Embargoed Until:
April 21, 2009
12:01 a.m. Eastern Time



Christopher Fleming

Most Americans Support A Health Care Reform Plan Requiring Individuals to Purchase Health Coverage Only When The Plan Also Includes Shared Responsibility With Government, Employers, And Insurers

Shared Responsibility Is More Popular Than An Individual Mandate On Its Own Among All Groups, Particularly African Americans And Upper-Income People; Support Is Highest For A Coverage Mandate Limited To Children

Bethesda, MD -- The idea of requiring all Americans to have health insurance is an important part of many plans to achieve universal coverage. On its own, this "individual mandate" does not command majority support overall or across partisan and socioeconomic groups. But most Americans do support a "shared-responsibility" plan that combines an individual mandate with expanded roles for employers, government, and insurers, according to a study by Tara Sussman and coauthors published today on the Health Affairs Web site.http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.3.w501

"The administration and key congressional Democrats, such as Senate Finance Committee Chair Max Baucus (D-MT), have put forward shared-responsibility approaches to expanding coverage. The individual mandate provides the vehicle for universal coverage, but public support for mandate-based reform increases markedly, particularly among African Americans and upper-income people, if requirements for government, employers, and insurers are also included," said study coauthor Bob Blendon, a professor of health policy and political analysis at the Harvard School of Public Health.

"Public support is even higher for a coverage mandate limited to children, but of course that would not achieve universal coverage except as a transitional measure," said Sussman, a doctoral candidate in the Ph.D. program in health policy at Harvard.

In a telephone survey of 1,704 adults age 18 and older, conducted between February 14 and February 24, 2008, half of the respondents were asked about a stand-alone mandate. The other half were asked about a shared-responsibility plan containing an individual mandate. In both cases, respondents were told that everyone would be required to have insurance, with a fine for those without coverage and government help for low-income people. The survey was designed by researchers from National Public Radio, the Kaiser Family Foundation, and the Harvard School of Public Health, and conducted by International Communications Research. Sussman and her coauthors note that attitudes might have shifted since the survey was conducted.

Overall, only 48 percent of respondents expressed support for an individual mandate on its own. The stand-alone mandate garnered majority support from self-described Democrats (56 percent), those making under $30,000 (59 percent) or over $100,000 (53 percent) annually, and those with less than a high school education (66 percent). By contrast, only 36 percent of Republicans and 38 percent of those with some college education or an associate’s degree expressed support, and the stand-alone mandate also failed to obtain majority support among those making between $30,000 and $100,000.

However, a shared-responsibility approach with an individual mandate was considerably more popular than a stand-alone mandate. Overall, 59 percent of the public supported this approach. Spreading responsibility among government, employers, insurers, and individuals was more popular than a stand-alone mandate among all subgroups of respondents, and this shared-responsibility approach obtained 50 percent support or better in each subgroup except Republicans (44 percent).

The biggest increases in support for a shared-responsibility approach, as compared to a stand-alone individual mandate, were found among those making $80,000 to $100,000 and among African Americans. Seventy percent of respondents in the $80,000-$100,000 range supported a shared responsibility approach, versus 27 percent who supported a stand-alone mandate. The idea of shared responsibility is particularly popular among African Americans, a key constituency of President Obama and the Democratic party. Eighty percent of African American respondents supported the shared-responsibility approach, versus 56 percent who supported a stand-alone mandate. (See Exhibit 2 in the article -- exact data points not shown.)

Sixty-five percent of respondents and majorities of both parties backed a coverage mandate limited to children.

Old Ideological Divides Still Arise In Discussion Of Mandate-Based Reform

As noted above, a majority of Democrats support an individual mandate, whether alone or in a shared-responsibility framework, and a majority of Republicans do not back such a mandate in either form. Moreover, even when Democratic and Republican survey respondents agreed on the mandate question, their reasoning sometimes revealed familiar ideological fault lines. For example, Democratic mandate proponents were substantially more likely than Republican proponents to cite the importance of getting everyone into the same insurance pool, so that the cost of caring for the sick can be spread across a broad population.

Similarly, many Democrats opponents of an individual mandate instead back a single-payer system, while many Republican mandate opponents see this type of reform as leading to government-run health care and higher taxes. "Policymakers in favor of mandate-based reform would do well to emphasize the arguments for it that resonate with people of both parties--that it is the right thing to do, that it will provide better care for the uninsured, and that it will save money for the insured," write Sussman and coauthors Blendon and Andrea Campbell, the Hayes Career Development Associate Professor of Political Science at the Massachusetts Institute of Technology.

After the embargo lifts, you can read the paper by Sussman, Blendon, and Campbell at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.3.w501



Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org. The full text of each Health Affairs Web Exclusive is available free of charge to all Web site visitors for a two-week period following posting, after which it will switch to pay-per-view for nonsubscribers. Web Exclusives are supported in part by a grant from the Commonwealth Fund.


©2009 Project HOPE–The People-to-People Health Foundation, Inc.