A Response to Cato’s Reply: Pollster.com Shows Disapproval Fading As Americans Learn More about Health Care Reform

The Cato Institute’s Michael Cannon has replied to Part 1 of my response to Cato’s report on the Patient Protection and Affordable Care Act (ACA) .You’ll find his reply here. Unfortunately, the Cato Institute website doesn’t have a space for comments, so I decided to respond here, on HealthBeat.

First, let say that Cannon’s reply is both civil and gracious. Thank you, Michael Cannon. I’m hoping that this debate will move forward as I continue to write about the rest of the Institute’s recent white paper, “Bad Medicine: A Guide to the Real Costs and Consequences of the New Health Care Law.” This seems to me a good opportunity to have an intelligent, rational dialogue about reform, comparing facts, while laying out two very different points of view, calmly and clearly.

In my original post, I had pointed out that in order to support his argument that the legislation “remains deeply unpopular,” Michael Tanner, the author of the July 12 Cato report, used an old number, dating back to May 22.  As it happens, the May poll, which showed 63% of respondents favoring repeal of the legislation, stands as the high-water mark for repeal during the seventeen weeks that Rasmussen has been asking the question on a weekly basis. This led me to suggest that Tanner “cherry-picked” a poll that squared with his thesis.

Cannon explains: “I’m not sure why Tanner didn’t include more recent numbers, but it may have been because it often takes 6 weeks for a paper to emerge from Cato’s publishing process.” 

Fair enough. I can imagine it might well take 6 weeks for a think tank to come out with a print version of a white paper. But Tanner’s report appeared online July 12. It would seem that the online version would have been updated to acknowledge that in the weeks that followed May 22, support for repeal fell, first to 60%, then to 58% (two weeks running), before tumbling  to 55%, and  finally hitting a low of 52% the week of June 25-26. 

At that point, Rasmussen’s pollsters observed: “This is the second lowest level of support for repeal in 17 weeks of surveying since the health care bill was passed by Congress. It marks what appears to be a continuing downward trend in support for repeal since June.” As I put it in my post: “in the five weeks following May 22, support for repeal consistently dropped, while opposition to killing the bill rose”  from 32% to 40%.

Here, Cannon objects: “this is not quite accurate.” After all he notes, the table I included with my post indicates that six weeks after the May 22 poll (on July 1)  support for repeal bounced,  rising to 60%. This is true, but the table also shows that the very next week, the number of respondents favoring reform plummeted, once again, to 53%, while opposition to repeal climbed to 42%.  (After I wrote my post Rasmussen released July 15 numbers, showing 56% favoring repeal and 38% opposed.)

Granted, the numbers do not form a straight line. Weekly poll numbers never do. But a trend line seems clear. Since May 22, the percent of respondents who want repeal has dropped from 63% to 56%, while the share who wants to keep the bill has risen from 32% in May to 38% today. (You’ll find a table showing poll results each week from March 23 to July 16 here.)

The problem with the Cato Institute report is that it gives us just one dramatic chart (see below) showing the results of that single May 22 poll which , it turns out, was an outlier. In the 17 weeks since Rasmussen has been asking about repeal, support has reached 63% only once, and opposition has never fallen lower that it did on May 22, when 32% objected to killing the bill.

Rasmussen Poll –May 22-23


Rasmussen Reports, poll of 1,000 likely voters, May 22–23, 2010, margin
of error +/- 3 percentage points, with a 95% level of confidence.

In my critique of the Cato report, I go on to cite other polls which confirm that as time passes, the more voters learn more about the reform legislation, the more they seem to like it. A  Gallup poll also suggests that opposition is largely confined to the one group that already has universal coverage–seniors. Here I quote Ezra Klein: “seniors, of course, aren't opposed to government-run health care. They love their Medicare, and insofar as they have a policy concern here, it's that the Affordable Care Act will interfere with the single-payer system they rely on.”

Cannon ignores the fact that the ACA is popular among the people it will actually affect, and suggests that I have picked polls that support “the Left’s theme.” (Here, he seems to imply that I’m cherry-picking. I’m surprised; this is the first time I’ve heard anyone suggest that the folks at Gallup are Lefties.)

