Many voters want mandatory insurance, employer role, yet...- MarketWatch
16 01 08 - 11:24
SAN FRANCISCO (MarketWatch) - As the presidential candidates tout their proposals to improve the nation's health-care system, it might behoove them to pay attention to a new survey that finds most Americans want to keep employer coverage in the mix and generally support mandated insurance.
In pursuing the goal of universal coverage, 81% want employers to maintain their role in providing health insurance to their workers or else contribute to the cost of it, an option known as "pay or play." That's according to a survey of 3,501 adults released this week from the Commonwealth Fund, a private foundation in New York that supports independent research on health-care issues.
A mandatory employer role was supported by 88% of Democrats, 79% of Independents and 73% of Republicans. About 158 million people receive health benefits through their jobs.
"The public view of employer responsibility is somewhat more in line with the Democratic candidates than with the Republican candidates," said Sara Collins, assistant vice president of the Commonwealth Fund.
Most Americans also find mandates for individuals palatable, with 68% of people supporting the notion that individuals should have to buy their own medical coverage if they don't have it already, with the government providing assistance for those who can't afford it.
Still, the so-called individual mandate showed greater variation by political party affiliation than the sentiment on employer mandates, with 80% of Democrats, 68% of Independents and 52% of Republicans saying they support a mandate requiring individuals to get coverage. Only 21% of Republicans and 13% of Independents strongly oppose it.
Universal coverage or tax incentives?
The candidates overlap in their general agreement that the health-care sector needs to make prices more transparent and make greater use of information technology. Most also push for a broader focus on preventive care.
When it comes to health insurance, both the leading Democratic and Republican candidates structure their proposals around the private market, but the parties differ markedly in the scope of their plans. The three leading Democrats want to build on the employer-based system, offer additional public and private options and force insurance companies to accept all who apply for coverage.
The leading Republican candidates don't subscribe to the Democrats' goal of universal coverage, preferring less regulation of insurance markets and more modest coverage expansions through changes in the tax code. They would like to provide incentives for people to buy insurance on the individual market, which likely would cut employers' role in health coverage dramatically. Also, they've been silent on the issue of employer mandates, Collins said.
"There's no question that the Democrats will cover more people. I think everyone agrees on that," said Jon Cohen, managing director of U.S. health-care advisory services for PricewaterhouseCoopers in New York, who wasn't involved in the study. "The Republicans, conservatively, will cover possibly 10% to 15% of people, but the Clinton and Edwards plans, because of the shared responsibility, will come closest to covering everyone."
Two-thirds of Americans support splitting the financing of health insurance for all among employers, government and individuals, according to the survey. Massachusetts has adopted such a shared-responsibility approach in its statewide reform effort, and California is looking to achieve a similar balance among stakeholders for the overhaul its lawmakers are negotiating.
Former New York Mayor Rudy Giuliani has embraced a proposal similar to one that President Bush laid out in last year's State of the Union address. In order to broaden the tax benefits of health plans beyond just those who have employer coverage, he wants a tax exclusion so people would pay taxes on family health plans valued over $15,000 or individual plans worth more than $7,500, but if they found cheaper plans they could put the rest of the money in a health savings account.
"Giuliani and [Fred] Thompson have said they want to move away from the employer-based model," Cohen said. "The change that those two Republicans are suggesting is a huge change. It's a pretty big question how people are going to react to that."
'Mandates make markets work better'
The issue of whether to compel individuals to buy insurance has been a hot one among Democratic candidates sparring over whose health reform proposal covers the most people. Both Sen. Hillary Clinton and former Sen. John Edwards call for an individual mandate while Sen. Barack Obama's proposal only requires that children have coverage.
Obama has argued that most uninsured people would buy coverage if they could afford it, a position that remains controversial. Many policy analysts contend that allowing healthy, affluent people to opt out of the insurance pool would deprive the sick of needed funds and keep the system dysfunctional.
"Mandates make markets work better because they reduce the adverse selection risk significantly, and thereby enable you to do the kind of regulation the Democrats want to do to make the market fair," said Len Nichols, a health economist and director of the health policy program at the New America Foundation, a nonprofit, nonpartisan research group in Washington. "There's a lot of stuff that doesn't hang together if you don't have mandates. It's not that I love mandates. It's that I want the damn system to work."
The ambition and specificity of the candidates' health proposals stands out compared with previous elections in 2004, 2000, 1996 and even 1992, Nichols said. "You really only had then, I would say, a few candidates who made this a big issue: [Paul] Tsongas and then [Bill] Clinton," he said. "The scale of effort is equal to or greater than '92."
On the Republican side, Nichols said Sen. John McCain presents a more "nuanced" health reform proposal than his counterparts by focusing on tax credits and cost control. "McCain does better than the other Republicans, but he doesn't do as well as even Obama on the Democratic side. They focus on the group-type market as opposed to the individual market. Once you in essence make the individual market as attractive in the tax sense as the group market, then you chase the healthy individuals out of the group."
Plenty of details have yet to be worked out on the candidates' health plans. But among the leading Democrats, Edwards has gone the furthest in specifying how his plan would work, Collins said. Edwards said he wants employers to contribute 6% of payroll, has said how he plans to enforce an individual mandate and has nailed down how much he'd expand Medicaid and the State Children's Health Insurance Program: up to 250% of the federal poverty line for children and parents, or about $50,000 for a family of four.
"Edwards, of the three, has the most detail," Collins said.
Mirroring other national polls that put health-care at or near the top of voters' domestic concerns, 86% of adults age 19 or older said the candidates' health-care views are important factors informing their ballot decisions, the survey found.
"We find that large majorities of adults across political affiliation and income say their views on health care are very or somewhat important in their vote," Collins said.
With 47 million Americans uninsured, widespread worry over the affordability of health coverage and U.S. businesses' competitiveness tethered by high benefits costs, it's no wonder consumers are demanding more specifics from the candidates this election cycle, Cohen said.
"The big difference now is there's much more discussion around universal health care," he said. "The debate now is much more substantive in terms of covering the uninsured."
Kristen Gerencher is a reporter for MarketWatch in San Francisco.