Journal Issue: Health Care Reform Volume 3 Number 2 Summer/Fall 1993
Four Questions for the Experts
These findings of public support for selected children's programs give rise to four specific questions about whether a children-first approach to health care reform can galvanize public support for a reform package. These questions are:
- What are the political advantages and disadvantages of initiating general health care reforms by expanding health care coverage for children?
- When it comes to financing, to what extent are voters willing to pay new taxes to expand coverage for children or to give higher priority to health coverage for children within existing revenues?
- What kinds of voters, beyond those directly affected, are likely to support expanded coverage for children?
- How does packaging of expanded coverage for children affect political support? What are the implications of targeting benefits to poor children versus guaranteeing benefits to all children?
The reactions of four political pollsters to these questions are presented below. Each is in the business of advising specific candidates—from President Bill Clinton to former Vice President Dan Quayle—on how to align their agendas with the people's perceptions. The discussion that follows is cynical, probing, and strategic. It demonstrates forcibly the care with which pollsters and political strategists evaluate their own data before endorsing policy positions for their candidates. In this sense, the discussion is inherently conservative and demonstrates far less the "democratic" possibilities of polling—discerning, and enacting the public mandate11—than it does the modern political use of popular symbols and the forging of candidate identities to be consistent with the public mandate. Representing the Republican side of the political aisle were Gary Ferguson, vice president of American Viewpoint, and David Sackett, vice president of the Tarrance Group. For the Democrats were Robert Green, vice president of Penn + Schoen, and Celinda Lake, then vice president of Greenberg-Lake, the Analysis Group.Politics and Policy
What are the political advantages and disadvantages of initiating access improvements by expanding health coverage for children?
Survey after survey attests to the public popularity of children's health care programs. So why isn't health care reform for children a reality? The pollsters' responses to this question offer a fascinating look at how issues are perceived in the arena of strategic politics.
"There are no political liabilities in talking about children's issues," says Gary Ferguson with American Viewpoint. "Unfortunately, that's all many officials do . . . . Policymakers run into snags when they try to outline specific programs."
David Sackett agrees. "The political advantage from fighting for expanded health coverage for kids is focused directly in the area of candidate image development. . . . Candidates who talk about the need to make sure that children receive adequate health care speak a message that more than two-thirds of American voters would agree with. In political campaigns, issues are utilized primarily to portray an image of the candidate. By talking about the issue of health care for children, the candidate implies his compassion and sensitivity and establishes a 'link' with voters on an issue where there is wide agreement."
"Good policy makes good politics," asserts Celinda Lake. "Being for health care reform puts incumbents and challengers on the side of change. Expanding health coverage to all children is a powerful way to be on the side of change for people."
"At the same time," Lake points out, "we should understand that by talking about expanding access for health care to children, we can lose much of the real energy in this debate, which is focused around the issue of rising health care costs. To tap this energy, we may also want to talk about getting health care costs for families and children under control. Reframing the issue of children's health care and drawing attention to both cost and access has interesting implications for the entire children's debate. Voters have trouble acting on children's issues because they cannot imagine who the bad guys are—who would be against this and why. On the other hand, they can readily imagine who the bad guys are in the health care debate and how greed leads to some horrible consequences. Merging the two issues may give some edge to the health care debate."Financing
When it comes to financing, to what extent are voters willing to pay new taxes to expand coverage for children? give higher priority to health coverage for children within existing revenues?
Financing is "probably the single most important question to focus on when looking at voter attitudes on children's issues," says Sackett, "because it clearly demonstrates the clear distinction between hypothetical and generic support for expanding children's programs, and a lack of willingness to pay for it out of their own pockets. This is where the rubber meets the road on expanding government spending on kids' issues."
This is also an area where the polling data are clearly subject to interpretation, like the proverbial half-full, half-empty glass. Sackett is especially heedful of a recent finding which showed that, "even when the American voters were told that by increasing their taxes by only $100 a year, all uninsured children would receive adequate health care, 45% indicate that they would oppose this and no more than 45% said that they would favor it."5
However, consistent with polling on adult health care financing, the pollsters point out that "almost everyone supports additional taxes on the rich or increasing 'sin' taxes to pay for children's programs."5
The children's arena also has the additional advantage of what Sackett and Lake have called the public's willingness to "reprioritize current tax dollars to favor children." Ferguson points to a finding from the State of the Child5 survey, which asked voters what they thought should be done with the 'surplus' in the Social Security trust fund. In answer, 47% said that the surplus should be devoted to a trust fund for children rather than returning it to the taxpayers or directing it elsewhere, a two-to-one advantage over the next option. "This response indicates that children's issues have a high priority and that Americans are interested in looking for creative solutions to children's problems within existing programs and funding sources," Ferguson concludes. Further support for this conclusion is seen in the strong national response to the "earmarking" approach pioneered in San Francisco. Nearly two-thirds (65%) of voters nationally favored reserving 2.5% of existing property tax revenue to be spent only on programs for children.5
Financing options, however, cannot be evaluated in a vacuum. Many of the same findings cited as important to the packaging of children's health programs (see discussion below) were seen to be determinants of support for public funding.
"It used to be that voters thought there was only waste in programs they did not like," Lake points out. "Now they worry that money they give for children's programs may be wasted as well. They also worry that money they give for children's programs may get lost in the great budget abyss, which is why they support targeted funding more than general tax increases."