He goes on to declare that he prefers consulting “Pollster.com,” which takes all available polls into account. When you do that, he argues, “you see that  . . . the trend line is not moving in the direction Mahar says it is.” This, I’m afraid, is simply not true. But I understand where Cannon got the idea. Pollster.com itself says: “The trend lines don’t look so good for supporters of the law.” 

Indeed, if you stand back and look at the chart below from a distance, that red line showing disapproval does rise sharply over time. But take a closer look, and you will discover that the chart begins in February of 2009, more than a year before the bill made its way through Congress. 

Back then, in February of 2009, very few pollsters were asking the public whether they liked the health reform legislation. (Those little colored squares on the chart above represent individual polls.) That is because it is very hard to ask people whether or not they like legislation that doesn’t yet exist. It was only after the final bill was passed, that people could begin to offer an opinion.

So if you’re looking for a trend, it’s only sensible to begin the day the bill was signed, March 23. (This is also when Rasmussen began polling). You can see the trend  from March to mid-July clearly if you  go to pollster.com’s website click on “tools” at the bottom of the chart, then click on “date range,” and change the beginning date to March 23 2010. (Make sure you change the year from 2009 to 2010).  Finally, click on “set range.”  You’ll get a new chart which reveals that on March 23 about 51% of respondents disapproved of the legislation. Today, that number has fallen to 46.8%.You also will notice that, since March the red line has been moving down quite smoothly.

The black line (indicating approval) has been wriggling around. This indicates that great many people still don’t know whether they like the bill: they won’t know what effect it will have on them and their families until it is implemented. But as I indicated in my original post, if you move beyond the “approve/disapprove” formula and ask more probing questions, polls from NBC/Wall Street Journal and Kaiser show that the majority of respondents either support the ACA or prefer that it “be given a chance to work with Congress making revisions as needed.” They don’t favor repeal. A Bloomberg News poll released last week confirms “that a full 61 percent of respondents don’t have an interest in repealing the health care legislation…(47 percent want to see how it works, 14 percent say it should be left alone). Just 37 percent want the bill repealed (as is the wish of the Republican leadership). (Let me add, I don’t think anyone sees Bloomberg News as a tool of “the Left.” )

Many Americans just are not sure how the legislation will play out. But they are certain of one thing: they do not want to see their legislators to return to vitriolic debate over health care reform. They want them to move forward, to discuss jobs and the economy.  If conservatives and libertarians push repeal theme in the fall elections, I believe that they will lose votes.

7 thoughts on “A Response to Cato’s Reply: Pollster.com Shows Disapproval Fading As Americans Learn More about Health Care Reform

  1. While I’m not especially interested in the back and forth about reform related polling because I don’t think it’s that important, in the interest of civilized debate, I would like to offer my take on Mr. Tanner’s paper.
    First, I happen to think that bringing health insurance coverage and access to healthcare for as many of the currently uninsured as possible is an important priority. Mr. Tanner offers no free market alternative for how to accomplish that. The only viable way I can see to do it is to provide subsidies to help people to buy insurance but couldn’t otherwise afford it. At the same time, as a taxpayer, I have a lot of concern about people trying to game the system by either hiding their income altogether or understating it significantly in order to qualify for a much larger subsidy than their actual income would entitle them to. At the very least, I would want to see a robust approach to income verification as subsidies are determined at the individual and family level as well as stiff penalties for those caught hiding income.
    As for the ultimate cost of reform, Maggie and others note that there are a lot of puts and takes here and most of the important provisions don’t even take effect until 2014 so nobody can say for sure how it will ultimately play out. However, if I were a Las Vegas bookmaker, I think the odds strongly favor costs coming in higher than estimated and, perhaps, materially so.
    Comparative effectiveness research is a good idea but it can’t be used to make coverage and payment decisions. The Independent Payment Advisory Board is a good idea but it has been effectively neutered as Mr. Tanner points out. Experimentation with payment models like bundling and capitation are fine but are unlikely to save much money over the intermediate term. The tax on high cost insurance plans doesn’t even take effect until 2018 and even then it just nibbles around the edges of the tax preference for employer provided health insurance which virtually all economists agree drives people to consume more healthcare than they would if the tax preference didn’t exist.
    At the end of the day, what we have with this reform is essentially the Massachusetts approach expanded nationally. In Massachusetts, reform was all about expanding insurance coverage in order to reduce the percentage of the population that lacks health insurance. They knew from the outset that they weren’t doing anything substantive about healthcare costs. This reform doesn’t do anything substantive either, in my opinion. I predict that by the 2016-2020 timeframe, we will finally see the need to get serious about costs which means rational rationing. By then, liberals will have to recognize that they got as close to universal coverage as we are likely to get and their low hanging fruit didn’t provide much of a harvest on the cost front. We will look at many of the strategies that Dr. Berwick supports but is being criticized for today and conclude that we really need to implement most of these yesterday!

