Journal Issue: Health Care Reform Volume 3 Number 2 Summer/Fall 1993
Since the forum session on public opinion and the future of children's health care, a new piece of survey research, Faulty Diagnosis: Public Misconceptions About Health Care Reform,15 surfaced to complicate the issue further. Based on national surveys and focus groups conducted for the Public Agenda Foundation over the past two years, Faulty Diagnosis concludes that the public understands neither the current health care system nor the proposed solutions to its current problems.
The foundation's research suggests that the apparent consensus behind national health care reform must be tempered by the fact that people define health care reform in many different ways. The public does not understand what is contributing to the cost problem nor can it identify who among Americans is most likely to be uninsured. Americans think the current system—whatever it is—is wasteful and ineffective, but they are not sure the solution is more government, because they distrust government's efficacy and efficiency. And, when asked if they would pay more to improve the system, only one in ten said they would suffer a tax increase.
It is against this relatively uninformed and bleak background that public support for children's health care should be evaluated. While children may not be health care reform's silver bullet, it is nevertheless indisputable that children occupy a special place in the public's favor. Consider this quote from a New York man asked by the Public Agenda Foundation to evaluate the cost of saving the life of a severely premature infant, and consider it in the context of the current rhetoric over cost containment and health care rationing: "You are asking me to save money by watching some premature infant die when he has a chance of being saved, while you are still wasting the kind of money we are throwing away. No way."16
As the health care debate veers more and more toward cost containment and away from access, it remains to be seen how children will fare. But a number of points seem clear from this review of public opinion and children's issues.
- Children are an attractive vehicle for moving along the health care reform debate, but they may not be sufficient for its enactment. There are numerous problems inherent in the implementation of health care reform legislation, as Green points out. Children can be helpful in overcoming some of these obstacles because of the diverse consensus over the importance in investing in their health. With 98% of the public in agreement that children should be able to see a doctor if they need to, even if their families cannot afford one,5 children offer an immediate public consensus on which to build specific proposals.
However, the popularity of a children's approach may not be enough. After all, championing the interests of 64 million nonvoting Americans requires more than a good idea, an enthusiastic public, or even sensible policy alternatives. With children present in only two in five American households, other constituencies must be activated to carry children's proposals forward.
- Children can be a symbol that helps dramatize and motivate the need for health care reform. It may be that children become most useful to the political debate over health care reform precisely because they offer a way around the impasse over competing proposals. As the pollsters point out, children are held "harmless" from the ugly realities of racism, classism, and the American work ethic. Lack of access to health care for children is a clear violation of the American dream, of the level playing field so dear to the rhetoric of our democracy. The notion that children's health care is emerging as a right, not a privilege, while adult access remains open to debate may, in fact, signal its usefulness as a first focus, if not a sole focus, in the health care reform arena. Incrementalism in which children lead the way has the advantage of using children as a strong symbol, with the payoff accruing to a larger audience. On the negative side, it can also be exploitive if it shortchanges children in the implementation. It is interesting to note that recent advertising campaigns from both Prudential and Aetna Life and Casualty insurance companies use images of children to dramatize the need for health reform in the form of managed care.
- Children may be able to lead the charge toward comprehensive health care reform, if they are part of a broader proposal from the beginning. This is, in fact, what Blendon's own recent research has been suggesting.17 Children first may not mean children only. When asked to choose between three specific proposals—(1) a national long-term health care plan, (2) a national health plan for all Americans, adults and children alike, or (3) a national health plan that covers children only—only 6% of California voters chose the children-specific plan.17
Moreover, in keeping with the Public Agenda Foundation's findings, health care reformers may find they have overestimated the public's support and underestimated the time necessary to forge a political consensus. In this context, a children's initiative may prove attractive as a first step, especially among groups like religious organizations, teachers unions, and advocates for the poor, where a strong commitment to children already exists even though it is part of a broader mission.
In many respects, the data and the pollsters' interpretations reinforce Robert Blendon's initial directive to do the following: (1) focus on children as the sole beneficiaries of the package; (2) focus the attention of a much broader constituency on the necessity of addressing children first; and (3) specifically address the concerns of middle-class voters. While the first proposition may be questionable, the others remain important, at least as suggested by current interpretations of public opinion polls.
At the same time, Blendon's prescription must be expanded to include the realities of partisan politics. The fact that talk is cheap and children are traditionally the symbols not the substance of policy proposals will continue until a "new politics" is forged with sufficient muscle to hold politicians accountable to kids. This new politics must incorporate several characteristics, the pollsters suggest. The notion that there is no discernible "enemy" preventing children from getting what they need, other than parents, suggests that any battle for child-focused health care reform would need to reframe the debate in political terms. Paying heed to the public's distrust of government programs by creating specific earmarked funds is one direction clearly supported by the data.
Second, as Robert Green points out, any specific child health package must not "materially affect the relationship of children, families, values and the government." Building on this constellation might, in fact, be one way to begin the public education necessary to a positive health outcome for children. The notion of delivering health care through the schools overcomes the problem identified in the data that children's health care has not yet emerged as a "public" issue.
"Politics ain't beanbag," as Martin Schram quoted in the opening to his book on the role of television in the presidential selection process.18 And politics is not synonymous with public opinion. The challenge to children's advocates and health care reformers alike is to shape a bridge between the public's search for answers on the health care issue and the world of partisan politics. For example, trading support for long-term care with seniors' advocates in exchange for a push for prenatal, preventive, and primary care for kids may help in fashioning a program that serves the needs of many groups and still uses children as a focal point for the package. Reading the tea leaves of public opinion would suggest that the marriage of children and health care reform offers distinct advantages.