Analysis:

Five keys to success based on new national surveys and extensive focus groups

The country wants health care reform, though we are at a pivotal point in the debate and the public needs to learn some key things about the plan for reform in order to really embrace it and create a sustainable majority for change.  Despite all the press coverage on health care, one in five do not know whether to support Obama and the Democrats’ plan.  This is why Democracy Corps and Greenberg Quinlan Rosner conducted two national surveys and six focus groups over the last month.   We are encouraged by what we have found, as the public is paying close attention and looking now to learn key things about the reforms that they have not been able to discern through the fog of congressional and political battles.

Voters need to hear clearly what reform will bring: never losing your insurance if you lose a job or get sick, the shift of control from insurance companies to people who will get more choice and lower costs.  The president will have to emerge as educator-in-chief as he explains to people how this plan works to reduce their costs (an insurance exchange with choice and competition, an emphasis on preventive care and wellness, insurance companies that cannot hike rates for pre-existing conditions or growing old), and how it is paid for.  And most important, this is all premised on the unacceptability of continuing the status quo, which means a future of rising costs for people, businesses and the country, insurance companies still calling the shots, more big and small businesses unable to afford insurance, and more people with no coverage. In this survey, a strong majority views continuing the status quo as the greater risk – as they have no doubt these things will worsen if we fail to reform health care.

As a result, a plurality support the president and Democrats’ plan for reform without any description, rising to 50 percent when it is described, even when financed by Medicare cuts and new taxes.  Among those under age 65, the majority grows to 54 percent, with 40 percent opposed.  Support for reform in the country has held up over the last three weeks, despite concerted Republican attacks on the “government takeover” of health care and the high costs of reform, suggesting the voters’ determination to find out whether the promise is real.

This plan prohibits insurance companies from denying coverage for pre-existing conditions or dropping coverage when someone gets sick and requires them to cover preventive care. It creates a health insurance exchange where individuals can comparison shop among different private plans or a public insurance option.

The plan requires all Americans to have health insurance while subsidizing the cost for those with low and moderate incomes. It requires all companies to provide health insurance for their employees or contribute to a fund that will help pay for their coverage with small businesses getting help covering some of the cost.

The plan will be paid for by reducing Medicaid and Medicare spending by 400 billion dollars over the next ten years and implementing some new taxes that might include a small sales tax on goods except for food, higher taxes on those making over 200,000 dollars OR new taxes on alcohol or sugary drinks.

That the plan gains support and a clear majority after they hear about the financing tells us that voters are serious about reform – willing to consider the whole package, if it is credibly paid for without hidden taxes.  The survey shows that voters believe that the long-term benefits of reform are worth the honestly acknowledged upfront costs (in the form of targeted taxes and spending cuts).

Still, there is only a small majority for the plan, and opponents are more intense in their opposition than supporters are in their support.  On the critical issue of whether your family will be helped or hurt by the plan, the country is split down the middle.  When the country last took up health care reform sixteen years ago, people moved quickly to make that personal judgment – and this became the most important predictor of support or opposition to health care reform.  In this round, it is already an important predictor of support for reform, even before the specifics of the plan for reform have been made clear.

Proponents and opponents of reform will be battling for the 35 percent of the electorate who are not satisfied with the health insurance system but satisfied with their personal insurance.  Conservatives and some in the media think these voters are not serious about change, but that misreads them, as we realize from our focus groups last week.  They are “satisfied” with their choice of doctors, that their employer is picking up most of the cost and that they may have better insurance than others. But, they are not happy about having traded off wages or gotten locked into a job because of health care or about the fate of a child with a chronic ailment who may not be able to get insurance in the future.  So, they are nervous about change, but they want it.

Achieving a sustainable majority of support for reform will require supporters to get the messaging right and the president and his allies in congress getting the details of the policy, and how it is paid for, right as well.  On the former point, we offer the following five strategic recommendations to buttress and deepen support for health care reform.

1. Voters need to hear clearly what changes health care reform will bring.  So far, supporters of reform have spent much of their energy reassuring voters about what the plan won’t do – namely take away their choice of doctors and plan.  And they have been successful as a solid majority believes that reform will maintain their choice of doctors.  But to expand support, voters also need to hear what positive changes reform will bring:

• Never losing health insurance when you lose a job or get sick
• Power shifted from insurance companies to people, who no longer face higher rates or lost coverage for a pre-existing condition, getting sick or getting older
• Reduced costs for you and your family, business and country.

While the public is uncertain about the plan’s goals and how it works, they are very clear about what want.   They want costs down, they want insurance companies to stop acting capriciously and they want the security of knowing you are always insured.  Those are the top reasons for reform, the most convincing reasons to go forward, and they contain the most emotion and passion.

While voters are skeptical this will save money, we have to win the cost argument, which is discussed below.

Never losing coverage and insurance for all is a core reason for going forward; indeed, that is what they think the president is trying to achieve and in all our surveys, “insurance for all” is the biggest recalled reasons for going forward with reform.  The security message was the strongest argument in favor of reform in our early June survey, with 72 percent responding favorably to the statement that the plan will “guarantee that quality, affordable coverage will be there for you no matter what happens, giving you the peace of mind that even if times get tough, you will always have access to quality health care at a price you can afford.”   With nearly 40 percent of likely voters dealing with unemployment in their immediate family in the last year, this purpose has rising importance – unlike in 1993 and 1994, when unemployment was falling.

