratic campaign is that there are a lot of competing proposals for expanding coverage that have emerged, and some of these are not new ideas. They’re things that have been around for a long time. We’ve heard Bernie Sanders talking about Medicare for All, but other candidates have talked about either a public option or building on the Affordable Care Act as ways to expand coverage, and what we generally find with those types of proposals is that they’re a bit less polarizing, and they tend to get higher levels of support than Medicare for All. Not all of them will get a majority of support among Republicans, but they certainly are more palatable to some Republicans than the idea of a single-payer health plan.

Mr. Nacinovich:
That’s a perfect segue. Let’s get into the latest proposals for Medicare for All, and how does the public currently view a national health plan in the context of some of these more recently introduced proposals of Medicare for All?

Ms. Hamel:
So, one of the things that we’ve started to do is to look at people who say that they favor Medicare for All but also say that they favor a public option, which is one of the most prominent sort of more moderate proposals compared to Medicare for All, and what we find is that there’s a really small share of the public that says they only favor Medicare for All and wouldn’t be in favor of a public option. So, that’s about 7 percent, and we think of those as the really hardcore Medicare for All proponents. There’s a large group that really favors both, and they say, “I’d be happy with either one of these options,”, and then there’s a bigger group that says, “Yes, I, would accept a public option, but I think a Medicare for All plan goes too far,” , and that seems to be the group that has the potential to be a larger share of the potential electorate as we think about moving into the 2020 election.

Mr. Nacinovich:
For those just tuning in, this is Voices from American Medicine on ReachMD. I’m Mario Nacinovich, and today I’m speaking with Liz Hamel, Vice President and Director of Public Operations and Survey Research at the Kaiser Family Foundation about attitudes towards single-payer health care. So, Liz, giving what we’ve talked about, we’re reminded that in all healthcare communications and across the ongoing debates on health care, that words certainly matter. In your view, what does terminology or how does terminology affect public thinking, and are there specific terms on the subject that trigger the broadest and most positive or the most negative reactions?

Ms. Hamel:
Yeah, certainly, and I think we’ve started to hear some of those terms thrown out in the campaign so far. We’ve heard President Trump talking about socialized medicine and socialism, and we know that’s a term that evokes a much more negative reaction from the general public. I think it’s no surprise that the advocates of a single-payer plan have settled on the term Medicare for All as their name for their plan. Medicare is a very popular program. It’s something the public understands, and it is also a term that tests really well. It gets a positive reaction from a lot of people. What we find when we ask people about the term single-payer, it’s actually poorly understood by the public, and so I think that’s why we saw Bernie Sanders, when he really started talking about this plan, calling it Medicare for All and not using that single-payer term because that’s something that’s a lot more confusing for people.

Mr. Nacinovich:
So, staying on that track, what are some of the most important features of a national health plan that are desired by supporters?

Ms. Hamel:
Yeah, one of the things that people really like about this sort of plan is that it would cover everyone. I think this is a goal that, you know, almost everyone can agree on. Even Republicans say, “Yes, I think that everybody in this country should have insurance,” so that’s a number one thing when we ask supporters of this type of plan what’s important about it – that it covers all Americans. People would also like to see it bring down healthcare costs, and so in the form of eliminating monthly premiums and getting rid of some of those high deductibles and high copays that people are experiencing with their insurance right now. That’s all also really important to people. I think people who are looking for a national health plan would also like to see it simplify the US health insurance system, so this is something we hear a lot about when we talk to people. People are frustrated about the cost of their health care, but they’re also frustrated about how complex the system is and how difficult it can be to navigate their current health insurance arrangements, and so that’s something that people who support this type of plan are looking to get out of it as well.

Mr. Nacinovich:
So, as a follow-up to that, are there similar features about the national health plan that are targeted by the opponents of these plans?

Ms. Hamel:
Certainly one of the things that I think opponents feel most strongly about is the idea that this type of plan could potentially take away people’s choice, particularly their choice of health plans. As Americans, we really like choice. We like to have choice in which doctors we can see, we like to have choice in the types of plans that we can have, and so opponents of these plans, have really gravitated to the idea that if we had this one-size-fits-all system, it would eliminate people’s ability to have that choice. Also the idea that it would make people have to change the insurance arrangements that they have now, so we know a lot of people aren’t that happy with their insurance, but there are a lot of people who are happy with what they have now, and so opponents would say that eliminating private health insurance and taking away the employer-sponsored insurance that people have now is a big negative of this type of plan, and, of course, we’ve heard a lot in the campaign discussions about not necessarily the cost to individuals but the cost to the country.

Mr. Nacinovich:
There’s also been some prevailing thought that incrementalism could lead to a national health plan, but what’s the public sentiment about incremental approaches such as Medicare and Medicaid buy-ins or government-run public options as stepping stones to universal coverage?

Ms. Hamel:
Yeah, I think all of those options that you mentioned start with a higher level of public support than Medicare for All starts with. I think it’s also important to note, though, that when we drill down and read people arguments made on either side of those types of plans, you can also change public sentiment, as well. We saw when the Affordable Care Act was being debated that the opponents branded it as a government takeover of health care, and many on the other side would argue that it was just an incremental approach, and so even if a Democratic candidate emerged who was advocating one of these more incremental approaches, I think it’s still vulnerable to attacks from the other side as increasing government involvement in health care, which we know is an argument that works for many people.

Mr. Nacinovich:
In a separate poll conducted last year KFF asked whether Americans would prefer a candidate who build on the ACA or favor a candidate who would replace the ACA with Medicare for All. What did you all uncover?

Ms. Hamel:
Yeah, we found that among Democrats that more of them would prefer a candidate who would build on the existing ACA rather than a candidate who would push for Medicare for All, and I think this mirrors what we see when we ask about some of these other proposals like a public option or Medicare or Medicaid buy-ins, that there is a larger contingent that’s willing to accept these more incremental proposals. We also hear people Democrats in particular, who say, “Look, we fought so hard to get the ACA passed. Let’s not throw it out and try something new. Let’s really keep trying to work on it, improve it, and do what we can with that because it was such a hard fight to get that passed in the first place.”

Mr. Nacinovich:
Well, with that parting comment, I’d like to thank Liz Hamel for joining me to shed light on how favorability may differ based on political party identification, word choice, and many other factors as we consider the possible variations along the path towards a possible single-payer government-run system. Liz, it was great having you on the program today.

Ms. Hamel:
Thank you for having me.

Mr. Nacinovich:
For ReachMD, I’m Mario Nacinovich. To access this episode and others from Voices from American Medicine, visit ReachMD.com/Voices where you can be a part of the knowledge. Thanks for listening.