1. 202.776.9066 | www.lakeresearch.com | March 6, 2009 Voter Attitudes on Health System Change Reforms Findings From A Survey of 800 Likely Voters Nationwide herndon A l l i a n c e Healing America’s Healthcare

2. 2 Strategic Summary Voters overwhelmingly support health system reforms. Voters understand the connection between coverage and health system change, and want a more affordable health system and coverage for all. Voters think about system reform in personal terms and consider how changes will affect their personal relationship with their doctors. Rising costs, lack of coverage, prevention of disease, and prevention of medical errors are areas where voters are most dissatisfied and want to see change. Voters most support: allowing providers who are not doctors to provide more routine care; providing incentives for people to actively manage their health; and reforming how we pay for care so that doctors are rewarded for better quality rather than quantity. Voters worry that changes will interfere with their doctors. They strongly support reforms that help their doctors do a better job. Messages on comparative effectiveness that reinforce giving doctors clinical and cost effectiveness information test very strongly. The broad consensus in support of health system reforms remains robust – even after hearing opposition arguments.

3. 3 Key lessons on system change build on previous waves of research for The Herndon Alliance. Health care is a core value to voters, who talk about it in moral terms when thinking about coverage, cost, and quality. Health care is personal to voters. With any reform package, voters worry about what they might lose or gain and are concerned about how it will affect their own situation. Voters view health care reform in terms of their personal relationship with their own doctors. Security, peace of mind, choice, and control are very important. Voters, especially women, want affordable health care they can count on. Rising costs are consistently a top concern for voters. Despite some tax sensitivity in this economic climate, voters continue to support providing quality, affordable health care for all even if it means raising taxes or a major role for the federal government.

4. 44 Key Findings: Context By a margin of over 2-to-1, voters support changes to the health care system that improve the quality of care we receive and help control rising costs. Voters express a strong desire for change in our health care system, with over two-thirds saying we need a complete overhaul or major reform. The greatest dissatisfaction among voters is with the rising costs of health care, and they strongly support reforms that will help control costs. People are happy with their doctors and trust their doctors’ training and ability to give good care. They want reforms that help doctors do their jobs and support doctors do what is right for their patients. Having doctors as messengers is important.

5. 55 Key Findings: Specific Reforms Voters solidly support payment reform and want to reward doctors for providing quality care. People feel strongly about prevention and they support providing incentives for people to actively manage their health before they get sick. –They are less supportive of penalties for people who don’t actively manage their health. Receiving care from health professionals other than doctors is a change that voters welcome. They strongly support encouraging patients, through lower costs or more flexible appointments, to see providers other than doctors and to free up doctors to spend time with those who need it most. Instituting comparative effectiveness reforms to supplement doctors’ clinical knowledge has solid support, but voters need to be reassured that scientific and cost effectiveness data do not replace or interfere with their own doctor’s judgment.

6. 66 Key Messaging Points Voters need to be reassured that change will help control costs and improve the quality of the care they receive. Messages in favor of reform test very strongly, especially messages that reinforce the doctor-patient relationship. –Voters think about change in personal terms and how it will affect their relationship with their own doctor. Messages need to resonate with voters on a personal level. Messages that focus on providing doctors with scientific and cost effectiveness evidence, modernizing the health care system with health information technology, and helping doctors and patients make informed choices are seen by voters as both supporting doctors and improving care for patients. Opposition messages raise some doubts for voters about reforms, and voters need to be reassured that changes will help control costs and improve the quality of the care they receive by supporting, not supplanting, doctors. Still, even after hearing opposition messages, voters strongly favor health system reforms by a 2-to-1 margin.

7. 7 Appendix Poll Results and Key Messages

8. 88 Voters express a strong desire for change in our health care system, with over two-thirds saying we need a complete overhaul or major reform. Does our health care system need complete overhaul, major reform, minor reform or no reform at all? 69%

9. 9 Voters’ greatest dissatisfaction is with the rising cost of health care and the lack of coverage for everyone. While they trust their doctors’ training and the quality of care, over one-third are dissatisfied with prevention of medical errors. 9 81% 62% 38% 29% 33% 52% 72% 78%16% Now I am going to read you some different aspects of the health care system in the U.S. For each one, tell me how SATISFIED you are with that aspect of our health care system – VERY satisfied, SOMEWHAT satisfied, SOMEWHAT unsatisfied, or VERY unsatisfied.