2. Build a narrative around taking power away from the insurance companies and giving it to people.  The control and power that insurance companies have over people, their ability to refuse care because of pre-existing conditions and use the fine print to drop people when they get sick is the part of the status quo that voters most want to change.  This is personal and emotional.

In this survey, insurance reform easily generated the broadest and most intense support of the eight different elements of Obama’s reform plan we tested.  This was straightforward and emotional in the focus groups:

• “I think the insurance companies need to have less power in the decision-making process” (Woman, 45-60 years old, college educated, suburbs of Chicago.
• “It’s crazy.  They are saying pay and pay and pay, and then when something happens, they don’t want to pay”(Woman, 30-45 years old, not college educated, Denver, CO)
• “The system generally from health insurance cherry picks the people that can afford it and then starts narrowing down classes of, well you’re generally healthy until the point where you actually have some coverage, you have some claims or the stories and then they boot you out.” (Man, 30-45 years old, college educated, suburbs of Chicago)

This suggests a narrative full of personal examples leading to the conclusion that people need reform that ends insurance companies’ ability to treat people like this and that shifts the power to people so those who have paid their bills and played by the rules have coverage when they need it.

With the Republicans seen mainly as trying to help the insurance and drug companies “make more profits” in this health care debate and the president rightly trying to bring all to the table, it is important to keep this purpose center-stage.

3. The president and reform advocates have to explain concretely the changes that will mean lower costs.  Right now, they do not see it, as more people think their costs will rise, given everything they have been hearing.  The $2,500 in lower costs that the president has promised seems illusory to people. That was a major failing sixteen years ago, as the actual mechanisms for lowering costs were a mystery for voters, but they cannot remain a mystery now.

Fortunately, people in the focus groups were quite prepared to believe a number of elements could produce real savings: the competition created by a health insurance exchange where people can choose from competing private plans and a public one and comparison shop; paying first dollar for preventive care and supporting wellness; and insurance reform that prevents insurance companies from raising rates when people age or get sick.  One of the strongest testing elements of the plan is the description of the exchange, including the public option.  Fully 72 percent support creating “a national health insurance exchange – a market where individuals and small businesses can comparison shop among different private plans or a public insurance option.”

Also, in the absence of an honest accounting of how this plan will be paid for, voters (who have heard the trillion dollar-plus price tags being discussed) assume that it will result in hidden taxes that will impact them.  But this survey shows that when voters are provided an honest acknowledgement that the plan will mean some Americans will have to pay more at first (in the form of targeted taxes) they believe this price is worth the long-term benefits of reform.

4. Show all voters and seniors that there are benefits for them, including prescription drugs. Seniors are the most satisfied with their health care and the least interested in reform – indeed, they are worried about all this new health care spending and possible changes to Medicare.  Seniors and voters broadly need to hear that addressing health care costs for seniors is central to the plan, not only that their Medicare coverage will not be undermined but that the plan also provides them with some tangible new benefits – and this probably requires a dedicated strategy to get heard.  In our survey, we found strong support among both seniors and the electorate as a whole for expanding prescription drug coverage by closing the Medicare “donut hole.” This was the strongest argument in the survey for the plan:

Under this plan seniors would still receive Medicare coverage, just as they do now with no reductions in benefits. But the plan would also provide seniors with better prescription drug coverage by eliminating the so-called "donut hole" – the gap in Medicare coverage that forces millions of seniors to pay thousands of dollars out-of-pocket for prescription drugs.

5. All of these points should be made with the dominant framework that continuing the status quo is unacceptable and unsustainable. Voters know that keeping the status quo means costs will keep rising for themselves and companies, insurance companies will stay in control, more employers will drop their coverage and more Americans will go without any insurance.  When put into that framework, people re-evaluate the risks of staying with the status quo and what they think could happen to their insurance.

When we offered voters the prospect of keeping the status quo, they quickly imagined very real horrors:

“[Under the status quo] when you get laid off you have no options….  When the insurance runs out you’re just desperate at that point.” (Man, 30-45 years old, College Educated, the suburbs of Chicago)

“For one, it tells us we need to change.  We need change for everybody.  It’s not just whether you are low-income, middle-income, high-income, it needs to change for everybody. … You can say that this new program isn’t the right program, but then tell me what is.  Don’t say staying the same is the answer, have an idea, have a thought.” (Man, 45-60 years old, not college educated, Denver, CO)

By a large margin, 51 to 43 percent, voters say they are more worried that reform will fail and costs will continue to rise making it “hard to afford the health care we need” than that reform will increase costs through higher taxes.  And perhaps most important, after hearing a battery of possible tax increases to pay for the plan a strong 56 to 39 percent majority say they would rather pay for the reform using some of those tax increases than “keep the health care system the way it is now."

That leads to a strong testing narrative:

Continuing the status quo in health care is not acceptable and not sustainable. Keeping the status quo means the insurance companies are still in charge, jacking up rates and denying coverage. It means more people losing insurance or enslaved to their job, prices skyrocketing for families and businesses and our companies less competitive. We need change so that people no longer lose coverage, get dropped for a pre-existing condition and see lower costs.

With Republicans seen as defenders of the status quo, there is even more punch in this framework for reform.

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