  2. Barry —
    You are correct to point out that the new federal health plan and the MA health plan are very similar. However, they are different in one very important way. The key weapon that the federal reform has that MA doesn’t have is the ability to control Medicare, the biggest single third party payer in the US and a payer that most private payers copy with great regularity.
    The appointment of Don Berwick is an important step in moving toward rational, not rationed, health care. As we have discussed many times on this site, there is a tremendous amount of waste in our medical system due to overutilization of high tech medical intervention and diagnostics and underutilization of very basic and inexpensive quality control techniques. Conservative estimates suggest that this amounts to over $500 billion a year in excess spending.
    The critical thing is for the powers in US health care to agree to use their power to push for more rational practice patterns. In the past, conservatives have been strongly in favor of that — see the private insurers efforts in the 1990’s. However, now they are unwilling to take any steps that lead to strengthening rational care, favoring only true rationing by making care unaffordable for large parts of the public by increasing co-pays and deductibles to the point that they are unaffordable for many people, who then will “self-ration” care, often on a somewhat haphazard basis with little or no attention to rational decision making. In many studies, this type of rationing has actually resulted in greater long-term costs as neglect leads to preventable very costly health disasters.
    The main motive of conservatives, including of course, the Cato group, is to destroy the Democrats reform plan and perhaps the Democrats themselves, ignoring the fact that most private insurers would be deliriously happy to have Medicare take an aggressive lead in rational cost control that they could then piggyback on.
    I talk with doctors every day who belong to every stripe of the political spectrum. I have never talked with a single one who does not believe that there is a tremendous amount of waste in US medical care, some of which they feel forced to engage in due to patient pressure, peer pressure, and fear of litigation.
    We will have cost control in the US, fairly soon, since it is impossible to continue the current spending cycle. The choice is not cost control or no cost control, but rather cost control by exclusion of low income and many middle class people from access to needed health care versus cost control by elimination of waste.
    It is my hope that members of both parties will grow a spine soon and address these issues, but meanwhile I hope that Berwick and his fellow reformers will be able to use mechanisms included in the health reform law to start down the path to rational cost control.

  3. Maggie,
    The polling numbers are irrelevant. What is relevant are the huge current expenses in time and evaluation that companies and organizations are wasting trying to adjust to an avalanche of government control regulations. Moreover, already, the actuarial projections per each wave of regulatory burden are resulting in projected cost increases to these organization. At the end of the day, the results will be a projected huge cost increase to the very engine that produces jobs. You’ll see the real poll results in November.

  4. Pat,
    Believe me, I hope you’re right. If you are, no one would be more pleased than I. I would have been a lot happier, however, if the Independent Payment Advisory Board were permitted to use all tools available to it to make changes in coverage and payment policy based on efficacy and cost-effectiveness. I also think it would have been extremely useful to phase out the tax preference for employer provided health insurance while lowering income tax rates and other taxes enough to insulate most of the population from an increase in their overall tax burden. That was a non-starter with the labor unions, though.
    I don’t know if you saw Susan Dentzer’s recent interview in Health Affairs with Geisinger CEO, Glenn Steele. I was somewhat discouraged by his comment that Geisinger has been able to reduce costs for its more complex Medicare patients by 7% which, while not nothing, pales in comparison to the 30% (at least) waste widely believed to permeate the healthcare system. For an organization that uses electronic records, has salaried doctors, a collaborative culture and even an insurer that covers 30% of its patient population, I thought they would be able reduce costs by considerably more than 7%. He also noted that there is significant practice pattern variation even within a given hospital, not just from one region to another. This is also discouraging, at least to me.
    With respect to your comment that doctors you speak to see plenty of waste in the system but feel the need to engage in it due to patient pressure, peer pressure and fear of litigation, aside from substantive tort reform like health courts and safe harbor protection from lawsuits for doctors who follow evidence based guidelines where they exist, what do you think it will take to eliminate much of this waste at the individual physician level in the exam room?