"Voters' cynicism about spending and taxes plays a role here," Lake explains. "Even people with children feel they may have a better use of that $100 for their own children. Properly framed, however, health care for all children can be one of the better ways of breaking through their cynicism and fiscal conservatism when families feel they have a tough time making ends meet."Who Cares for Kids?
What kinds of voters, beyond those directly affected, are likely to support expanded coverage for children?
"While it is inconceivable that a political speech or message this year can go beyond thirty seconds without using the phrase 'for our children's future,' the unfortunate fact remains that American voters act, and react, based on their own self-interest," David Sackett asserts.
"Translating broad support for addressing children's issues into specific programs for children is difficult in practice," admits Robert Green, who points to the fact that a majority of adults do not have children at home.
"The only significant indicator which can be reliably utilized to measure real support for expanding coverage for kids is the presence of school-aged children in the home," Sackett agrees.
But Ferguson is impressed by the fact that, in reviewing the data, "support for children's issues is not determined by partisanship or ideology." Indeed, findings from the State of the Child5 poll showed that "majorities of nearly every subgroup of voters say they would be more likely to vote for a children's candidate (one who supported increased spending on programs for children) including self-identified Democrats (76%), Independents (58%), Republicans (61%), and even a majority of conservative Republicans (56%), who tend to be the most tax-sensitive voters." In interpreting these data, pollsters Lake and Sackett conclude that "the attraction of children's issues is sufficiently powerful to cut across partisan identification, appealing especially to women and younger swing voters." Among those most likely to vote for a candidate who supported increased spending for children's programs are working women (78%), younger women (80%), black voters (83%), and younger college-educated voters (78%). Green also conducted a poll which found conservatives strongly supportive of children's health programs.7
"Children's health care is not a partisan issue," says Lake emphatically, citing data from the State of the Child poll, which found that, although Democratic voters are slightly more supportive of making children a priority (66%), a majority of Independents (59%) and Republicans (56%) want to make children's programs the top priority for government spending.5
Yet Lake admits that "there are real limits to how much they will vote altruistically, even for children. The core supporters for this expenditure are women and minorities with young children, and the uninsured. Similarly, older voters who are grandparents of young children are significantly more supportive than older voters without young grandchildren."
Lake's work on the State of the Child report showed that, while older Americans are the least supportive of children's programs, there is strong support in this group nevertheless. In only one group (voters over 64 years old) does less than a majority (47%) rank children among their top three priorities. In this one group, children trail national health insurance and Social Security.5
"The key will be to make this program (children's health) part of some bigger debate that directly affects more people," Lake concludes.Packaging Children's Health Programs
How does packaging of expanded coverage for children affect political support? What are the implications of targeting benefits to poor children versus guaranteeing benefits to all children?
The pollsters are unanimous on the necessity of "mainstreaming" children's health care, agreeing that targeting benefits to the poor instead of guaranteeing benefits to all children would make the task far more difficult politically.
"Framing this as an access issue for poor children can narrow support for both children's issues and the health care issue and is extremely dangerous," warns Lake. "Middle class voters worry that if the government is most focused on providing health care for the uninsured and poor, it may be overly willing to sacrifice quality for the middle class."
"Building a coalition of Americans who would support increased spending for children's health care will be difficult enough without eliminating the self-interest motivation of parents who have a level of concern about their own children," says Sackett. "If people are expected to pay more for a program to help children, it better be perceived as helping their children, or they will not only not support it, they will vigorously oppose it," Sackett concludes.
Ferguson agrees, citing data gathered by Penn + Schoen which found that most Americans (84%) agree that not only poor families need help raising their kids, but that middle-class and working poor families also need some help from the government.7
Green is sensitive to what he terms "the test posed by David Blankenhorn and Barbara Whitehead of public policy that resonates with the private concerns of the family" and warns that any child health package must not "materially affect the relationship of children, families, values and the government."12
This warning is echoed by both of the Republicans. "Americans want to see some changes in systems rather than just throwing money at problems," says Ferguson, "both because of tight economic times and because of the way people view public agencies."
Sackett goes even further in noting the dangers of the welfare connection, citing a finding in which four of ten Americans agree with the statement that "we spend too much on welfare and that is what politicians mean when they talk about children's programs."7
But a cynical politics that plays out the welfare debate in the children's arena might well backfire, cautions Green. "With children, it is much harder to make an argument about the undeserving poor. Children are not blamed for their situation in life. I have always thought this was the primary reason we see such strong support for social and health care programs for children in research. In the August 1991 survey we conducted for the National Association of Children's Hospitals and Related Institutions (NACHRI), even an examination of conflicting concerns such as the role of families, values, recessionary times, deficits, and bureaucratic waste did not seriously affect sup port for more social spending for children."7
While the welfare connection may not impede children's programs, it often obscures them. Among the data examined by the pollsters were a number of critical findings which suggest that the public is often unable to speak out in support of children's services because it lacks understanding of the specific programs—from Medicaid to WIC—under which children are covered. One recent poll found that only one in ten Americans could correctly select poor children as the largest single group of people served by Medicaid; two in five confused Medicaid with Medicare.10 A poll conducted for the Public Agenda Foundation in 1988 found that only 30% of respondents were familiar with WIC.13 In this sense, packaging also affects the ability of proponents to protect or champion child-focused reforms that occur within existing programs.