As health care reform legislation moves forward in Washington, the political environment is somewhat different than the last time a major overhaul of the health care system was attempted sixteen years ago. In early 1993 the sense of a health care crisis was far more widespread than it is today – a 55% majority in 1993 said they felt the health care system needed to be “completely rebuilt” compared with 41% today. Health care costs were also a broader problem in 1993 – 63% of Americans said paying for the cost of a major illness was a “major problem” for them, compared with 48% currently.

The issue of limiting overall health care spending is also more prominent in 2009 than it was in 1993. Somewhat fewer today say the country spends “too little” on health care, and a larger share believe that limiting the overall growth in health care costs is a higher priority than expanding coverage. But overall, public support for guaranteed access to medical care for all Americans remains widespread.

Health Care Spending

Relatively few Americans believe the country as a whole is spending the right amount on health care at this point, but there is no consensus on what the problem is. Just as many Americans say we are spending too much on health care (38%) as too little (40%).

This represents a sharp turnaround in the balance of opinion from three years ago. In early 2006, a 57% majority said that the country as a whole was spending too little on health care, while about half as many (26%) said we were spending too much. And this shift in opinion crosses party lines – more Democrats, Republicans and independents today say the country spends too much on health care than said this in 2006.

In April 1993 – as Bill Clinton was initiating his health care reform effort – 49% of Americans felt the country was spending too little on health care, while 36% said the country was spending too much. Just a year later – in June of 1994 – the public was divided, much as it is today, with 38% saying too much and 40% saying too little.

Most Democrats (51%) believe we are spending too little on health care in this country, while about a third (34%) say too much. By comparison, a plurality of Republicans (43%) say we are currently spending too much on health care, with 30% saying too little. Overall, the share of Americans saying we spend too much on health care rose from 26% to 38% since 2006, and this rise occurred among Republicans (up eight points), Democrats (up 14 points) and independents (up 11 points) alike.

While a minority viewpoint, Republicans are roughly twice as likely as Democrats (19% vs. 10%) to say the country is spending the right amount on health care. This viewpoint is particularly prevalent among conservative Republicans, 23% of whom express satisfaction about current levels of health care spending.

By a 50% to 30% margin college graduates are more likely to say the country spends too much, not too little, on health care. By contrast, adults with no more than a high school diploma tend to think we spend too little (46%) not too much (32%) on health care in this country. There is a similar, though less prominent, pattern when it comes to income levels.

Most Back Overhaul; Fewer Than in 1993 See Crisis

Most Americans believe that the nation’s health care system is in need of substantial changes. Four-in-ten (41%) say the health care system needs to be completely rebuilt, while 30% think it needs fundamental changes. About one-in-four (24%) believe that the health care system works pretty well and needs only minor changes.

But there is less support for completely rebuilding the health care system than there was during the early stage of the Clinton administration’s unsuccessful effort to revamp health care. In April 1993, a majority of Americans (55%) said the health care system needed to be completely rebuilt. As discussion of Clinton’s proposals progressed, support for completely rebuilding the health care system declined. By June 1994, just 37% said the health care

system needed to be completely rebuilt.

Support for a complete rebuilding of the health care system is lower than in early 1993 among all partisan groups. Today, 53% of Democrats, 38% of independents and 28% of Republicans support completely rebuilding the health care system. In April of 1993, 70% of Democrats, 55% of independents, and 41% of Republicans supported completely rebuilding the system.

People with no more than a high school education (47%) or some college (42%) are far more likely than are college graduates (31%) to favor a complete rebuilding of the health care system. The education gap was even wider in 1993, when 63% of those with no-college and 56% of those with some college education said the system needed to be completely rebuilt, compared with 36% of college graduates. Income is also a factor, with those living in low income households backing the most dramatic overhaul of the health care system.

Health Reform Priorities

Most Americans favor ensuring health coverage to all Americans, and most also say it is very important to limit the overall annual increase in health care costs. Neither of these objectives, however, receives as overwhelming support as they did in early 1993. When Americans are asked to prioritize between these two goals, most continue to say that expanding health insurance to all is the more important goal. But the share who rate costs as the more important concern is nearly double what it was in 1993.

The public’s overall support for expanding health insurance to cover all Americans remains widespread, though more sharply partisan than in 1993. In the spring of that year, 83% of Americans favored changing the health care system so that all Americans would have health insurance that covers all medically necessary care. Today, 75% support such a reform .

The difference is that support for universal health insurance was more bipartisan in early 1993 than it is today. While there has always been a partisan gap, two-thirds (67%) of Republicans said they favored health coverage for all Americans in 1993, compared with barely half (52%) today. By contrast, the share of Democrats backing this kind of change remained a solid 92% in both years.

There has also been a 15-point drop in the share of independents backing universal health insurance – from 89% in 1993 to 74% today.

The share of Americans who say it is very important to change the health care system in this country in order to limit the overall annual increase in the nation’s health care costs is also slightly lower today (61%) than in 1993 (69%). Today fewer than half of Republicans (47%) rate this as very important, compared with 72% of Democrats and 60% of independents.

When asked whether reining in health care costs or expanding health care coverage is the more important goal for the nation, 56% prioritize guaranteeing access to all while 36% side with limiting growing health care costs. Opinion was more one-sided in early 1993, when 74% prioritized expanded health care coverage and just 20% saw reining in costs as the bigger concern.

The balance of opinion among Republicans is the reverse of what it was in 1993. Then, 55% prioritized expanded care while 37% emphasized reining in costs. Today, 37% prioritize expanded care while 54% emphasize reining in costs. While most Democrats and independents continue to see expanding access to health care coverage as the higher priority, it is by slimmer margins than was the case sixteen years ago.

Fewer See Cost of Care as Major Problem

In the current survey, far fewer say health care expenses are a major problem for themselves and their families than was the case in 1993. Just under half of Americans (48%) say that paying for the cost of a major illness is a major problem, substantially lower than the 63% who said this in early 1993. Similarly, about a third of Americans (34%) say paying for the cost of routine medical care is a major problem for them. In 1993, 40% said this was the case.

But for the most part, it is those who are relatively well off who are feeling more at ease. Just 27% of high income Americans say the cost of a major illness is a major problem for them today, down from 48% in 1993. By comparison, 67% of low income Americans say this is a major problem, little changed from 73% sixteen years ago.

Similarly, the share of high income Americans who say paying for routine medical care is a major problem fell from 25% in 1993 to 13% today. Meanwhile, just over half of low income Americans – at both points in time – say this is a major problem for them.

There is far less concern about the quality and availability of medical care in people’s communities. Just 24% say the quality of medical care in their community is a major problem for them and their families, and 21% say the availability of medical care is a major problem. These figures are virtually unchanged from 1993. Income is an overwhelming factor in these assessments, as lower income people are far more likely than higher income people to say health care quality and availability are major problems for them.

Nationwide, 43% of Americans say paying for the cost of health insurance poses a major problem for them and their family. Fully 59% of Americans with family incomes under $30,000 say health insurance is a major problem for them. Not surprisingly among the low income who currently have no health insurance 73% rate insurance costs as a major problem.

The share of Americans who say paying for the cost of prescription drugs is a major problem dropped from 44% in 2006 to 34% today. This decline has occurred across both age and income categories at about equal rates.