  5. Barry —
    I think the figure of a 7% reduction is a good first step, but obviously not the end. It will take time.
    As to what needs to be done: there needs to be teeth in the adoption of guidelines, most likely in the form of third party payers, led by Medicare. As a recent article in the Minneapolis Star-Tribune about failure to implement proven guidelines to prevent blood infections shows, adoption of even the most inexpensive meets incredible failure of doctors and managers to accept change (or perhaps to accept dilution of their own authority.)
    As to being discouraged, I believe that this will happen because it HAS to happen. The economic burden of failure is too high for society, the choice of using exclusion as a cost saving device too politically unsound.

  6. Barry, Pat S., Hoyt, Barry (second comment)
    Barry, I’m glad we agree on the importance of universal coverage.
    As for people gaming the system a) there are always some people who cheat on their taxes and don’t declare all of their income, and usually these are the wealthiest Americans, not the poorest (The wealthiest have more to gain by cheating, are more likely to own their own business, which allows them to accept cash which they never report, and they and can afford accountants to help them.)
    That said, I agree that we should make a real effort to verify income when people apply for subsidies. But the myth that poor people who need help from the government are adroit at milking the system goes back to Ronald Reagan’s fantasies about welfare moms driving Cadillacs. (It’s now widely acknowledged that Reagan was a story-teller; he liked to illustrate his speeches with anecdotes, but he was a spinning tales; he was not a sociologist referring to real research.)
    Turning to cost-savings and reform, you’re mistaken.
    The Mass plan made no real effort to cut healthcare spending. This legislation is filled with ways to reduce waste.
    You are right that Medicare cannot explicitly make payment decisions based on comparative effectiveness research, but that reserach will be made widely available to doctors and patients–consolidated in easy-to-find sites on the web.
    Everyone will be encouraged to practice evidence-based medicine–which means looking at comparative effectivness.
    When doctors and hospitals do this, outcomes are generally better. And there will be financial rewards for better outcomes. When outcomes are worse, providers will find that they receive no pay increases, no bonuses from Medicare. (Private insurers have said they plant to follow Medicare’s lead. They just want Medicare to provide political cover.)
    And since there will be fewer rewards for volume (for instance, Medicare is slashing fees for in-office diagnostic testing) providers who don’t improve outcomes will be hard-pressed to keep their income at current levels.
    While Massachusetts made little or no attempt to reduce waste, Berwick has been charged with improving the quality of Medicare and lowering the cost. Private insurers have said that they will follow Medicare’s lead.
    You predict that costs will come in higher than expected. This is what the conservatives say: anything that government does is always more expensive than first estimated.
    But the most recent Medicare reform saved 3 times as much as CBO estimated.
    And the U.S. postal service now offers over-night delivery that is less expensive than Fed Ex and, in my experience, more reliable than UPS.
    Also, see Pat’s comments and my reply
    Pat S.–
    Yes, Medicare is the key to national health reform.
    Massachusetts has nothing comparable in terms of clout. And with Berwick at the helm, I’m confident we will see real savings.
    Also, the legislation gives Berwick and the Sec. of HHS an enormous amount of power. Medicare can go around Congress: For instance, if a pilot project to save money work in one region, Medicare can roll it out nationwide, without permission from Congress.
    This is an enormous change.
    And yes, normally conservatives favor cutting waste, but in this case, ideology trumps common sense. Their main motive is to discredit Obama and re-take Washington.
    I’m not counting on Congress “growing a spine.”
    I’m actually astounded that this Congress has gone as far as it has in passing legislation that, over time, can transform how we pay for care and how it is delivered.
    Now, I think Medicare ( and the administration) will have to carry the ball. There is much that Medicare can do before 2014. There is much that the FDA can do in terms of insisting on transparency.
    Already, state regulators are taking a close look at insurers’ requests to raise premiums. This means insurers will be pushing back against hospitals that over-charge. State regulators in some states will, no doubt, get involved there.
    Conservatives in Congress will fight every inch of the way, but I don’t think they will find much suppport from the public. Americans are tired of the vitriolic debate about heatlhcare.