10. 10 In an engaged debate, voters support overhauling how we pay for and deliver health care by over 2-to-1. Initial Reform Ballot

11. 11 Statements for and against health system reforms: 11 FOR We need to overhaul how we pay for and deliver health care so that doctors can focus on providing high quality care for you and your family and so that patients have the best information necessary to manage their own health and focus more on prevention. The health care system should provide the right information and incentives for doctors not just to provide more health care, but the most effective high quality health care based on scientific evidence. This will make the health care system more responsive to patient needs, more convenient, and give us peace of mind. AGAINST America has high quality health care because we allow doctors and patients the freedom to choose the treatments and medicines that are right for them, not faceless government bureaucrats. This so- called reform is about putting the government in charge of our personal health care decisions, tying the hands of your own doctor and creating a one-size fits all health care system run by a huge, costly new bureaucracy that we can’t afford in these tough economic times.

12. 12 Over 6 in 10 women and older men support reform by a margin of over 2-to-1. Younger men are more hesitant about health system changes. Initial Reform Ballot

13. 13 Support for reform is strong across all the important political groups, with the strongest support among Democrats and Independents, and with over half of Republican voters on board. Initial Reform Ballot

14. 14 The broad consensus in support of health system reforms remains robust – even after hearing opposition arguments. Final Reform Ballot

15. 15 Voters solidly support payment reform that would reward doctors for providing quality care. Darker color indicates intensity * Asked of half of sample. +62 points Our health care system rewards doctors for providing more tests and procedures rather than better care, but more is not always better. We should reform how we pay for care so that doctors are rewarded for better quality, as measured by patients’ health outcomes instead of by how much the doctors do. This would allow patients and doctors to focus more on the health of their patients and the most appropriate treatment. *

16. 16 Voters feel strongly about prevention and they support providing incentives for people to actively manage their health before they get sick. * Asked of half of sample. In order to control skyrocketing health care costs and promote a healthier society, we should provide incentives for people to actively manage their health before they get sick or engage in behaviors that may adversely affect their health. For example, people who eat healthy, get regular exercise, and avoid smoking would get discounts on the costs of their health coverage.* Darker color indicates intensity +54 points

17. 17 They are much less supportive of penalties for people who don’t actively manage their health. * Asked of half of sample. In order to control skyrocketing health care costs and promote a healthier society, we should have penalties for people who don’t actively manage their health or engage in behaviors that may adversely affect their health. For example, people who are overweight, don’t exercise, and smoke would pay more for their health coverage. * Darker color indicates intensity -2 points The greatest drop-off between strong support for penalties vs. incentives is among: pre-retirement voters (-41 point margin) white non-college women (-39) older women (-37) Democrats (-36), especially weak Democrats (-42).

18. 18 By an overwhelming margin, voters support allowing health professionals other than doctors to provide more care to free up doctors and help control costs. 18 * Asked of half of sample. Darker color indicates intensity We should allow providers who are not medical doctors – such as nurses, nursing assistants, physician assistants, and others – to provide more routine treatments and procedures as long as they are properly trained and supervised. We need to encourage patients, through lower costs or more flexible appointments, to see these providers instead of doctors. Doing so will free up doctors to spend time with those who need it most and it will help control costs for routine care. +57 points

19. 19 Instituting comparative effectiveness reforms to supplement doctors’ clinical knowledge has solid support. Voters need to be reassured that scientific and cost effectiveness data do not replace their doctor’s judgment. 19 We should create an independent national organization that supports health care providers by giving them information about the most effective treatments. This information would be based on the best available evidence from scientific research and would help ensure that doctors are relying on independent evidence as well as their own personal judgment when making decisions about a patient’s care. +56 points * Asked of half of sample. Darker color indicates intensity

20. 20 Messages in favor of reform test very strongly, especially messages that reinforce giving doctors information to provide good care. Comparative effectiveness has overwhelming support with or without explicitly mentioning costs. % Convincing (intensity in dark) Now I am going to read you a series of statements people have made in support of health system changes like those we have been discussing. Please tell me whether each is a very convincing, somewhat convincing, not very convincing or not at all convincing reason to support these changes to the health care system. * Asked of half of sample.

