Commentary: A pollster's view of Obama's health care reform missteps

Ipsos Public AffairsAugust 21, 2009 

In mid-August only seven months into his administration, the once invincible Barack Obama finds himself on the defensive — sliding rapidly in the polls and facing waning support for health care reform.

This was not supposed to be.

Prevailing wisdom held that the stars were finally aligned for meaningful health care reform at the national level: a majority of Americans supported reform, President Obama had the credibility to push an aggressive agenda, and the mistakes of the Clinton health care debacle were clearly learned and assimilated.

The Obama Administration had gone to great lengths to avoid what it viewed as the fatal flaws of the Clinton reform efforts. They kicked off the reform process by engaging all the key stakeholders in the health care debate: insurance companies, the pharmaceutical industry, and professional medical associations. After outlining the broad parameters of a solution, they then booted the specifics over to Congress. This time it would be a bottom-up rather than a top-down process. With the political obstacles addressed, and public sentiment firmly behind the Administration, the path to comprehensive health care reform was open, or so they thought.

Recent polling numbers, however, tell an uncannily-similar tale to the Clinton experience of 1993-1994.

Before the Clinton health care debate, strong majorities of Americans favored health care reform, roughly the same percent as supported reform in early 2009. But just as in 1994, support for reform is now fading (in some polls it is now less than 50%) in the face of an intense, emotionally-charged debate.

What might explain these similarities?

In our view, Obama's problems stem from his misreading of Clinton's failed reform efforts in '94. Our contention is that the flaw of the Clinton plan was not solely political in nature but a fundamental misreading of public opinion. That is, the central challenge of health care reform has never been exclusively about the political process — smart political horse trading. Instead, the central question has always been about how to effectively communicate the specific, tangible benefits of reform to the American public.

Indeed, health care reform — whether now or in 1994 — should never have been framed in abstract terms — "public option, the right thing to do," or "universal coverage." Instead, it should have been sold from the beginning by explaining its constituent parts, perhaps in piecemeal, showing clear benefits to people, and staying away from vague concepts that could be easily re-framed.

In pollster speak, health care reform proponents have incorrectly identified the "ballot question" — it is not general support for health care reform, but support for specific items that bring tangible benefits to people.

Recent Ipsos polling data makes our point well (see below). The abstract concept of the "public option," for instance, finds only a slight majority of support (52%). Specific items, in contrast, find stronger majority support (62% to 91%). See some examples of this below.

Overall Support for Public Option:

It is necessary to create a public health insurance plan to make sure that all Americans have access to quality healthcare 52%

Access to quality healthcare for all Americans can be achieved without having to create a public health insurance plan 44%

(Volunteered: Don’t know/Not sure) 4%

One of the points being debated is whether or not the government should create a public health insurance plan as an alternative to private insurance plans. Which of the following is closest to your opinion?

Support for Healthcare Reform Specifics: Total support Total oppose

Offering tax breaks or incentives to small businesses so they can provide health insurance to their employees and their families 91% 8%

Allowing the government to negotiate for discounts on drugs 71% 25%

Requiring that all employers offer health insurance to their employees and their families 70% 28%

Requiring that all Americans are enrolled in a health insurance plan – whether through their employer or through a public insurance plan 69% 26%

Limiting the amount of damage payments that patients can be awarded in malpractice law suits against healthcare providers 62% 31%

Please tell me how much would you support or oppose the following measures in order to allow all Americans to have access to quality healthcare? Do you…?

Source: McClatchy-Ipsos Poll

Why do specifics work better than abstract packaging? In our view, there are a number of reasons.

First, abstract concepts like "health care reform" or "universal coverage" can mean different things to different people, and hence, can be easily re-framed by opponents. In our experience, all-encompassing omnibus reform bills of great complexity usually fall flat on their face as the most vulnerable measure comes to define the general initiative.

In this case, the weakest link in the Obama plan is the "public option" provision. This element finds only weaker support in public opinion and makes an easy "anti-big government" target for opponents of reform. While Obama and his administration already seem to be downplaying this item, the damage might have already been done.

Second, abstract packaging of any government initiative in the U.S. can be easily re-framed in the pejorative as a "big government" solution. International polls show consistently that Americans are a small government, low-tax people when compared to other countries. Anti-big government rhetoric, in other words, is very sticky in the U.S.: "big government takeover," "bureaucrats rationing Granny's healthcare," "limiting choice," and "death panels" — all raise the specter of the "big government" bogey man.

Third, the evidence from polling on reforms in other countries shows that citizens typically prefer gradual rather than rapid reform — human beings are conservative by nature. This is especially the case for essential services such as education, social security, and health care. A vague, cumbersome health care pitch only reinforces the notion of "radical change." Being specific suggests "gradualism" to people — something easily digestible and ultimately doable.

Lastly, in our experience, most new administrations — whether they are in the U.S. or in other countries — make the fundamental mistake of confusing the requirements of successful electoral campaigning with that of effectively pushing a specific policy agenda. The first is about selling hope (or fear), while the second is about selling multiple benefits, often to disparate constituency groups. Successful electoral campaigns are general in nature, whereas successful policy solutions address the specific — one is selling heaven, the other is about good horse trading.

So what can be done?

To proponents of health care reform, we say: sell the specific benefits of the package and show how they will impact people's day-to-day lives in practical ways — the "what's in it for me" pitch. The Administration's communication strategy needs to focus on those specific, tangible benefits of reform that resonate with the electorate. Obama's failure to engage the general public with this level of the detail is largely responsible for the Administration's loss of momentum.

We see, though, some signs of a new tact in both Obama's outreach as well as proponent advertising. To date, however, many proponents are still casting the reform in moralistic language. This strategy alone, in our opinion, will fail as "Big Government" versus "Doing the Right Thing" is an unfair fight given the American experience. In contrast, "Little Johnny should not be denied health care just because he has a preexisting condition" versus "Big government" is a winner. Once again, be specific and make it real.

Finally, as mentioned, a general omnibus solution will always be defined by its weakest link — so drop "the public option" and be specific with the rest. Obama seems to be doing this now. For the sake of proponents, hopefully the inclusion of the "public option" has not permanently defined the entire initiative as "big government." Nothing is wrong with gradualism. Better something, than nothing.

To opponents, the key to your success is keeping the debate at the abstract "Big Government Is Bad" level. But beware the devil is the details.

ABOUT THE WRITERS

Clifford Young and Mark Burles are pollsters with Ipsos Public Affairs

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