    They don’t know what to think about reform, but most want to wait and see.
    Meanwhile, they want Congress to focus on two things: Jobs and the Economy and Jobs.
    Hoyt– When you talk about the high cost of an “avalanche of govt” regulations, I have no idea what you’re talking about.
    Granted, insurers will have to meet regulations which will force them to insure sick people and spend a fair share of premiums on providing health care for customers. This, of course, is good for all of us.
    Can you point to other govt regs that will cost a fortune?
    The November elections will not be a referendum on health care. They will be a referendum on jobs and the economy. Why hasn’t Congress created jobs and stimulated the economy? The answer is that Republcans are resisting spending the money need to do these things.
    Taxing employer based health insurance was a non-started with almost everyone who has employer-based health insurance–i.e. the majority of Americans.
    Even if you could protect most people from the cost with tax credits, they wouldn’t understand the complicated math. They would just know that middle-class taxes were being raised during a recession. Politically, a complete non-starter.
    Reducing expenses by 7% at a time when healthcare expenses are rising by 5-7% elsehwere in the country is an enormous victory.
    Of course we cannot reduce spending by 30%; even though 30% of our health care dollars are wasted, you cannot suddenly tell doctors who are making $400,00: “Next year, you’ll earn $275,000. Get used to it.”
    You cannot tell brand-name hospitals that have more beds than they need, more operating rooms than they need (all very busy in the a.m. when surgeons like to operate, all empty in the afternoon), more hotel-like amentities than they need, more mahogany panelled confernce rooms for certain specialists than they need, more multi-million dollar equipment to treat prostate cancer (which may or may not save lives) than they need, more diagnostic testing equipment than they need, and more exectuives earning more than $300,000 a year than they need — that they should shut down one-third of the hospital (including one-third of all beds, one-third of all ORs,) auction off the unneeded medical equipment, cut all salaries over $300,000 by a third, and send all ER patients who are not suffering a medical emergeny to a community health plan that is open off-hours. (Hospitals like to have their ERs crowded– many of their insured admissions come from the ER, even if the patient didn’t need to be hospitialized. And all patients who turn up in an ER undergo a battery of tests–an important source of revenue since most of them are privately insured or on Medicaid of Medicare)
    When cutting 30% of the waste, we’d also have to tell drug-makers and device-makers that Medicare, Medicaid and all govt’ payers would refuse to buy their products unless they cut prices of their most expensive drugs and devices by one third.
    Finally, a significant of the excess spending lies in those “grey areas” of medicine. See my recent post on Atul Gawande’s article on end-of-life care.
    It’s difficult to say exactly where they should have stopped treating Sara.
    Obviously the first attempts to buy her another one to four years made sense. Perhaps they could have stopped after the third round of chemo–but they still already would have spent a fortune on treatments that had a reasonable chance of succeeding.
    And both Sara and her family were adamantly opposed to stopping treatment. The doctors also couldn’t know whether she might turn out to be one of those patients on the long tail. Given her relative youth, her determination, the young child–would you have told her: no more treatment unless you and your parents sell your homes, and spend everything you have to pay for it??
    This was a hard case but a great many cases are hard, and full of ambiguities.
    I think a palliative care specialist could have persuaded Sara to give herself a break, go home with her child, have pallaitve care or hospice specialists come in sometime after (or even before) that third round of chemo.
    But, as I say in the post, if Atul Gawande couldnt’ find the words . . . This isn’t somethign that all doctors can do. You need training, and experience in talking to patients about death.
    Pat S.
    Yes physicians and hospital exectuives, like most human beings, resist change.
    And change does represent a challenge to their authority.
    I think in many cases, it will take a combination of financial carrots and sticks–rewards and penalties, not for individuals, but for doctor/hospital groups–to get people to change how they provide care. (Berwick is right, I think, financial carrots and sticks only demoralize indiviudals, but can work with large, collaborative groups.)
    I think we’ll also find that younger doctors are quicker to embrace change.
    And as time passes and dinosaurs who view themselves as Giants of the Earth retire, this will be easier.