MENLO PARK, Calif. – As economic conditions remain poor, a majority of the public continues to say that they or a member of their household have delayed or skipped health care in the past year, according to the Kaiser Family Foundation's April health tracking poll.

Perhaps because Americans continue to struggle with the cost of medical care in their own lives, the country's overall economic problems have not dampened their interest in pursuing health care reform: a solid majority of the public (59%) believes health care reform is more important than ever, compared with the thirty-seven percent who say we can't afford health reform because of economic problems.

"Our polls suggest strong general support for health reform, but the public can be swayed on the key details," said Kaiser President and CEO

Drew Altman . "There is still a tremendous opportunity for leadership but also for interest groups to define the direction of the health reform debate."

The most common actions taken due to costs were substituting home remedies or over-the-counter drugs for doctors visits (42%) and skipping dental care or check ups (36%). Additionally, three in ten (29%) did not fill a prescription for medicine and two in ten (18%) cut pills in half or skipped doses.

Not everyone can forgo care, and overall one in four (26%) Americans say someone in their household has had trouble paying medical bills in the past year.

Support for Some Methods to Pay for Health Reform, Others Less Popular

One of the crucial challenges for health reform is the financing of the plan.

Seven in ten (71%) Americans strongly or somewhat favor increasing income taxes for those in families making more than $250,000 per year, but there is much less support for increasing income taxes on all taxpayers (28%).

The poll indicates some support for taxing unhealthy behaviors, sometimes called "sin" taxes. When asked if they would favor or oppose increasing taxes on a package of items including soda, alcohol, junk food, and cigarettes to pay for health reform and provide coverage for the uninsured, six in ten (61%) favor such taxes while roughly four in ten (37%) are opposed. Asked about each of these items specifically, the poll suggests there is somewhat more support for increasing taxes on cigarettes, wine and beer than on snack foods or soda.

Another tax change that has been discussed by some policymakers as a financing option is changing the tax treatment of employer-based health insurance. Roughly half (52%) of the public is opposed to changing the law so workers with the most generous health benefits would pay taxes on the money their employer puts towards their coverage, while 41 percent are in favor. Those who currently have employer-sponsored health insurance are even more likely to oppose the proposal (62 percent oppose, 33 percent favor).

One other potential area of revenue discussed by policymakers for health reform comes from changes to the Medicare program. When asked about making changes to the program as a way to keep Medicare financially sound, reducing payments to managed care plans and other private insurers is "strongly" or "somewhat" supported by two-thirds (66%) of the public. Two-thirds (65%) also support reducing Medicare payments to doctors and hospitals.

Ideological Divide in Support for Public Plan

There has already been an ongoing debate about whether a public plan option should be included in health reform. Generally, two-thirds of the public (67%) "strongly" or "somewhat" favor creating a public option "similar to Medicare." More than eight in ten Democrats and six in ten political independents "strongly" or "somewhat" favor having a public plan, but just about half (49%) of Republicans agree.

Another way to measure Americans' views on the public plan debate is giving the public a choice of two methods and asking which would better encourage price competition among health plans. When asked whether private plans competing with just each other or with a government-administered public insurance plan similar to Medicare would do a better job of lowering costs and improving quality, Democrats favor including a public plan by more than 3 to 1 (71% to 19%), and political independents back this approach 53 percent to 40 percent. A majority of Republicans, on the other hand, prefer having private plans compete without a public plan (54% to 39%).

Simulating a Public Debate with Potential Arguments Shows Malleability of Opinion

In an attempt to measure the firmness of public support for key policy approaches in health reform, a handful of arguments for and against such policy options were tested on the public in preparation for what could be a robust, fast-moving debate.

Employer mandates have been a staple of previous reform debates and are likely to be considered this year as well. When the public is initially asked if they support "requiring employers to offer health insurance to their workers or pay money into a government fund," seven in ten (71%) support the concept. When the supporters are exposed to a one-sided argument stating that the approach may mean some job loss, overall support for mandates drops dramatically (to 27% for and 65% against). When the initial opponents of employer mandates are told that mandates are "more fair because today some employers pay for health insurance and some do not," then support overall rises from its initial level to 78 percent for and 17 percent against.

Public support and opposition to public plans can be similarly swayed. When the 67 percent who initially supported public plans are told that they could give the government an unfair advantage over private plans, overall support drops to roughly three in ten (32% favor, 59% oppose). When supporters were offered a different argument, that public plans would be the first step toward single-payer, government-run health care, overall support again eroded, but not as much (41% favor, 50% oppose).

As discussed earlier, there is initial majority (61%) support for "sin" taxes to finance health reform. While this idea hasn't been broadly debated publicly this year, some arguments for and against the approach were tested. Support for the approach declines overall (39% favor, 57% oppose) when supporters are told that the tax increase would hit low-income people the hardest. When initial opponents are told that the tax increase would raise money for reform and improve health by encouraging healthier habits, overall support increases moderately (70% favor, 27% oppose).

The survey cannot gauge in advance what arguments will be used in the health reform debate, who will make them and how well the arguments will be heard and absorbed by the public. And the fact that arguments are made does not make them accurate. What the simulations can tell us, however, are how possible arguments can alter potential public support.

Public Realizes Medicare Faces Challenges, But Most Uninterested in Personal Sacrifices

Roughly three-quarters (77%) of the public view Medicare as "very important" for the country, and just over half (53%) say the same for their own family. As might be expected, an even larger share of seniors (78%) and those living in households making less than $30,000 per year (68%) say that Medicare is very important to them personally.

While Medicare is valued by the public, many Americans under age 65 are concerned that the program will not be there for them when they need it. More than eight in ten (85%) are "very" or "somewhat" concerned that the program benefits available to seniors today will not be available when they retire. Three in four Americans say either the program is already in financial crisis (30%) or is facing major financial problems (44%). At the same time, though, more incorrectly believe that Social Security will be first to face a major financial shortfall (52%, compared to 39% who correctly named Medicare).

The survey suggests the public recognizes that rising health care costs are a primary culprit in Medicare's financial troubles: eight in ten cite this as a "major reason" for the program's difficulties, putting it at the top of a list of seven possible causes. But at the same time, roughly seven in ten say that "doctors and hospitals charge too much" and "too much fraud in the program" are also major reasons for the impending financial problems, causes which are seen as secondary by many experts.

Despite widespread concern about Medicare's solvency, most Americans are not interested in reform proposals that require personal sacrifice. The most popular option is to allow the government "to negotiate with drug companies for lower drug prices" (86% favor), followed by having the program pay for new treatments and technologies only if they provide better results (75%). The Medicare changes detailed earlier as possible revenue raisers are next in popularity, but it should be noted that seniors are less supportive -- only half favor reducing payments to insurer plans or providers. About half the public (53%) would support requiring higher income seniors to pay higher Medicare premiums. Proposals that would more broadly impact individuals -- such as raising payroll taxes, raising the age of eligibility for Medicare or requiring all seniors to pay a larger share of costs -- all received less than majority support.

Methodology

The survey was designed and analyzed by public opinion researchers at the Kaiser Family Foundation and was conducted April 2 through April 8, 2009, among a nationally representative random sample of 1,203 adults ages 18 and older. Telephone interviews conducted by landline (902) and cell phone (301, including 98 who had no landline telephone) were carried out in English and Spanish. The margin of sampling error for the total sample is plus or minus 3 percentage points. For results based on subgroups, the margin of sampling error is higher.