21. 21 Text of Most Effective Messages [Comparative Effectiveness w/out Costs] We need to make sure doctors have access to the latest research that compares the effectiveness of different types of treatments, such as comparing which drugs work best. That will help doctors and patients choose the best treatment for their patients’ situation and make more informed choices rather than risk receiving less effective treatments. [Comparative Effectiveness w/Costs] We need to make sure doctors have access to the latest research that compares the clinical and cost effectiveness of different types of treatments, such as comparing which drugs work best. That will help doctors and patients choose the best treatment for their patients’ situation and make more informed choices rather than waste money on less effective treatments. [Evidence-Based Medicine] Advances in health care occur so fast we need to provide doctors with constantly updated information based on the most current scientific evidence available. The best information should be available to your doctor and only effective health services should be covered. This would help your doctor do what’s right for you and give you the best quality care.

22. 22 The Comparative Effectiveness message tests better with seniors and Republicans when it explicitly cites cost effectiveness. It does better with Democrats, women and independents when cost is not mentioned.

23. 23 Second tier messages about reducing over-use of the health care system, helping doctors avoid malpractice suits, and modernizing the health care system are still strong, but lack intensity. 23 % Convincing (intensity in dark) Now I am going to read you a series of statements people have made in support of health system changes like those we have been discussing. Please tell me whether each is a very convincing, somewhat convincing, not very convincing or not at all convincing reason to support these changes to the health care system. * Asked of half of sample.

24. 24 Text of Second Tier Messages 24 [Over-use Doesn’t Help] We have amazing advanced technology in health care, but just because it’s there doesn’t mean we have to use it every time. Over-use of the health care system contributes to the high cost of tests and treatments for everyone, and often does nothing to improve our health and can actually harm it. We need to support doctors with the best information about prevention, and the treatments that actually work the best for patients. [Evidence-Based Medicine w/Liability] Advances in health care occur so fast we need to provide doctors with constantly updated information based on the most current scientific evidence available. The best information should be available to your doctor and only effective health services should be covered. This would reduce doctors’ risk of malpractice lawsuits and help your doctor do what’s right for you by protecting doctors and enabling them to give the best quality care. [Modernize w/Doctor Time] It is time to modernize our health care system in order to control costs and keep our high quality health care. If we continue with our outdated system of using paper records, rewarding doctors for providing tests and treatments without regards to quality, and not supporting healthy living, doctors will keep spending more time on paperwork and less time on their patients.

25. 25 While opposition messages raise some doubts for voters, they are much weaker than supporting messages. Interfering with the doctor is the strongest concept in opposition messages. Now I am going to read you a series of statements people have made in opposition to some of these health system changes. Please tell me whether each raises serious doubts, some doubts, minor doubts, or no real doubts in your own mind about reforms to the health care system. If you are not sure how you feel about a particular item, please say so. In a head-to-head contest, even after hearing opposition arguments, support for health system reform remains strong, with a +29 point margin favoring reform (56% support, 27% oppose).

26. 26 Text of Opposition Messages 26 [Rationing] Doctors offices are already struggling with too much paperwork and a shortage of staff. Adding rules and regulations to what kinds of treatments doctors should provide and having financial incentives for so-called cost efficiency will lead to rationing of care, so millions of Americans will be denied access to their choice of health treatment. [Interfere w/Doctor] Forcing doctors to accept government mandated guidelines about treatments means putting government bureaucrats in charge of our health care, not your doctor. And pushing care down to lower level providers like nurses means we’ll get lower quality care from people with less training. This isn’t reform, it’s a government takeover that will hurt patient care.

27. 27 Methodology Lake Research Partners designed and administered this survey that was conducted by telephone using professional interviewers between February 2-8, 2009. The survey reached a total of 800 likely voters nationwide. Telephone numbers for the sample were generated by random digit dial (RDD) methodology. The margin of error for this survey is +/- 3.5%.

28. 202.776.9066 | www.lakeresearch.com | March 6, 2009 Voter Attitudes on Health System Change Reforms Findings From A Survey of 800 Likely Voters Nationwide herndon A l l i a n c e Healing America’s Healthcare