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Potential divergent paths on health care reform

March 8, 2021

Topics: Quote of the Day

Insights From Public Opinion Polls

By Robert J. Blendon, Sc.D.; John M. Benson, M.A.; Eric C. Schneider, M.D.
JAMA Network, March 5, 2021

As a result of the 2020 election, Democrats now have control of 3 bodies of national government: the presidency and both houses of Congress. But their margins in the Senate and House of Representatives are slim, which likely means very close votes on major legislation. In 2019, average Democrats differed from average Republicans in their views across 30 policy-related issues about what government should do in the future by 39 percentage points, more than double the gap in 1994.

Universal Coverage and National Health Insurance Reform

On the issue of universal health insurance coverage, the 2 parties’ constituents appear to be sharply divided. Nearly 9 in 10 Democrats (87%) (n = 703 surveyed) reported that they believe it is the responsibility of the government to ensure all individuals in the US have health insurance coverage, a view shared by fewer than 1 in 4 Republicans (23%) (n = 580 surveyed). Among Democrats, 75% reported that they prefer a health insurance system mostly run by the government, whereas 79% of Republicans reported that they prefer a system based mostly on private health insurance.

The same survey of 2150 individuals also addressed specific coverage proposals and found majorities of Democrats (n = 703 surveyed) expressed support for each of 3 options: building on the Affordable Care Act (ACA) (93%), Medicare-for-All (85%), and a Medicare buy-in to the ACA sometimes called “the public option” (82%). In contrast, only 30% of Republicans (n = 580 surveyed) expressed support for building on the ACA and 28% supported Medicare-for-All. While 62% of Republicans (n = 580 surveyed) reported that they support a Medicare buy-in to the ACA, that support does not represent an endorsement of the notion that government should ensure universal coverage. In addition, 64% of Republicans reported that they support replacing the ACA with a state-based private health insurance alternative compared with 36% of Democrats (n = 703 surveyed).

US Health Care System Reform

Currently, enthusiasm for broad reform of the US health care system is limited among both parties’ constituents. In a Gallup poll from June to July 2020, 55% of Democrats (n = 407 surveyed) and 53% of Republicans (n = 323 surveyed) indicated that they have a great deal or quite a lot of confidence in the current US medical system. About two-thirds of Democrats (68%) (n = 703 surveyed) indicated that they believe the federal government should be more involved in health care, a view held by only 17% of Republicans (n = 580 surveyed).

Race and Disparities in Health Care

65% of Democrats (5147 surveyed) reported that they believe Black people are treated less fairly than White people when seeking medical treatment compared with 11% of Republicans (4542 surveyed).

Potential Direction of US Health Care Policy

Because of partisan divisions in Congress, the administration will probably rely more on executive orders and administrative actions than legislative solutions to address these problems.



By Don McCanne, M.D.

It looks like the partisan divide is as bad as ever, with 75% of Democrats reporting that they prefer a health insurance system mostly run by the government, whereas 79% of Republicans reported that they prefer a system based mostly on private health insurance. The problem is that President Biden is more concerned about supporting the Affordable Care Act than he is about whether the insurance programs are public or private.

Although he does support the public Medicaid program, the conservative states remain resistant to it, so he is likely to depend more on the ACA marketplaces which are exchanges of private plans. The expanded health coverage under the American Rescue Plan is primarily an increase in government subsidies for the private health insurers.

There is a tremendous difference between the private insurers and the traditional Medicare program. An improved version of Medicare could be used to create a program that is universal, comprehensive, affordable for each of us by financing through equitable, progressive taxes and by avoiding excessive cost-sharing barriers to care, providing choice of health care professionals and institutions as opposed to choices in insurance products that limit care; that is, it would allow you to get health care whenever and wherever you need it. Private health plans would accomplish none of these goals, yet their current dysfunctions would continue to burden us.

The partisan divide theoretically has us aligned on one side that prefers a government-run program like single payer Medicare for All, and another side that has us aligned with the private health insurers and their dysfunctional programs. So why is the side aligned with the government – presumably Biden’s Democratic side – realigning itself with the private insurers on the Republican side? Didn’t the Democrats win, albeit by a very narrow margin? So why are the Democratic leaders moving into the Republican camp? Is neoliberalism the third force that is shifting the balance?

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About the Commentator, Don McCanne

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Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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